Stroke

ISDNs to ensure that they lead and engage in activities to promote leadership and culture across their networks, with a particular focus on: • the importance of culture and leadership in successful stroke teams; • addressing systemic biases in the current leadership of stroke teams, actively promoting both medical and non-medical leadership; • emphasising the multidisciplinary nature of high quality stroke care and diversity of leadership; • promoting collaboration across the stroke pathway, including diagnostics, rehabilitation, and working with the third sector; and • development and implementation of a 'Stroke Leadership Academy'. a) Develop national programme and offer that can be adopted locally to support leadership development in ISDNs. b) Ensure each NHS region has a nominated individual who is experienced in stroke leadership and with mentoring skills, to support clinical leads within ISDNs. c) ISDNs to ensure protected time for leadership activities, specifically focused on strengthening leadership and culture at network, trust and team level. d) ISDNs to use funding provided for network activities to support these leadership activities. e) Review, twice yearly, progress on leadership and culture objectives, based on domains outlined by the CQC and in the NHS People promise. This should be done at network level, and ISDNs should encourage organisations and teams to engage. f) Deliver resilience training, active listening sets, NHS policy and change management skills leading to 'learning cohorts' fostering shared development across the ISDNs.

Review regional guidance produced from GIRFT visits, implementing recommendations to ensure local services meet NICE 2019 and RCP 2016 guidance. a) ISDNs and providers to continue review recommendations from their visits and agree local implementation.

All regions will have a fully functioning stroke networks (ISDNs) by April 2021 and must focus on establishing operational and governance best practice. a) ISDNs to fully operational leadership and management teams, with clear governance and reporting structures in place. b) Develop materials on leadership and cultural change that localities can use to enable change. c) Define a minimum set of data and develop a key performance indicator (KPI) data dashboard to support quality improvement across networks. Integrate patient reported outcomes and experience (PROMS and PREMS) into the dashboard. d) ISDNs to develop and implement local data dashboards to inform and track local improvement activities. Dashboards to include the national KPIs (previous action), tailored with metrics to reflect local priorities. e) Publish a concise statement of intent / ambitions for priorities of each ISDN (must include thrombectomy, access to needs-related not time-related community stroke rehabilitation, stroke prevention and address health inequalities) with trajectories for improvement using percentage change from baseline as a barometer of success. f) Review progress on the ambitions annually. These reviews should be used to identify support that can be targeted at local systems to support change. g) Nominate and fund one individual per year to attend a stroke leadership academy. h) Implement inpatient and home bed day calculators to inform systems of workforce requirements. i) Review service optimisation needs of regions and secure capital funding for delivery of infrastructure changes.

ISDNs to draw up local emergency plans, informed by the data, to reduce symptom onset-to-door times. Work with regional and national ambulance teams to produce a 5% annual reduction from baseline and improve sensitivity and specificity of pre-hospital assessments. a) Train all ambulance crews in stroke recognition and ensure they are educated in the use of validated tools (e.g. FAST). b) Document and describe the case for rapid deployment of validated pre-hospital decision support aids, both digital tele-triage and physiological, and agree a timeline for implementation. c) Review categorisation of calls from patients with stroke symptoms. Map data to visualise regional deliverability and produce an impact assessment. d) Approach royal colleges to agree upon content of training modules to support pre-hospital practitioners. e) Embed stroke competencies in paramedic training so staff can prepare patients appropriately for admission to hyper-acute stroke services according to agreed protocols. f) Provide communication training to help providers manage patients with aphasia. g) Provide ongoing stroke-specific training as part of continuous professional development. h) Establish a method to ensure that new evidence and guidance related to stroke care gets into front-line ambulance trust practice. i) Participate in local Stroke Research Network trials and studies.

