Improving stroke rehabilitation: implementing the national clinical guideline for stroke

Audrey Bowen

Stroke Association John Marshall Memorial

Professor of Neuropsychological Rehabilitation

From this......to this

2012 2016

Intercollegiate Stroke Working Party

Chair ICSWP Prof Tony Rudd CBE National Clinical Director for Stroke ICSWP 40 members, 26 organisations

ICSWP guideline co-editors

Martin James Gavin Young Audrey Bowen

questions

searches

appraisals

draft recommendations

ICSWP consensus

public consultation

revise

publish

How is the guideline

produced?

Changes include structure, focus & completeness of the guideline

Preface – includes ‘what’s new’

Key recommendations & Choosing Wisely

Chap 1 – Introduction

Chap 2 – Organisation of Services

Chap 3 – Acute Care

Chap 4 – Recovery & Rehabilitation

Chap 5 – LT Management & 2O Prevention

Chap 6 – Commissioning Services

12/30 key recommendations H/ASU resources Ch2

Transfers of care Ch2

Rehab ‒ intensity Ch2

Org psychological care Ch2

Care homes Ch2

Early mobilisation Ch3

Work & leisure Ch4

Aphasia assessment Ch4

Hydration and nutrition Ch4

Life after stroke, reviews Ch5

Commission overall service Ch6

Commission specific rehab Ch6

Today’s topics

• Commissioning: broad and specific

• Resources: orthoptics, dietetics, psychology

• Organisation & delivery:

–psychological care

– ESD

– care homes

• Early mobilisation

Commissioning Overall Structure of Stroke

Services

6.1.1A Commissioning organisations should ensure that their commissioning portfolio includes the whole stroke pathway from prevention (including neurovascular services) through acute care, early rehabilitation, secondary prevention, early supported discharge, community rehabilitation, systematic follow-up, palliative care and long-term support.

Commissioning Rehab

Services 6.4.1A Commissioners should commission stroke rehabilitation services in accordance with the recommendations in this guideline to provide: ‒ an inpatient stroke unit capable of providing stroke rehabilitation for all people with stroke admitted to hospital; ‒ a specialist early supported discharge service to enable people with stroke to receive rehabilitation at home or in a care home; ‒ specialist rehabilitation services capable of meeting the specific health, social and vocational needs of people with stroke of all ages; ‒ services capable of delivering specialist rehabilitation in out-patient and community settings in liaison with in-patient services.

Resources recommendation2.4.1J

SRU should have a single MDT including specialists in:

• medicine;

• nursing;

• physiotherapy;

• occupational therapy;

• speech and language therapy;

• dietetics;

• clinical neuropsychology/clinical psychology;

• social work;

• orthoptics;

• with easy access to pharmacy, orthotics, specialist seating, assistive technology and information, advice and support for people with stroke and their family/carers.

New in

2016

PT WTE/5 bed

OT WTE/5 bed

SLT WTE/5 bed

Psy WTE/5 beds

Diet WTE/5 bed

Nurs WTE/1 bed

Cons physic

HASU 0.73 0.68 0.34 0.2 0.15 2.9 24/7, min 6 rota

ASU 0.84 0.81 0.40 0.2 0.15 1.35 5 days ward rounds

Rec. 2.4.1B A hyperacute +/ acute stroke service should provide specialist medical, nursing, and rehabilitation staffing levels matching the recommendations Table 2.1.

Table 2.1 Recommended staffing levels for stroke units

Evidence for: resources recommendations

Workforce to provide holistic & compassionate care to patients and families (Francis, 2013) Organised in-patient stroke unit care (Stroke Unit Trialists' Collaboration, 2013) SU minimum staffing levels from observational studies of service reconfigurations & national registries (Ramsay et al, 2015, Turner et al, 2016) SU admission, therapy intensity, psychology QS 1-3 (NICE Quality Standards, 2016)

Where are we ...?

• Commissioning: broad and specific

• Resources: orthoptics, dietetics, psychology

• Organisation & delivery:

– psychological care

– ESD

– care homes

• Early mobilisation

Prominence of psychological care 2.12 Psychological care – organisation & delivery A-G A Services for people with stroke should have a comprehensive approach to delivering psychological care that includes specialist clinical neuropsychology/clinical psychology input within the multi-disciplinary team. B Services for people with stroke should offer psychological support to all patients regardless of whether they exhibit specific mental health or cognitive difficulties, and use a matched care model to select the level of support appropriate to the person’s needs.

C Services for people with stroke should provide training to ensure that clinical staff have an awareness of psychol. problems following stroke & the skills to manage them

D Services for PWS should ensure that the psychological screening & assessment methods used are appropriate for people with aphasia & cognitive impairments

E Services for PWS should provide screening for mood & cognitive disturbance within 6wks of stroke (in the acute phase of rehabilitation & at transfer of care into post-acute services) & 6 & 12 mths using validated tools & observations over time.

