London Stroke Care Tony Rudd London Stroke Clinical Director The - - PowerPoint PPT Presentation

▶
london stroke care
SMART_READER_LITE
LIVE PREVIEW

London Stroke Care Tony Rudd London Stroke Clinical Director The - - PowerPoint PPT Presentation

Jun 25, 2023 346 likes •607 views

London Stroke Care Tony Rudd London Stroke Clinical Director The Case for Changing Stroke Care Above Target London Stroke Units Sentinel Audit Comparison 2004 and 2006 Below Target Target 91 90 89 88 88 86 84 83 90 80 80 77 76 76

slide-1
SLIDE 1

London Stroke Care

Tony Rudd London Stroke Clinical Director

slide-2
SLIDE 2

The Case for Changing Stroke Care

25 25 24 21 21 19 19 14 12 12 9 9 8 6 6 5 4 4 2 1

  • 1
  • 3
  • 3
  • 4
  • 4
  • 5
  • 7
  • 9
  • 12

91 90 89 88 88 86 84 83 80 80 77 76 76 75 72 71 71 71 70 70 68 68 66 65 65 62 61 60 55 51 49 45

90

Target Below Target

Above Target

London Stroke Providers against Sentinel Audit 12 key indicators 2006 Change in London Stroke Providers against Sentinel Audit 12 key indicators 2006 vs 2004 scores

London Stroke Units Sentinel Audit Comparison 2004 and 2006

slide-3
SLIDE 3

Decision to reorganise care

  • National Stroke Strategy
  • National Stroke Audit
  • Darzi review of medical care in London
  • Lobbying from London Stroke community
  • Ruth Carnall and SHA choosing stroke and

major trauma

  • Clear case for change
  • Good evidence as to what should be done
  • A clinical community wanting to see change
slide-4
SLIDE 4

The scale of the problem of stroke in London

  • Second biggest killer and most common cause of disability
  • Population >8 million
  • 11,500 strokes a year in London – 2,000 deaths
slide-5
SLIDE 5

Process for implementing change

  • Agreement from all London PCTs and

formation of JCPCT to support the process and to invest additional £20m/annum

  • Project board with representation from

commissioners, clinicians, managers, patients, voluntary groups

  • Agreement that additional funding paid as

enhanced tariff if quality standards met

  • Split care into hyperacute, acute, transient

ischaemic attack and community care

slide-6
SLIDE 6

Process for implementing change

  • Setting the standards based on evidence
  • Development of range of models –

consultation with professionals

  • Bidding process requiring close collaboration

between managers and clinicians from each provider

  • External review of applications
slide-7
SLIDE 7

London Stroke Strategy

  • Centralise hyperacute (hyperacute stroke units

HASU) care into 8 units situated to provide easy access to the whole population (no more than 30 minutes by ambulance)

  • All acute stroke patients admitted to HASU. This is

not just a thrombolysis service

  • Further 20 stroke units for on going rehabilitation
  • Improve community care and longer term

rehabilitation

  • Neurovascular services for patients with TIA
slide-8
SLIDE 8

30-minute blue light ambulance travel time from the hyper-acute stroke units

The green area shows the areas that are within 30 minutes travel time (under ambulance blue light conditions) of a proposed HASU

slide-9
SLIDE 9

London SHA Stroke Strategy

  • London Clinical Director and Stroke and cardiac

networks working to support units needing to improve quality

  • Development of local leaders
  • Clinical Advisory Group
  • Educational programmes developed (>400 additional

nurses and 100 therapists recruited to work in stroke)

  • Regular inspections to ensure quality of care

maintained

  • Obligation to submit continuous audit
slide-10
SLIDE 10

Where are we now?

  • All units open
  • All achieved high level standards
  • Subject to regular inspection and requirement

to submit data

  • Close collaboration between stroke units and

HASUs

slide-11
SLIDE 11

Processes of Care

0% 2% 4% 6% 8% 10% 12% 14% 16%

3.5% 10% 12%

Feb-July 2009 Aim Feb-July 2010

Thrombolysis rates

14%

Jan-March 2011

slide-12
SLIDE 12

Processes of Care

2 4 6 8 10 12 14 16 18 20 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug 2009/10 2010/11

Average length of stay

slide-13
SLIDE 13

Department of Applied Health Research Department of Applied Health Research

Doing improvement science: a study

  • f major system reconfiguration in

England

Naomi Fulop Professor of Health Care Organisation and Management

IS London Launch, 26th June 2012

slide-14
SLIDE 14

Department of Applied Health Research

A study of the effectiveness, acceptability & processes of implementation of two models of stroke care