Implement the National Optimal Stroke Imaging Pathway, including: • working towards 24/7 access to imaging • aligning with NICE guidance for TIA • reducing unwarranted variation in poor access to MRI • improving brain imaging within one hour of arrival for all patients with stroke • reducing duplication of MRI and CT within 24 hours of arrival; • ensuring 24/7 access to CT angiogram and CT perfusion; and • incorporating guidance from Sir Mike Richards' diagnostic imaging review. a) Deliver the NOSIP with support from the relevant stakeholders to develop detailed implementation plans. b) ISDNs to work with Imaging Networks to perform a gap analysis of current imaging practice against NOSIP, agree a local plan and actively monitor progress towards implementation. c) Consider community diagnostic hubs for the delivery of TIA imaging. d) Review the workforce requirements of all radiology services to ensure their establishment is correct. All services should maximise recruitment and retention and all staff should be supported to work to the top of their licence (Recommendation 4 of GIRFT's Radiology report https://www.gettingitrightfirsttime.co.uk/wp-content/uploads/2020/11/GIRFT-radiology-report.pdf).

Provide infrastructure, training and technology to share images between hospitals and clinicians to support image interpretation (see also Recommendation 9 from GIRFT's Radiology National Specialty Report - All trusts must meet the RCR standards for the use of IT). a) Ensure rapid inter-hospital sharing of imaging is available. b) Provide training to support stroke clinicians to interpret imaging, leveraging Imaging Network subspecialist expertise and opinion. Develop and deliver stroke-specific training workshops. c) Increase regional availability of AI decision-support tools and training. d) Provide national support for regional roll-out of AI working closely with ISDN footprints.

Services to adopt the new nomenclature for acute stroke services. a) Adopt nomenclature, ensuring communication of changes and uniform use.

Consider an accreditation system for stroke services. a) Review the need for and benefit of an accreditation system for all stroke services. This would build on previous examples (e.g. Angels, Royal College of Radiology's Quality Standard for Imaging (QSI)) and include community and rehabilitation care.

Reduce door to intervention times for all stroke subtypes. a) Develop and implement a set of critical-time standards for acute stroke care. b) Complete a review of the time-critical interventions of thrombolysis, thrombectomy, primary intracerebral haemorrhage. Produce a detailed service improvement plan and monitor progress. c) Deliver carotid endarterectomy within the specified time frame.

Ensure access to highly specialised stroke units for patients with stroke in <4 hours and for >90% of their stay. a) Improve awareness of the benefits of organised stroke care to executive and bed management teams to ensure rapid access to and maintenance of stroke units. b) Reduce use of stroke unit beds by general medical patients – reclassify beds and reallocate staff where necessary.

Ensure equitable and timely access to services that reduce the risk of complications following stroke, including: • reduce time to swallow screen, with or without speech and language team (SLT) assessment, and review relationship with the use of antibiotics in the first seven days; • deliver definitive feeding solutions for those patients with prolonged dysphagia; • avoid health inequity in access to multidisciplinary care across the days of the week; • reduce falls risk and subsequent harm from falls; and • implement stroke-specific VTE assessment and ensure treatment / intervention. a) Investigate variation and improve timely access to initial swallow screen and speech and language therapy assessments and interventions. b) Ensure all patients are cared for on units with a designated antimicrobial stewardship lead. c) Ensure percutaneous endoscopic gastrostomy (PEG) tube insertion happens within 72 hours of referral. Those units at the extremes of PEG tube insertion timing should ensure all activity is accurately coded and explore their variation in use. d) Improve time from referral to placement of definitive feeding solution. e) Offer 7/7 access for all patients to the stroke MDT using a capability-based workforce model to enable the delivery of physiotherapy, occupational therapy, dietetics and SLT assessments and interventions. f) Build upon current patient falls prevention programmes to produce a stroke-specific programme using existing research and guidance (e.g. the RCP's National Audit of Inpatient Falls). g) Review rates of falls and fractured neck of femur. h) Embed a patient and stroke specific falls prevention programme consistent with NICE guidance and which transfers with the patient, following their recovery journey to home or a community setting. i) Embed an osteopenia prophylaxis pathway. j) Adhere to guidance on venous thromboembolism (VTE) assessment and treatment.

