Dr John Coop, Angela Williams, Dr Martin James and Tina Wills describe a collaboration to produce an evidence-based model of stroke care that reflects local health culture and needs

Mortality from stroke is decreasing within the North & East Devon Health Authority (N&EDHA) as it is nationally.1 However, more than half the patients who survive a stroke have some residual disability.2 The risk of stroke increases with age, with most strokes occurring in people over the age of 65 years. Ongoing care of stroke sufferers therefore accounts for a significant part of health and social care resource use.

There are wide variations in the types of services that stroke patients receive.3,4 A meta-analysis of 10 stroke units has shown that organised stroke care leads to a reduction in mortality, and length of stay plus improvements in disability outcomes.5

However, more information on those components of rehabilitation in stroke patients that have most impact on outcome is needed.

Shaping the East Devon PCT stroke service

East Devon Primary Care Trust (PCT) is situated to the east of the city of Exeter, in the N&EDHA, South West England. The PCT covers a rural community, with seven community hospitals and 66 GPs in 13 practices.

The N&EDHA has a population of 482 920, of whom 126 203 (26%) are resident in the East Devon PCT.6 With 21% of the population aged over 65 years, the proportion of elderly patients in this health authority is higher than the average for England and Wales (16%).

The N&EDHA identified stroke as a local priority, as well as a national priority. A working party representing all partner health and social care organisations and the voluntary sector produced a 5-year strategy in 1996. Its overarching objective was to develop a comprehensive stroke service spanning prevention, primary care, acute services and rehabilitation and patient and carer information over the next 5 years for local patients within agreed budgets.

In December 1998 a Stroke Management Group was established to decide how best to configure stroke services that reflected the rural environment and the local health culture and needs, in accordance with the health authority's stroke strategy. Like the Stroke Strategy Working Party, the group had a broad, multidisciplinary membership representing all partner organisations and the voluntary sector.

The group produced a high level 'flow' care pathway across organisational boundaries and professions to support the implementation of a dispersed model of care that provided best practice within an acute stroke unit, community hospitals and primary care (see Figure 1, below). The Stroke Steering Group replaced the Stroke Management Group at the beginning of 2000 to continue to oversee implementation of the reconfigured stroke service.

Figure 1: Stroke multidisciplinary care pathway
algorithm

The prioritisation of stroke as East Devon PCT's Long-Term Service Agreement (LTSA), and agreement with the other PCG/Ts to adopt each other's LTSAs once developed, presented an opportunity to phase strategic development based on this initial work in East Devon PCT.

A collaboration was set up between the NHS Executive South West Regional Office, N&EDHA, East Devon PCT and GlaxoSmithKline UK Ltd to develop and implement the Stroke LTSA for East Devon PCT. A GSK project manager was appointed in November 1999.

In January 2000 a stroke coordinator was appointed in the community, funded through the Joint Investment Plan for Older People, to work with the consultant stroke physician based at the acute trust.

The main objectives of the stroke coordinator are to coordinate stroke services, and facilitate and support changes in clinical practice within the community hospitals, so providing best practice for stroke services across the PCT beyond the acute stroke unit.

To support change in clinical practice, engender a quality cycle of improvement and encourage local ownership of services, the stroke coordinator leads seven stroke interest groups.

A comprehensive stroke service

To ensure that the stroke services are sustainable and robust, the evidence base to all aspects of care is clearly acknowledged in the LTSA and based on the Department of Health's Compendium of Clinical and Health Indicators 2000.6

Prevention of stroke

The aim of the service is to maximise health improvement by the effective delivery of primary prevention measures to detect and control stroke risk factors.

Primary care

The key activities in primary care relate to:

1. Primary and secondary prevention:

  • Setting up a stroke 'at-risk' register and stroke register
  • Detection and control of risk factors (see Table 1, below)
  • Starting appropriate secondary prevention treatments
  • Continuation of monitoring
Table 1: Risk factors requiring detection and control in primary care
  • Hypertension
  • Atrial fibrillation
  • Peripheral vascular disease
  • Heart failure
  • Diabetes
  • Smoking
  • Alcohol consumption
  • Lack of physical activity
  • Obesity
  • Diet and dietary salt intake
  • Increased cholesterol levels

2. Conducting 6-month follow-up assessments of stroke patients

Acute services and rehabilitation

The dispersed model for stroke services aims to provide fair access and effective delivery of stroke care for diagnosis, acute management and rehabilitation, and long-term rehabilitation, with an acute stroke unit.

The aim is to spread best practice in the community, keeping stroke care at community hospitals and reducing institutionalisation.

1. Diagnosis

  • Rapid access stroke clinic for diagnosis. GPs can refer patients for diagnosis who have suffered a suspected stroke but are able to remain in their usual place of residence
  • Appropriate availability of CT scanning for stroke patients admitted to one of the seven community hospitals or the acute hospital stroke unit

2. Acute management and rehabilitation

  • Implementation of coordinated multidisciplinary team assessment and rehabilitation for patients admitted to one of the community hospitals or to the RD&E stroke unit or another ward at the RD&E
  • Dysphagia service
  • Use of multidisciplinary patient-centred goal setting at the RD&E hospital and the community hospitals
  • Team working and working relationships within and between the staff of the RD&E stroke unit and the staff of the community hospitals
  • Discharge communication from the RD&E hospital and the community hospitals

3. Long-term rehabilitation

  • Community rehabilitation teams across East Devon PCT to work in private homes and residential homes
  • Fully developed team member roles, e.g. family support worker
  • Effective multi-agency working relationships

Patient and carer information

Our aim is to provide patients and carers with the best possible service through a number of joint initiatives with the User Involvement Group and the Stroke Association:

  • Patient version of stroke care pathway
  • Stroke counsellor support available to all stroke patients and their carers
  • Support for carers:
    • quality written material available to patients and carers in all the hospitals
    • recording communication with carers
    • a rolling programme for carers, in conjunction with the Stroke Association, to address educational, support and communication needs

Benefits to patients

To date there have been many achievements and practice improvements to benefit patients:

  • The results of the 1998 and 1999 Sentinel Audits showed that the Stroke Unit at the acute trust, Royal Devon and Exeter Hospital NHS Trust, provided an above-average quality service across the domains, and highlighted the achievement of improvements between the two audits.
  • A rapid access stroke clinic started in January 2000 and funded by the Joint Investment Plan for Older People improved facilities for the assessment of patients with suspected strokes and transient ischaemic attacks who are not admitted to the acute stroke unit.

