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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
Slide 2
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..
Slide 3
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
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
Slide 4
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
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
Slide 5
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
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
Slide 6
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
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
Slide 7
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
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?
Slide 8
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
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
Slide 9
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
ABDOMEN
PR:
NERVOUS SYSTEM AND HIGHER MENTAL FUNCTIONS
OTHER RELEVANT FINDINGS (Oral, Hands, Breast etc)
Admissions proforma 2005
Slide 10
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
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
Slide 11
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
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!
Slide 12
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
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...
Slide 13
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
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
Slide 14
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Where Where
• Acute admission areas• EU and MAU on one hospital site
Slide 15
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
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?
Slide 16
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
• 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
Slide 17
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
We fancied a logo!We fancied a logo!
Slide 18
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
• 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.
Slide 19
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
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
Slide 20
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
PhysiotherapyPhysiotherapy
Slide 21
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Physiological monitoringPhysiological monitoring
Slide 22
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
OT assessmentOT assessment
Slide 23
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
AspirinAspirin
Slide 24
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
CT within 24 hoursCT within 24 hours
Slide 25
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Aspirin within 24 hoursAspirin within 24 hours
Slide 26
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Manual handling assessmentManual handling assessment