  • London
  • Prof Naomi Fulop, Prof Tony Rudd, Prof Charles Wolfe,

Dr Christopher McKevitt, Prof Steve Morris, Mr Nanik Pursani, Dr Angus Ramsay

  • Manchester
  • Dr Pippa Tyrrell, Prof Ruth Boaden

1st September 2011 – 31st August 2014 NIHR Health Services & Delivery Research Programme

slide-15
SLIDE 15

Department of Applied Health Research

slide-16
SLIDE 16

Department of Applied Health Research

Conceptual framework

  • Our conceptual framework combines
  • Traditional approach: ‘what works, and at what cost?’
  • With ‘how?’ and ‘why’?
  • ‘Diffusion of innovations’ (Greenhalgh, 2004): how the

nature of the innovation, the approach to implementation, and context interact

  • ‘Social matrix’ (Webster, 2007): how the nature of

relationships between key stakeholders influences implementation

slide-17
SLIDE 17

Department of Applied Health Research

What works and at what cost?

  • ‘Before’ v ‘after’ and comparison between 2

models

  • Processes: e.g. national & local audits covering

provision of care (e.g. SINAP and SLSR)

  • Outcomes: e.g. mortality, QALYs gained
  • Costs: e.g. staffing, treatments, length of stay,

implementation costs

  • Model changes in terms of short term (1st 3

months after stroke) and longer (1 year)

slide-18
SLIDE 18

Department of Applied Health Research

Previous evaluation of new London stroke model

  • Compared costs & outcomes ‘before’ (July 2007-July 2008)
  • vs. ‘after’ (July 2010-June 2011) introduction of new London

stroke model

  • Calculated costs and benefits at 90 days using data from a

range of sources (SINAP, LMDS, SLSR, audit data)

  • Headline results:

– Increases in ambulance times (emergency call to arrival at hospital): ‘before’ 50 minutes, ‘after’ 62 minutes – 12% fewer deaths at 90 days after vs. before (adjusted for national trends outside London)

slide-19
SLIDE 19

Department of Applied Health Research

London Stroke Survival vs Rest of England

Hazard ratio for survival in London 0.72 95%CI 0.67-0.77 p<0.001

19

slide-20
SLIDE 20

Department of Applied Health Research

Previous evaluation of new London stroke model

Headline results (cont.) – Lower costs per patient at 90 days: ‘before’ £14,117, ‘after’ £13,306

  • New model: reduced mortality & represents good value for money

(Morris et al, 2011)

  • But:

– Limited follow-up in ‘After’ period – Did not include costs of setting up the new model e.g. NHS and public consultations

  • These limitations will be addressed in current study
slide-21
SLIDE 21

Department of Applied Health Research

Evaluating the process of implementation

Qualitative analysis of:

  • key processes & factors influencing the

implementation and sustainability (e.g. role of

contextual factors, governance, consultation)

  • views of impact/experience

Through use of:

  • stakeholder interviews (e.g. ‘winners’ & ‘losers’) x2
  • interviews with patients/carers
  • documentary analysis
  • observations of meetings
slide-22
SLIDE 22

Department of Applied Health Research

Emerging findings: a taster

Approach to process of reconfiguration differed

e.g. how resistance was managed Greater Manchester:

“the minute it felt like unanimity was being compromised on that clinical discussion on the 24 versus the 4 hour pathway, I think we were always going to be minded then to tilt towards holding unanimity and taking what might be a small step, but still the right step.” (Commissioner)

London:

“Stroke was their [clinician representatives’] life, and they wanted to get the best for stroke […] but actually what got it through was being straight with them, trying to explain it to them, but in the end holding the line.”

(Commissioner and Project Board Member)

slide-23
SLIDE 23

Department of Applied Health Research

Feedback/outputs

Formative evaluation

  • Regular feedback to local services/commissioners

e.g. through stroke networks, to enable learning

  • Lay versions for patients & the public
  • Feedback to wider NHS – lessons for

reconfigurations of stroke services and other service reconfigurations

  • Usual academic dissemination routes: peer

reviewed journals, conferences

slide-24
SLIDE 24

Department of Applied Health Research

Challenges in doing improvement science

  • Partnerships between NHS and academic

researchers – different drivers, different expectations Some issues arising:

  • timing of findings
  • process for dealing with uncomfortable findings
  • need to be flexible to respond to e.g.
  • rganisational turbulence
slide-25
SLIDE 25

Department of Applied Health Research Department of Applied Health Research

Win-win partnerships for improvement science