Cardiff and Vale University Health Board Stroke Team at Cardiff and Vale University Health Board

Clinical challenge
To improve performance against the SSNAP care performance indicators, particularly the 4hr direct admit to an acute stroke unit.

Solution
The Cardiff and Vale University Health Board (CAVUHB) introduced the Stroke Service Transformation Programme (SSTP) in January 2018. A number of key actions were introduced as part of the SSTP that contributed to the overall improvement in performance and have continued to date. These include:

1. Daily Stroke Huddle; morning conference call between CAVUHB hospital sites to discuss stroke demand and capacity, actions to create capacity and review of breaches from the previous 24 hours.
2. Completion of RCAs for each 4hr breach. Discussion and action taken at daily Stroke Huddle to understand reasons behind delays and identify themes in order to implement corrective measures. 
3. Stroke Escalation Card including aim to create 2 empty beds on the acute ward at all times 
4. Stroke Champions in EU and AU to support the stroke pathway with defined roles 
5. Stroke CNS currently piloting extended hours 8am – 8pm Monday to Friday in response to analysis of the SSNAP data which revealed a high volume of stroke queries between the hours 5-10pm. 
6. Implementation of a daily afternoon 4pm huddle to review stroke capacity and ensure beds available going into the night 
7. A Standard Operating Procedure developed for patients admitted as medical outliers, stroke mimics or who are palliative who no longer require stroke specific input/ do not have rehabilitation potential. These patients can be transferred off the stroke pathway to a general medical ward or ward that best meets the patient’s requirements. 
8. Developed an IT solution, The Stroke Dashboard for active performance monitoring
9. Introduced Vocera, a communication tool to aid and improve collaborative working between the Emergency Department (ED), Patient Access and the Stroke team

SSNAP data was used to monitor the effectiveness of a new 7-day therapy service on the acute stroke unit which commenced in November 2017.  Weekly breach analysis using SSNAP data identified where key performance indicators were not being met; including patients out-lied on medical wards, delays in admission to the acute stroke unit from ED or the therapy team not informed of new patients in a timely manner i.e. inpatient stroke events.  The ‘Duty Therapist’ role was introduced to hold a bleep pager connected to the ‘code stroke’ alert system, to communicate with the stroke CNS regarding new patients, to facilitate flow on the unit and create beds for new admissions within 4hrs, and to coordinate therapy assessments towards 24 and 72 hour targets. 

Impact
After the introduction of the SSTP, performance progressively improved from 43.5% to 65.9%. From July 2018 onward, once key actions were fully embedded, monthly performance has consistently achieved above the All Wales’ average.

The improvements were also reflected in the SSNAP results; access to the Stroke Unit improved from a Band E to D.
 
The Duty Therapist role has also achieved positive results with >95% achievement on all therapy targets since the introduction of the role. The ‘Duty Therapist’ role has continued with positive feedback from therapists and the CNS team, particularly improved communication and awareness of each other’s roles and caseload.
 
Actions from the SSTP continue and for the period July - September 2018 CAVUHB achieved an overall score of 75, which puts us firmly at Level B. 

Reflection
The success of the SSTP was down to the excellent communication and engagement across the whole Stroke Team who is dedicated to providing a high quality stroke service and ensuring patients receive the best possible care.
 
The Stroke Team at C&VUHB continues to review its performance against SSNAP targets on a weekly basis. The objective for C&VUHB is to sustain and continue improving our performance against the 4hr direct admit indicator.