London-based physios and other healthcare professionals working in stroke care have changed their practice in a radical way – thanks to the implementation of a new strategy.
Introduced in February 2010, the London Stroke Strategy was designed to tackle the entire stroke pathway.
As well as covering prevention, it also deals with acute care and hospital services, rehabilitation and life after stroke.
Sara Gawned is a band 7 specialist stroke physiotherapist in one of the capital’s eight dedicated hyper-acute stroke units (HASUs).
Based at St George’s Hospital, south London, she says the strategy has led to major changes for physios.
Stroke patients are ‘blue lighted’ to St George’s, where they are assessed and given a scan within one hour of arrival, and then thrombolysis (clot-busting drugs), if indicated, Ms Gawned explains.
Once patients are through accident and emergency they go straight to the multidisciplinary HASU team.
‘As physios we work closely with the whole team – but particularly with the occupational therapists and speech and language therapists – in the 72-hour period that patients are with us.’
‘The key thing from a physiotherapy perspective is the timely assessment of every patient after coming into the HASU and making sure they have the right treatment and advice.
Everyone now appreciates that early therapy assessments are key and that as physiotherapists we play an important part in the hyper-acute care of stroke patients,’ Ms Gawned says.
‘Then, once patients are stable, we aim to get them up and mobile within 24 hours.’
The next task for physios is helping decide and advise where the patient needs to go next.
Most patients who have had a small stroke or transient ischaemic attack (TIA) go home, and early supported discharge teams support their rehabilitation at home, if needed.
If it’s not safe for them to go home, patients are transferred to their local stroke unit.
St George’s also has an acute stroke unit, and the whole physio team works there too.
‘In the HASU the turnover of patients is very quick and throughput is very high. It can be quite demanding,’ say Ms Gawned.
‘It works well for us having a HASU and stroke unit because we get a mix in terms of work pattern and complete both hyper-acute assessment and rehabilitation.
But it’s also nice for the patients who stay here, because they have the same physio to continue their therapy and a good relationship can be built, which is so important.’
Growing interest in research evidence
Gary Owufu-Gyamfi is a band 7 specialist stroke physiotherapist at the stroke unit at Queen’s Hospital in east London. He says the strategy has lead to beneficial spin-offs in physiotherapy practice.
‘As physiotherapists we have found we are more acutely aware of standards and guidelines than before. Previously, you would have to have a special interest to be aware of the national guidance, but now we all follow the national stroke guidelines and we all work towards the same aims,’ he says.
Mr Owufu-Gyamfi says the stroke multidisciplinary team meetings are now held every week, and are better attended than previously.
Staff look at the management of patients, goal setting and the steps being taken to achieve them, and discharge planning.
‘Representatives of all the specialisms attend, including clinical staff and nurses, and everyone gets involved and contributes.’
With better funding and more staff and resources, research is now also a growing part of the physio’s role.
‘By working together on research projects we are all working more cohesively than before. And we are using the research to directly inform practice,’ says Mr Owufu-Gyamfi.
Having a large group of stroke patients all in the same place is key. ‘For example, we have a band 6 who is experimenting with using a robot arm with patients – a big focus of our particular department is upper-arm function.
‘Another group of band 5s and 6s is looking at group rehabilitation versus one-to-one care.
And we can see the cause and effect on these studies instantly, because we are working with the same group of patients day in, day out.
And from a patient perspective, our increased knowledge base means they get the best possible treatment at the best possible time.’
He adds: ‘The introduction of the strategy has also improved awareness of stroke among patients and family members.
This means they are much more involved in the treatment and rehabilitation process and understand the kind of improvements it’s possible for the patient to make.’
Staffing levels have increased
Kerry Thompson is stroke services coordinator at the Royal Free Hospital in north London – home of a particularly successful stroke unit.
Asked what she feels has been the stand out improvement under the London Stroke Strategy, she says: ‘Studies show that mortality and morbidity rates have dropped since the introduction of the strategy, and that’s what I’m most pleased about.
‘So more people are surviving stroke and less have disabilities, because they are getting into the right setting and are being seen by the right specialists on day one.’
Ms Thompson outlines the physio’s role.
‘The new model has specific guidance on how quickly physiotherapists have to get to patients at both HASUs and stroke units.
Currently the standard is that 75 per cent of patients are seen by therapists within 72 hours of admission, so it’s quite a lot of pressure, especially if patients come in over the weekend, because we have five-day working for physios.’
But staffing levels have increased to cope with these demands.
‘We have stringent rules in terms of staff per patient or stroke bed, so staffing levels have increased across all therapies, and that’s actually been really useful in the current economic climate, with staffing levels being protected to maintain the new service standards in stroke care,’ says Ms Thompson.
The reason for increased staff is because the more patients are coming along the pathway, and the physios now have more roles and responsibilities as stroke unit team members than before.
‘Key roles for physios involve linking with patients and family members and making sure the process and outcomes for both patients and families is as positive as possible, and that they all understand the pathway,’ says Ms Thompson.
‘Physios in stroke units have also had to learn to link with HASU colleagues so they can pick up and run with patients once they have been assessed at the HASU and passed along to us.’
Ms Thompson accepts patients onto the unit, guiding them through the pathway and making sure the multidisciplinary team knows what to expect when patients arrive. She also has to ensure patients are discharged appropriately.
‘We work with social service and community colleagues and ensure the “outflow” is working well from acute care.
’She describes it as having one foot in the hospital and one in the community – knowing exactly what is available in rehabilitation services in each area.
And she says the five cardiovascular and stroke networks in London, which oversee stroke services in the capital, are also a key part of this.
