Early Supported Discharge (ESD) team and

Beech Ward Supporting Patients following Stroke

Tony Brown Modern Matron

Claire Walford Occupational Therapy

Lead

Stroke • There are more than 100,000 strokes in the UK

each year; that is around one stroke every five minutes. (Stroke Association 2017)

• There are over 1.2 million stroke survivors in the UK. (Stroke Association 2017)

• Stroke is the fourth single leading cause of death in the UK. (Stroke Association 2017)

• Stroke is one of the leading causes of disability; over half of all stroke survivors have a disability. (Stroke Association 2016)

Strokes Services at St Margaret’s Hospital

• Stroke pathway

- 14 inpatient stroke/neuro beds

- 13 Early Supported Discharge Services (ESD) for Stroke

About us

Speech and Language Therapy Team

Clinical Psychology

•The speech and language therapists are responsible for assessing and treating any difficulties with communication and/or swallowing.

•A communication assessment may include assessment of language: (understanding, expression, reading and writing); and speech (the muscles used for articulation). It may also look at areas such as voice, fluency, facial weakness and non-verbal communication.

•A swallowing assessment will focus on the safety of the swallow process. If swallowing has been affected by stroke the SLT will offer advice on consistencies of food and drink that are safe to swallow; and may offer exercises or strategies to work on improving swallowing.

•The SLT will also advise the wider MDT on communication with the Patient

About us

Therapy Assistants Assistant Practitioners

About us

Physiotherapy Occupational Therapy

About Us

Nursing

• We have a team of nurses led by the senior sister who have all had training in caring for patients follow a stroke

• The team work very closely with the therapy team to ensure a continuity of care/ rehabilitation

Medical

• The medical team comprises of a:

• Consultant

• Senior grade doctor

• Junior doctor

Aphasia Facial weakness Ataxia Impaired object recognition

Limb apraxia Reduced balance Memory difficulties

Dysfluency Alterations in muscle tone Pain

Shoulder subluxation Shortness of breath Difficulty sequencing

Conditions we manage

Dysphonia Dysarthria Processing impairments

Dysphagia Low mood Sensory/proprioceptive impairments

Apraxia of speech Muscle weakness Neglect

Fatigue Visual deficits Reduced coordination

Low mood Joint stiffness Potential for retained secretions

Emotional lability Planning difficulties Difficulty problem solving

National guidance on stroke

Prompt assessment

GUIDELINES

ESD comparable to inpatient services

Rehab on ‘same day’

WHAT WE DO

First assessment within 24 hours

Intensive Therapy

GUIDELINES

Minimum of 45 minutes of each relevant discipline

5 days a week

WHAT WE DO

5 therapy sessions per week including therapy at the weekend

6 month review

GUIDELINES

All Patients should be reassessed at 6months

WHAT WE DO

All Patients are offered a review 6 months post-discharge

Goal Setting

GUIDELINES

Each patient should be given opportunity to participate in process of goal setting

WHAT WE DO

Person specific goals

Personal health plan (PHP)

MDT Goal setting meetings

(1) National clinical guidelines for stroke, 2016

Beech Ward Inpatient Stroke/Neuro rehabilitation

The National Stroke Strategy (DH 2007) ‘High Quality Specialist Rehabilitation’ states

people who have had strokes should have access to high-quality rehabilitation and with

their carer, receive support from stroke-skilled services as soon as possible after they

have a stroke. People with disability after stroke should receive rehabilitation in a

dedicated stroke inpatient unit and subsequently from a specialist stroke team within the

community (NICE 2013)

• Enable the stroke Service User to reach, and maintain, optimum potential in their

physical, psychological and social functional abilities whilst ensuring integral

family/carer inclusion and support to the rehabilitation process as appropriate;

• Maximise independence of the stroke Service User and their family/carer to enable

full participation within the community and in paid, supported and voluntary work

where appropriate;

• Reduce avoidable disability, dependency on social care and the need for the stroke

Service User to enter prematurely into long term care;

• Support patients with long term neuro conditions with rehabilitation during a period of

escalation in their symptoms that requires admission to a community bed.

