Challenge
Improve mRS scoring in the acute setting to reflect patient improvement following ESD input.
 
Following receiving the quarterly SSNAP results for Central Nottinghamshire Early Supported Discharge Team (ESD) within Sherwood Forest Hospitals we became aware from the slides that the patients were declining following a period of intensive community rehabilitation, despite showing improvement on discharge from ESD.
 
We decided to do a comparison of mRS on discharge from the Stroke Unit and compare this against the mRS on admission (which is not taken into account on SSNAP) and on discharge. It was found that nursing staff were completing the mRS on discharge from the stroke unit and were looking solely at the patients from within the ward environment – so if the patient did not require any intervention throughout the day or night from a nurse then they were scored highly on the MRS (0-1) and when reassessed within the community environment they were found to have more needs and requirements for lower scores (3-4) as required ongoing rehabilitation from ESD.

Solution
The team complete a monthly comparison of the MRS results for Stroke Unit discharge scores and ESD admission scores and real time examples have been used as learning to creating thinking out of the box, as to what the patient would need to achieve at home.
 
Alongside with the Stroke Specialist Nurse, these were presented to the multidisciplinary team and it was felt that a better approach would be to complete the MRS on a weekly basis within the Multidisciplinary Team meetings to gain a holistic overview of the patient with an introduced flow chart to assist decision making. 

Impact
Following the introduction of completing the mRS in the weekly MDT, it has shown an increase in similarity of scoring for Stroke Unit discharge scores and ESD admission MRS scores. SSNAP comparison reporting has improved showing a more accurate reflection of the work and rehabilitation ESD provide to patients.
 
Looking at SSNAP’s report of ESD team results from August to November 2016 and 2017 there is an increase in the number of patients who have demonstrated no change or improvement in 2017 compared to the majority of patients in 2016 showing no change or decline in functional ability.
 
In August to November 2016, the SSNAP results reported that there were 73 discharges from ESD during this period.  Of these 73 discharges, 8 patients deteriorated by 2 points on the mRS, 12 deteriorated by 1 point and 22 made no change, based on the ward mRS (i.e.- hospital discharge mRS of 0 and ESD discharge mRS of 2 would equate to a 2 point deterioration). 23 patients improved by 1 point, 4 by 2 points and 4 by 3 points on the mRS.
However, out of the 60 discharges in the August to November 2017 report, 1 patient deteriorated by 3 points, 8 deteriorated by 1 point and 17 made no change, based on the ward mRS . 21 patients improved by 1 point, 9 by 2 points and 4 by 3 points on the mRS.
 
The in house data collated and shared on a monthly basis, continues to show improvements. For example in September 2017 there were 12 discharges from ESD, of these, based on the ward mRS, all 12 patients made no improvement. However, 7 of the mRS were incorrectly calculated in the Stroke Unit and 7 of these patients would have made an improvement in relation to the mRS.
 
Looking at March 2018 data, following the implementation of completing mRS in the weekly MDT it showed that over half of the patients discharged from ESD made improvements in relation to the mRS. To put into context, there were 21 discharges from ESD, of which 11 made and an improvement and 5 had no changed but were scored the same as ESD on admission. However there were still 5 patients who had an incorrectly calculated mRS on discharge from the Stroke Unit, which then reflected that 4 patients made no change and 1 got worse. When comparing these scores to the ESD admission mRS, 4 of these patients would have also made an improvement and one would have had no change if calculated correctly.





Reflection
From the SSNAP data, it shows that 57.5% of patient discharged from ESD either made no improvement or got worse, compared to 42.5% showing an improvement, majority of which were due to incorrectly calculated mRS on discharge from the Stroke Unit.

Following implementation of calculating a mRS in the weekly MDT, the SSNAP data from August to November 2017 now shows that 57% actually improved following their ESD rehabilitation compared to 43% who showed no improvement or worsening based on the discharged mRS from the Stroke Unit.
 
However, looking at the data collated in March it is still evident that further teaching and education is required as patients who are discharged before a MDT is conducted continue to have incorrect mRS scores calculated, which has since been delivered to the staff on the stroke unit. This included the importance of accurate MRS scoring and its impact within the SSNAP audits and Stroke Service rankings in the East Midlands. 
 
We believe following this training, we will see further improvements in the patients mRS, which will reflect the intensive rehabilitation patients receive in their own homes, and improving their quality of life.

This case study was written by Helen Eccleshall (ESD OT and Team Lead), Emma Gillies (Stroke Nurse Specialist, Acute Stroke Unit) and Katie Summers (ESD Physio and Team Lead), Stroke Early Supported Discharge Team and Acute Stroke Unit, Sherwood Forest Hospitals NHS Foundation Trust. 


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