Listening to patients’ voices
Before the London Stroke Strategy was implemented, separate networks existed for cardiac care. But under the new strategy it was decided that stroke and cardiac networks should join.
The objective of networks is to bring together clinicians, other professionals and managers from all constituent organisations. They also work with patients to listen to their views and work to implement them into the pathway.
As a long-standing director of the South London Cardiovascular and Stroke Network, Lucy Grothier was a member of one of the steering groups that helped develop the strategy.
‘There were a lot of people involved,’ she says. ‘The entire London healthcare system played its part and that’s why it worked so well. Patients, health professionals, clinical staff all collaborated.’
‘The networks were then responsible for implementatingthe strategy, including developing the quality standards,’ she says.
‘All organisations involved are being assessed, it’s an on-going process.’
‘It’s been a lot of hard work for a lot of people, but it’s made such a different to patients.
Each hospital currently does is own patient experience monitoring, but we know that total length of stay is down from over 17 days in 2009 to 6.4 days in the latest quarter.
And 90 per cent of patients in London now spend 90 per cent of their time in hospital in a stroke unit.’
‘The key element for me is the specialisation of care which patients receive, according to their needs, and in the right time frame.
When patients ring 999 they get into hospital within 20 minutes. It is reportedly the best stroke service in the world.’
And she adds: ‘We really value physiotherapy as a key part of the multidisciplinary teams which we work with. It’s an essential specialism for these stroke centres so patients can restore their function.
It’s crucial that physio starts as soon they are admitted.’
Concerns about quality of after-care
The Stroke Association is an enthusiastic advocate of the new approach. London Health asked Chris Clark, its UK director of life after stroke services, to take part in the project from the outset.
‘We recognised, even before the publication of the National Stroke Strategy, that London presented a real problem in terms of stroke care,’ he says.‘Services weren’t targeting where people were actually suffering from stroke.
So there were excellent services in the centre of London, but relatively little on the outskirts where most of the population are based.’
‘I was invited on to the steering board for the project, with several NHS representatives, and throughout the whole process of putting together the strategy there was a meeting of minds on what was needed to improve stroke care in London.’
Crucially, he says, patient representatives were involved at every stage. ‘It really was a model of patient and public involvement.’
However, Mr Clark insists there is still work to be done. ‘London is now extremely successful in addressing the emergency response to stroke and urgent care and rehabilitation, but the further you go from the blue flashing light, the less intense the strategy,’ he warns.
‘The feedback we’ve had from patients has been largely very positive, but we continue to hear stories that patients are not receiving the after-care they need once they leave the acute stroke units. And many say early supported discharge is still not being offered.’ fl
See the CSP’s Physiotherapy works: Stroke publication at: www.csp.org.uk/physiotherapyworks
London Stroke Strategy
Hyper acute stroke units offer the immediate response to a stroke. The patient is stabilised and receives specialist assessment on arrival, and a computed tomography (CT) scan and thrombolysis (if appropriate) within 30 minutes. Length of stay is up to 72 hours.
Stroke units provide multi-therapy rehabilitation, including physiotherapy, and ongoing medical supervision and TIA assessment at a local hospital. Patients stay until they are well enough for discharge from an acute inpatient setting.
TIA services provide a quick diagnostic assessment and access to a specialist within 24 hours for high-risk patients, or within seven days for low-risk patients.
In London, stroke is the second biggest killer and the most common cause of disability. More than 11,000 people with stroke are admitted to London hospitals each year – about one every hour.
There has been a nationwide drive to improve stroke care and outcomes for patients following the launch of the Department of Health’s National Stroke Strategy in 2007, which set out plans for the development of stroke services in England over 10 years.
Following this came the London Stroke Strategy, called for the introduction of eight dedicated HASUs, manned by specialist teams with rapid access to high-quality equipment 24 hours a day, seven days a week.
Patients would stay in HASU a maximum of 72 hours, and dedicated stroke units were then ear-marked to continue specialist treatment and intensive rehabilitation.
People having a mini-stroke or TIA would also now receive the highest-quality care, always being assessed by experts within a dedicated timeframe.
There are eight Hyper acute stroke units in the London Stroke Strategy area
- Charing Cross Hospital Fulham
- The Royal London Hospital Whitechapel
- King’s College Hospital Denmark Hill
- St George’s Hospital Tooting
- Northwick Park Hospital, Harrow
- Princess Royal University Hospital, Kent
- Queen’s Hospital, Romford
- University College London Hospital
Data on 5,227 patients in London from April to September 2011
- 4,235 (81%) patients arrived in hospital by ambulance
- 135 (2.5%) in-hospital strokes
- 38% received brain imaging within 30 mins of arriving
- 95% received brain imaging within 24 hours
- 74% were admitted to a HASU within four hours of arriving at hospital
- 14% were thrombolysed
Median ‘door to needle time’ was
- 46 minutes
- 93% were ‘swallow screened’ within 24 hours
- 86% of patients were assessed by a physiotherapist within 72 hours.
(Taken from The London Stroke Strategy: Impact on quality of hyperacute care, by Hilary Walker and Tony Rudd on behalf of the London Clinical Advisory Group (November, 2011)
Key strands of the London stroke strategy
- An additional £21 million a year provided for acute stroke care, but only paid if hospitals deliver the required quality
- A new system of HASU care organised into eight units, sited so no one lives more than 30 minutes away by ambulance
- All acute stroke patients admitted to HASU in the first instance
- 24 stroke units in place for ongoing rehabilitation
- Improvements made to community care and longer- term rehabilitation
- Neurovascular services available for patients with TIA.