Supporting NHS Wales to Deliver World Class Healthcare AWSSIC Cardiff and Vale NHS Trust Storyboard...

Supporting NHS Wales to Deliver World Class Healthcare

AWSSICAWSSICCardiff and Vale NHS Trust Cardiff and Vale NHS Trust

StoryboardStoryboard

Learning Session TwoLearning Session Two

2525thth March 2009 March 2009

All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative

Thankyou for asking me to presentThankyou for asking me to present

• Newcomer• On sabbatical (in Llandrindod ?!)• Hope to contribute in the future..


Cardiff and Vale NHS Trust

Is one of the largest NHS Trusts in

the UK. It provides day-to-day health

services to a population of around 500,000 people living in Cardiff and the Vale

In 2008/2009 the Trust's total income is £634 million and we

employ approximately 14,000 staff


A driver for changeA driver for change

Death, dependency and good outcome in randomized trials of rt-PA given within

3 hours of acute ischaemic stroke

17.3

38.4

44.3

18.4

51.4

30.2

0

20

40

60

80

100

Thrombolysis Control

Alive andindependent

Alive butdependent

Dead

Differences/1000: 141 extra alive and independent (P<0.01)130 fewer dependent survivors (P<0.01)12 fewer deaths (NS)

Cochrane Library 2003

(3 trials, n=869)NNT 10


Will tPA redefine acute medicine and acute Will tPA redefine acute medicine and acute neurology?neurology?

• An overload of dilemma• An evolving story

• Patients haven’t worked out what they can and can’t do

• Immature motor signs

• Motor signs: immature, mature, mature with musculoskeletal complications

• Sensory signs often at their best• Visual fields and eye movements are useful• Cognitive deficits

• Can be difficult to get the doctor and patient to focus


Will tPA redefine acute neurology?Will tPA redefine acute neurology?

• A normal (or normalish) CT scan

• Neuroradiologist needs to call the shots• A dangerous but effective treatment, often for a

syndromic diagnosis

• Stroke seems too crude a diagnosis to make • A health service not used to dealing with stroke as an

emergency (3-6 hours)

• No pain or bleeding, no spots or screaming• Lack of neurology experience amongst junior general

medics


How could we start the thrombolysis ball How could we start the thrombolysis ball rolling?rolling?

• Start at the front door• How are people assessed?


MEDICAL ADMISSIONS : MULTIPROFESSIONAL RECORD

DATE: ___________________ TIME: _____________ CONSULTANT: ________________________________

PRESENTING COMPLAINT S

O

A

P

PAIN SCORE 0 1 2 3 4 5 6 7 8 9 10

TRIAGE NURSE _____________ TRIAGE TIME _____________ TRIAGE CODE 1 2 3 4 5

NEXT OF KIN:

1. Name: 2. Name: Address: Address: Contact No: Contact No:

Relationship to Patient: Relationship to Patient:

Aware of Admission YES NO Aware of Admission YES NO

Past Medical History Current Medication

Allergies

CARDIFF AND VALE NHS TRUST

YMDDIRIEDOLAETH GIG CAERDYDD A’R FRO

OBSERVATIONS BP ___________________ PULSE ___________________ O² SATS ___________________ O² GIVEN __________ % GIVEN RESP RATE ___________________ TEMP ___________________ BM ___________________ PEAK FLOW ___________________ GCS A V P U VISUAL ACUITY ___________________ CAP REFIL TIME ___________________ URINE ___________________ MSU SENT Yes / No PREG TEST Yes / No: Result:

ADDRESSOGRAPH

Or

NAME:

ADDRESS:

DATE OF BIRTH/AGE:

TELEPHONE No: MARITAL STATUS: RELIGION: OCCUPATION:

GP NAME: ADDRESS: TELEPHONE No:

Admissions proforma


ABDOMEN

PR:

NERVOUS SYSTEM AND HIGHER MENTAL FUNCTIONS

OTHER RELEVANT FINDINGS (Oral, Hands, Breast etc)

Admissions proforma 2005


Remember, if it is an acute stroke (< 6 hours of symptoms) they may be eligible for thrombolysis

NERVOUS SYSTEM AND HIGHER MENTAL FUNCTIONSConscious level Eye opening Motor response Verbal responseMini-mental test scoreCoverings of the nervous system Head Neck SpinePostureGait Romberg’s testCranial Nerve II Acuity II, III Visual Fields Pupil responses Optic fundus III, IV, VI V Sensory Eye movements Motor VII VIII X Palatal movement XI XII Cough Swallowing PhonationLimbs Inspection Tone Strength Coordination Reflexes Sensation

Admissions proforma 2007


Why are people not being randomised into trials of thrombolysisWhy are people not being randomised into trials of thrombolysis??

• IST 3 trial• External validation

• Your centre is ok to be involved

• Audit done by someone else

• Plugged in to a research mentality

• Do the ethics application

• Sort out paperwork• Organise visit by IST3

coordinator• Satisfy research

standards in UHW• Start!


Since October 2007; 9-5, Mon-Friday.Since October 2007; 9-5, Mon-Friday.

• 3 patients randomised into the trial

• 4 patients treated on licence

• Need to extend to out of hours

• Need to involve more people on the rota

• Needs to become part of the dumpety-dump of the acute medical take

• Education, education, education...


Aspirin administration as identified in a previous audit

• All stroke patients to receive aspirin in a timely fashion unless clinically contra-indicated

• If patient was unable to swallow safely there was no consistency in considering PR or NG administration


Where Where

• Acute admission areas• EU and MAU on one hospital site


Aspirin in the first 24 hoursAspirin in the first 24 hours

• Pharmacist agreed to collect data prospectively

• Over two weeks five patients on the acute medical unit had aspirin prescribed on admission

• None had it written as po/pr/ng

• How could we raise the aspirin profile?


• Dear All,• • The recent RCP and NICE guidelines recommend that Aspirin

300mg daily be given to all patients presenting with acute stroke in whom intracerebral haemorrhage has been excluded by brain imaging. This should be continued for two weeks.

• • This dose of Aspirin can be given by mouth, through an NG

tube, or rectally.• • To ensure that Aspirin is given to this group of patients,

many of whom have a swallowing problem, please prescribe Aspirin 300mgs daily PO/NG/PR.

• • Thankyou,• Tom Hughes• Hamsaraj Shetty


We fancied a logo!We fancied a logo!


• Dear All,• • The recent RCP and NICE guidelines recommend that Aspirin

300mg daily be given to all patients presenting with acute stroke in whom intracerebral haemorrhage has been excluded by brain imaging. This should be continued for two weeks.

• • This dose of Aspirin can be given by mouth, through an NG

tube, or rectally.• • To ensure that Aspirin is given to this group of patients,

many of whom have a swallowing problem, please prescribe Aspirin 300mgs daily PO/NG/PR.

• • Thankyou,• Tom Hughes• Hamsaraj Shetty

Reliable comparable (before and

after) data not available yet.


Lessons learntLessons learnt

• Meaningful data are difficult to obtain• It is very time consuming• Someone needs to have dedicated time to

do it during the working week and it has to be part of the routine service

• It is possible to introduce change, particularly if you can become the change


PhysiotherapyPhysiotherapy


Physiological monitoringPhysiological monitoring


OT assessmentOT assessment


AspirinAspirin


CT within 24 hoursCT within 24 hours


Aspirin within 24 hoursAspirin within 24 hours


Manual handling assessmentManual handling assessment

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