About us

Close working links with: Stroke Association Social Care Community stroke groups Surgical Appliances Community therapy teams Vocational rehabilitation services

Patient

Speech and Language Therapy

Clinical Psychology

Occupational Therapy

Medical

Nursing

Physiotherapy

ESD

• ESD services have been developed with the aim of accelerating hospital discharge and providing intensive rehabilitation at home at an equivalent intensity to that provided in an acute stroke unit (Cobley et al. 2013)

EPUT West Essex ESD • Newly diagnosed stroke (haemorrhagic and ischaemic) • West Essex GP • Age 18 or over • Medically stable • Able to actively engage in rehabilitation programme • Able to transfer with assistance of 1

• When supporting acute hospitals with discharge into ESD we

consider: • Support networks • Home environment • Identified goals • Care needs

About ESD

Clinical Psychology

Occupational Therapy

Speech & Language Therapy

Physiotherapy

Case Study

32 year old female. Lives with husband and 2 daughters: 3 years old and 6 months old. Works as a book keeper but currently on maternity leave. Sustained right anterior cerebral artery stroke Presentation: Left sided weakness Left sided sensory loss Increased tone/spasticity left arm and leg Transferring only from bed to chair with assistance of 2 nurses - not Mobile Therapy input: Physiotherapy – Strengthening and facilitation of normal movement patterns, gait re-education, provision of orthotic to assist left foot/ankle when walking, provision of home exercise programme to complete independently and with support of family to increase function, referral to Spasticity Management Clinic Occupational Therapy – Cognitive assessment – no problems identified, therapy to improve upper limb function, therapy to increase independence with washing/dressing, practice of activities of daily living particularly related to caring for baby, fatigue management – pacing activities to enhance rehabilitation gains. Clinical Psychology – Assistance in managing low mood and frustration.

Case study continued

Patient Goals:

To walk indoors with the assistance of 1 person

to walk on my own with a stick in my house

To negotiate a flight of stairs at home with the help of 1 person

to negotiate the stairs at home on my own.

To open the front door to therapists on my own using a stick to walk

To change my baby’s nappy standing up on my own

To stand and prepare my baby’s bottles at the kitchen counter on my own.

To return to driving

Pathway/Discharge:

Admitted to acute 01.07 referred to Beech Ward 12.07 admitted to

Beech Ward 14.07 discharged with ESD 26.07 and continued with ESD to

complete 6 weeks of rehabilitation Onward referral to Papworth

Community Neuro Therapy Team.

Feedback from patients Matthew, 54 year old who ran his own IT company. He was admitted to hospital with

slurred speech and a left facial droop. CT head found a right striato-capsular infarct

Therapy input

SLT- dysarthria

PT- balance, upper limb, outdoor mobility

OT- cognition, upper limb

Unfortunately I suffered a stroke in early December and was admitted and treated in Charing Cross Hospital, Hammersmith. Due to the swift actions of the medical teams I was discharged after a couple of days into the care of SEPT and early discharge team to continue my recovery at home. Despite being across NHS authorities the information the ESD at Epping had on me the 1st visit was accurate and complete, allowing them to devise a recovery plan specifically for me. Both the Occupational and Physiotherapists team were superb throughout and encouraged me to undertake tasks designed to aid my recovery. Even in some of my difficult times they were there to help me overcome issues I faced. Their knowledge and guidance were 1st class and I looked forward to their visits and the exercises designed to make recovery quicker and easier. In summary without their knowledge and attention to detail I believe my recovery period would have been prolonged and with that I have huge admiration to their dedication of recovery patients such as myself. Without the caring nature of this team I’m sure a lot of patients wouldn’t make full recoveries whether in the short or long term.

New Initiatives

- Exploring the potential and opportunities to utilise the hydrotherapy pool at

St Margaret’s Hospital as an additional treatment option

- Use of outside areas and horticultural therapy by establishing a gardening

group

- Establishment of a mindfulness based therapy group for patients and carers

and relaxation groups

- Provision of the ward based cake and chat group

- Links with Action for Carers

- Every patient completes a satisfaction questionnaire at discharge

- The opportunity for patients to gain face to face interventions over the

weekend in ESD as well as during the week

- Stroke education group in liaison with Stroke Association

- Software to support therapy e.g. therapy applications on iPad

- Improving links with community stroke groups/ clubs

References

• Cobley, C., Fisher, R., Chouliara, N., Kerr, M., Walker, M. (2013). ‘A

qualitative study exploring patients’ and carers’ experiences of Early

Supported Discharge services after stroke’. Clinical Rehabilitation, 27 vol. 8,

pg. 674.

• Department of Health (2007). ‘National Stroke Strategy’

• National Institute for Health and Care Excellence, 2013. Costing report:

Stroke Rehabilitation.

• Royal College of Physicians, (2016). National Clinical Guidelines for Stroke

(fifth edition).

• Stroke Association, (2016). State of the Nation, stroke statistics.

• Stroke Association, (2017). State of the Nation, stroke statistics.