Challenge
To minimise delays to hyper-acute stroke unit (HASU) admission for all stroke patients.

Solution
We developed a system for checking and reviewing data. This governance process aims to help team members understand why there may be delays in getting patients to the stroke unit. For each measure, during data input or at the review process, we identify each patient who did not achieve the measure. We then categorise each measure according to common reasons for failure.
For example, delays admitting to the HASU can be divided into:

• Delays in identifying the stroke
• Delays in referral to our team
• Delays in scanning
• Delays in assessment by our team
• Difficult diagnoses (other neurological illnesses similar to stroke making identification difficult)
• Lack of available beds
• The patient is too unwell with another serious illness to transfer to HASU

We can therefore identify the themes or common cause behind each measure. We also report qualitatively on what the delays were: for example it is important to understand the reasons that a stroke patient was not transferred to the stroke unit, or if a non-stroke patient was put into a stroke bed in the HASU, and what had been done about it.

Impact
Many more patients are now being treated in a specialist stroke unit where they can receive specialist care by a multidisciplinary team. Similarly patients are being admitted to a stroke unit (SU) faster than in previous years ensuring acute care processes are delivered as soon as possible. This ensures that patients have the best possible chance of surviving and making a full recovery after their stroke.

Hospital arrival to SU admission:
In 2013/2014: 3h 26 minutes
In 2016/2017: 2h 33 minutes

Percentage of patients directly admitted to SU in 4 hours:
In 2013/2014: 55.7%
In 2016/2017: 73.6%

Reflection
This feedback helps to plan how the team will respond when faced with difficult or unusual circumstances; e.g. using other CT scanners if the primary scanner is occupied. It may stimulate cross team learning about how to differentiate complex stroke patients, or reinforce HASU planning of the best use of available beds, or in putting a case forward for more beds (capacity planning). Some cases will remain clinically appropriate or unavoidable decisions – this methodology provides assurances to those unfamiliar with stroke care that the right decisions were made to deliver best care wherever possible.

This case study was written by Dr Andrew Hill, Stroke Specialist Physician at St Helen’s and Knowsley NHS Trust.


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