F Services for people with stroke should include specialist clinical neuropsychology/clinical psychology provision for severe or persistent symptoms of emotional disturbance, mood or cognition.

G Services for people with stroke should consider a collaborative care model for the management of people with moderate to severe neuropsychological problems who have not responded to high-intensity psychological interventions or pharmacological treatments. This care model should involve collaboration between the GP, primary & secondary physical health services & case management, with supervision from a senior mental health professional & should include long-term follow-up.

Explains the 3 main models of psychological care

Stepped care: start all at the lowest level intervention and step up to the next level if they do not adequately respond. Matched (or stratified) care : initial triage so people start on most appropriate step, which may be the highest level. Collaborative care has four components: • collaborative identification of problems; • goal-planning; • self-management training and support to facilitate

intervention plans, behaviour change and emotional coping; • and active monitoring and follow-up.

Evidence: recommendations for organisation & delivery of

psychological care

Absence of stroke-specific evidence for stepped care

Collaborative care > usual care for depression and anxiety in mental health (Archer et al, 2012)

Mostly Working Party consensus, Gillham SIP (2011) & NICE QS (2016)

ESD: transfers of care from hospital to home

2.7.1A Hospital in-patients with stroke who have mild to moderate disability should be offered early supported discharge, with treatment at home beginning within 24 hours of discharge.

+ Recommendations B-E

3.8.1E Provide early supported discharge to patients who are able to transfer independently or with the assistance of one person. Early supported discharge should be considered a specialist stroke service and consist of the same intensity and skill mix as available in hospital, without delay in delivery.

Evidence for: organisation & delivery of ESD

ESD reduces dependency & admission to institutional care (Fearon et al, 2012) but some uncertainties about delivery remain

NICE guideline (2013b)

NICE QS4 (2016)

Working Party consensus

People in care homes

• Do not routinely provide specialist OT for people who have reached the end of their stroke rehabilitation and are now living in a care home (‘Choosing Wisely’).

• Do offer assessment and activities that might improve quality of life (Sections 2.17 and 5.9).

People in care homes Transfers 2.7.1K People with stroke, including those living in care homes, should continue to have access to specialist services after leaving hospital, and should be provided with information about how to contact them. Care homes 2.17.1A People with stroke living in care homes should be offered assessment and treatment from community stroke rehabilitation services to identify activities and adaptations that might improve QoL. Life after stroke - further rehabilitation 5.9.1.1A People with stroke, including those living in a care home, should be offered a structured health & social care review at 6mts & 1 year after the stroke, & then annually. The review should consider whether further interventions are needed, & the person should be referred for further specialist assessment if: ‒ new problems are present; ‒ physical/psychological condition/social environment changed.

Evidence for: recommendations for people in care homes

Rehabilitation for older care home populations MAY slightly reduce disability for some but uncertainty (Crocker et al, 2013)

3mt person-centred, goal-setting by OT/OTA did not benefit disability, mood, QoL (Sackley et al, 2015)

Working party consensus

Early mobilisation

3.12.1B Patients with difficulty moving early after stroke who are medically stable should be offered frequent, short daily mobilisations (sitting out of bed, standing or walking) by appropriately trained staff with access to appropriate equipment, typically beginning between 24 and 48 hrs of stroke onset. Mobilisation within 24 hrs of onset should only be for patients who require little or no assistance to mobilise.

4.15.1B People with acute stroke should be mobilised within 24 hours of stroke onset, unless medically unstable, by an appropriately trained healthcare professional with access to appropriate equipment.

Recommendations in full

3.12.1A Patients with difficulty moving after stroke should be assessed as soon as possible within the first 24 hours of onset by an appropriately trained healthcare professional to determine the most appropriate and safe methods of transfer and mobilisation. 3.12.1B Patients with difficulty moving early after stroke who are medically stable should be offered frequent, short daily mobilisations (sitting out of bed, standing or walking) by appropriately trained staff with access to appropriate equipment, typically beginning between 24 and 48 hours of stroke onset. Mobilisation within 24 hours of onset should only be for patients who require little or no assistance to mobilise.

Evidence for: recommendations for early mobilisation

Very early, more frequent, higher dose mobilisation focused on out-of-bed activities led to greater disability at 3mts, no effect on immobility-related complications or walking recovery (AVERT, 2015).

Early mobilisation might be best in short, frequent amounts but that hypothesis requires testing (Bernhardt et al, 2016).

Today’s topics

• Commissioning: broad and specific

• Resources: orthoptics, dietetics, psychology

• Organisation & delivery:

–psychological care

– ESD

– care homes

• Early mobilisation

A suite of guideline documents

Full guideline Easy read Concise guideline

https://www.strokeaudit.org/Guideline/Patient-Guideline.aspx

Thanks for all their work

• RCP Stroke Programme

• Intercollegiate Stroke Working Party (ICSWP) Members of the ICSWP

• Sub-group leads & reviewers

• Lay representatives

• Peer reviewers

Thank you for listening