Clinical challenge
To improve patient flow through ED to a stroke unit and the time of water swallow screen thus improving the patient journey and identifying oral route for patients.

Solution
We have a registered nurse per shift, from HASU, who provides 24 hour cover to assess and treat patients in ED, alongside the medical team, who are brought on the stroke pathway. It is recognised that the service has expanded significantly, from our SSNAP data, and the caseload of patients has increased. The service is set to expand further in the next 6 months with the Intra-Arterial Thrombectomy service being made available to all Greater Manchester stroke patients.
 
In September 2017, following a review of our SSNAP data, we started a test of change to provide a stroke support nurse (band 3) to assist in the timely assessment of swallow and moving patients to the appropriate environment away from the ED. They are also the gatekeeper of all stroke pathway patients in ED and liaise with appropriate team members. The hours of work are 10:00-22:30hrs to facilitate the busiest times of the day.

Impact
In evaluating the test of change, in January 2018, the impact of the role has been significant and instrumental in improving the patient journey and in our SSNAP results. Water swallow screen within 4 hours has shown a 6.8% increase to 87.8%, which the highest we’ve achieved in Salford before. The median time from arrival to ED to a stroke unit has not changed significantly but this is also driven by outside sources, such as local DGH’s not taking their stroke patients back in the agreed 72 hours. This resulted in 147 breach days in the period of test of change (September 2017-January 2018). Looking at the qualitative aspect the role has been highly praised from all departments involved and the clinical director from stroke services has received emails from the ED regarding the positivity of this role. It has been difficult to analyse fully as the service has been covered by staff already employed within the service and within the ward establishment. We have not been able to provide a 7 day services, as we have had to allow for days off and annual leave.

Reflection
A business case was put forward to Executives to ask for the Band 3 role to become permanent and was accepted. Five Band 3 support staff are in post and have been given specific training in water swallow screening, clinical observations, venepuncture and cannulation, Immediate Life Support and have all attended the Stroke Foundation Program, which is an in-house 12 week stroke specific training program for the multidisciplinary team. They are the gatekeeper of stroke patients within the ED department ensuring movement to the appropriate ward within the 4 hour target. The role is continuing to be evaluated through our SSNAP data and in-house auditing and has scope to expand to differing hours to meet the service.

This case study was written by Sarah Heathcote (Advanced Nurse Practitioner), Rebecca Jones (Ward Manager HASU), and Neil Holden (Data Auditor) at Salford Royal NHS Foundation Trust


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