Other major initiatives across the community include:

  • Reconfiguration of the dysphagia service to provide an equitable service across the district for screening, assessment and management of dysphagic stroke patients
  • A pathway approach that specifically allows for collaborative patient-centred goal setting and discussion of discharge provision and timing, aiming for a seamless transition at discharge
  • Development of a joint health, social service and voluntary services rehabilitation team across the PCT, ensuring that high quality rehabilitation and support are maintained in the community for patients and carers
  • Joint health and social service training for domiciliary care workers to raise awareness of the care of stroke patients in their own homes
  • Use of a patient diary to give users the opportunity to communicate their experiences of the stroke care pathway
  • Development of a patient version of the stroke care pathway.

Evaluating the East Devon PCT stroke service

Fundamental to the process of reconfiguring stroke services is a system of routine data collection and analysis of reliable and valid process and outcome data.

Clear, measurable attainable targets for performance objectives, including measures of inputs, outputs, process measures and final outcomes, have been adopted for each element of service development and implementation.

Thus the evaluation of the stroke service moves beyond a focus on 'cost and volume', with objectives reflecting the six areas of the Performance Assessment Framework (Table 2, below).

Table 2. Example of performance objectives used to evaluate the stroke service
Stroke service Performance measure Performance objective
Primary prevention

A. Proportion of the predicted numbers of hypertensive patients in a practice who have a prescription for antihypertensive drugs ('proportion detected')

B. Proportion of the hypertensive patients in each practice who have their most recent blood pressure value recorded as (a) <=150/90 mmHg and (b) <=140/85 ('proportion controlled')

To reduce the incidence of first and recurrent stroke attributable to hypertension
Secondary prevention Percentage of stroke patients who at 6 months have a raised blood pressure and who are on treatment Effective secondary prevention of vascular disease, principally stroke, in stroke patients

Acute stroke management & rehabilitation

Percentage of stroke inpatients screened for dysphagia Prompt screening of patients to ensure early and appropriate action taken to reduce or avoid complications of stroke
Acute stroke Percentage of stroke inpatients with documentary evidence of a multiprofessional case conference discussion within 2 weeks of admission Multiprofessional case conference discussion of a stroke inpatient within 2 weeks of admission to coordinate involvement of a multidisciplinary rehabilitation team
Long-term rehabilitation Presence of communication difficulties at 6 months To identify patients with communication difficulties at 6 months post stroke event in order to minimise the impact on health-related quality of life and handicap after stroke

Long-term rehabilitation

Rate of emergency re-admissions for any reason within 30 days of discharge Reduce or avoid complications of stroke since unplanned re-admissions may reflect an adverse outcome of post-stroke healthcare
Patient and carer education, support & communication Documentary evidence of the provision of verbal and/or written information to patients and their carers about stroke To ensure that patients and carers have timely information that they require

Beacon status award

The work undertaken to establish the organised stroke service within the East Devon PCT was recognised by the NHS, who awarded the PCT Beacon status in September 2000.

A range of activities have already been undertaken and planned, to share the learning and experience on the development and implementation of the stroke service. These have primarily been with the local partner organisations, using methods such as newsletters, meetings, reports and clinical governance training events.

Activities to be undertaken over the next 2 years include:

  • Interactive visits
  • Website development
  • National conference presentations
  • East Devon PCT 'learning conferences' to be held in September 2001 and January 2002
  • Field enquiries and Beacon stroke packs to distribute on request.

Conclusion

The successful development and implementation of a LTSA for stroke has arisen from the collaboration of key stakeholder organisations and service users, crucially involving social services in the Joint Investment Plan, with agreed objectives to reduce mortality and institutionalisation due to stroke.

References

  1. Whelton PJ, Klag MJ. Recent trends in the epidemiology of stroke: what accounts for the stroke decline in Western nations? Curr Opin Cardiol 1987; 2: 741-7.
  2. Rudd A, Goldacre M et al. Health Outcome Indicators: Stroke Report of a working group to the Department of Health. Oxford: National Centre for Health Outcomes Development, 1999.
  3. King's Fund Consensus Statement. The treatment of stroke. Br Med J 1988; 297: 126-8.
  4. Lindley RI, Erastus OM, Marshall J et al. Hospital services for patients with acute stroke in the United Kingdom: The Stroke Association survey of consultant opinion. Age Ageing 1995; 24: 525-32.
  5. Langhorne P, Williams BO, Gilchrist W, Howie K. Do stroke units save lives? Lancet 1993; 342: 395-7.
  6. Department of Health. Compendium of Clinical and Health Indicators 2000. Source: Office of National Statistics.

NHS Beacon Awards
Beacon status is awarded to practices, trusts and other healthcare organisations within the NHS that have demonstrated good practice. The NHS Beacon programme aims to spread best practice across the health service. For further information visit the website: www.nhs.uk/beacons

     

Guidelines in Practice, September 2001, Volume 4(9)
© 2001 MGP Ltd
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