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How to implement evidence-based stroke care

Alec Fraser and colleagues discuss four challenges that were overcome in successfully implementing better stroke services.

The National Stroke Strategy published in 2007 advocated more specialised acute and hyper acute care for stroke patients. In the same year NHS London published a Framework for Action which included a commitment to deliver these changes for Londoners.

Five years on and much has been achieved. While London’s collective figures in the RCP Sentinel Audit of stroke services in England were often below the national average – the opposite is now the case. 75 per cent of London stroke patients were directly admitted to a stroke unit while the national figure was 39 per cent. 75 per cent of London hyper acute stroke units achieved all seven standards for quality acute stroke care; the national figure was 7 per cent (based on 2010 Sentinel Audit figures).

Equally impressive are the increased thrombolysis rates. In early 2009, 3.5 per cent of London stroke patients received thrombolysis, by the end of 2010 that figure had risen to 12 per cent.

London now has eight hyper acute stroke units treating all stroke patients in the first 72 hours after a stroke, complemented by 21 stroke units to which patients are admitted following the completion of the HASU element of their care and prior to supported discharge to community care services. HASU and SU care offers specialised medical, nursing care including an expanded therapies team.

This step-change in service delivery has required leadership and coordination from the London stroke and cardiac networks and central NHS London teams such as the Pan-London Stroke Clinical Advisory Group.

Here we focus on transformational change at the hospital unit level. We interviewed clinical and managerial staff involved in the redesign of local stroke services at Northwick Park Hospital in North London as part of a wider research project focused on the implementation of evidence based stroke care.

Northwick Park Hospital is part of the North West London Hospitals Trust. It serves a population of over 500,000. As part of a regional reconfiguration, the hospital’s stroke unit has been upgraded to a 50 bed combined HASU and SU over the past two years and now features a radically expanded MDT.

A key characteristic which distinguishes Northwick Park Hospital from other London centres which won bids for HASU status is that it was not a neuro-specialist centre and therefore had more ground to make up in terms of medical and radiological resources as part of the London plan.

Six key factors were highlighted as influential in successfully implementing evidence based change into stroke care:

  • Leadership & collaboration
  • Role of SHA, PCT and network
  • Increased funding and staffing
  • Data – A&F
  • Ownership, education and MDT working
  • Excitement

However, four significant challenges had to be managed and overcome in order to deliver successful implementation:

1. Speed of change

The downside of the buzz created by winning the contract to supply one of London’s 8 combined HASU and SUs back in the summer of 2009 was that there was relatively little time to get everything in place by summer 2010.

Working to an externally derived timeframe meant there were teething problems such as the final stages of building work being unfinished when the new HASU was due to open and staff having to be exceptionally flexible and conscientious in the first few weeks following the go-live date. There were three inter-connected areas of particular concern, which are discussed in turn, and were exacerbated by the speed of change.

2. Incorporation of new staff

Across all clinical professions, there has been a very significant increase in staffing numbers, and amongst some existing staff who have overseen the process, job descriptions have changed to meet the new realities of delivering HASU and SU care for a vastly expanded patient group. Thus there has been a rapid and comprehensive shift in organisational dynamics. Such a shift has to be well managed if patient care is not to suffer.

3. Challenging local organisational weaknesses

A significant challenge at Northwick Park and indeed encountered by other London hospitals involved in the reconfiguration has been achieving nursing excellence for stroke patients whilst incorporating a very large increase in nursing numbers over a very short period of time.

Compounding this already difficult issue are the facts that HASU and modern SU nursing competencies are different and more demanding than those of traditional stroke care nursing, the traditional nursing culture at the hospital vis a vis care of the elderly had been poor, and there had been  a lack of suitably qualified and experienced nurses applying for such posts.

The trust tackled these issues by appointing a dynamic head of nursing and stroke matron to lead reform of nursing across the care of elderly speciality, investing in increased nursing education and qualifications for staff and finally, recruitment from abroad.

4. Traditional perceptions of stroke

Looking across London and thinking about the reconfiguration of stroke service as a whole, it is true to say that despite the excitement generated around the changes promised by the new London model of stroke care delivery, traditional, negative views around the nature of stroke and  possibilities for rehabilitation have not been entirely eradicated yet. This is true both within the stroke unit and outside among the wider public.

Some staff need to be pushed harder towards improvements than others and improvement and subsequent normalisation of evidence based care is an ongoing project and there are still great strides to be made – in particular in primary and community care provision both pre- and post-stroke across the city.

The impressive changes delivered across London and demonstrated in detail at Northwick Park highlight the importance of collaborative clinical and strategic leadership between healthcare professionals and managers.

Stringent, evidence based policies and guidelines devised consensually by a wide range of stakeholders at SHA, PCT, network and hospital unit level are closely monitored and performance is incentivised by linked tariff payments in the reconfigured London model.

In any healthcare system, the balance between the centre and the point of delivery is a delicate one, however, it is the commitment and leadership of staff and the quality of their interactions at both the centre and the bedside which is proving so successful in London’s reconfigured stroke services.

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