Improve access to and time to thrombectomy intervention. Aiming for 8% of all patients with stroke accessing thrombectomy by 2025. a) Develop the Thrombectomy Implementation Group (TIG) further to coordinate the national response, working closely with stakeholders. b) Develop clear plans with implementation milestones and use data to monitor process and outcomes. c) Implement hub and spoke pathways within ISDNs to deliver thrombectomy with sustainable 24/7 access for the residents of each ISDN. This should involve specialised commissioning, the regional medical directors and all current referrers and providers. d) Revise, pilot and implement new SSNAP metrics of process of care for thrombectomy, linking with specialised commissioning dashboards. e) Implement imaging software (AI/decision-support tools) to rapidly identify patients that would benefit from thrombectomy.

Conduct clear assessment of the health inequalities specific to geographical regions and groups. a) Undertake comprehensive review of the reversible risk factors of stroke in specific ISDNs appreciating hard to reach groups and social economic factors. Including but not exclusive to smoking, diet, alcohol and drug consumption, exercise levels, educational attainment, housing, employment, language barriers, hypertension, hypercholesterolaemia and atrial fibrillation.

ISDNs, working with ICSs and PCNs, to engage in a coordinated approach to CVD prevention. a) NHSE&I to coordinate the design and content of a CVD prevention data dashboard to support ISDNs with local prevention strategies. b) ISDNs to engage with all stakeholders (local authorities, public health, patient groups) to agree an overall strategy for CVD prevention. The strategy should be linked to Regional CVD-R board priorities and the Long Term Plan CVD prevention priorities, using agreed data extracts from Public Health England's National Cardiovascular Intelligence Network and the new CVDPREVENT audit to understand performance, identify opportunities and track progress. c) Ensure every ISDN has access to the stroke prevention dashboard, which is monitored on a quarterly basis, supported by CVDPREVENT and RightCare. d) Publicise the 'every contact counts' message for improved brain and heart vascular health.

ISDNs to oversee and support the implementation of pathways for secondary prevention including cryptogenic stroke and TIA management. a) Ensure each ISDN has clear protocols in place for blood pressure lowering, lipid management and anticoagulation therapy for at risk populations. b) Develop a clinical consensus pathway for secondary stroke prevention and investigation of cryptogenic stroke (including review of European Society of Cardiology recommendations) and recommend how best to embed in provider organisations. This must include rapid access to carotid endarterectomy. c) ISDNs to adopt and adapt ESO recommendations, with support from the ICSWP. d) Each ISDN to have formal cryptogenic stroke regional MDT meetings where individual patients are discussed and referred for complex interventions, including but not exclusive to carotid endarterectomy, PFO closure and left atrial appendage occlusion. These meetings should have all relevant experts in attendance, including those who undertake the procedures. e) Commission and deliver 6-week, 6-month and 12-month post-discharge reviews. Providers to coordinate data collection to monitor delivery of post-discharge follow-up and include adherence to secondary prevention. f) Assess and evaluate remote, wearable devices and access to implantable devices. This should be supported by a national procurement framework.

ISDNs to work with their local systems and ensure adherence to NICE guidance for TIA. Patients with suspected TIA must be assessed seven days a week with remote triage to prioritise assessment within 24 hours. Assessment must include appropriate investigations including brain imaging, carotid vessel imaging (where appropriate) and rhythm check to exclude atrial fibrillation. a) Review stroke services and ensure access to 7-day TIA assessment. This should begin with a gap analysis covering pathway elements including senior clinical triage, same day imaging and initiation of appropriate secondary prevention within 24 hours. b) Provide access to alternative specialist rapid-access clinics e.g. acute neurology, transient loss of consciousness clinics, falls and first fit clinics. c) Each ISDN to have an agreed a pathway of care to support provider delivery. d) Work towards 7-day MRI access and discontinue inappropriate CT scanning for TIA. e) Establish capacity to review TIA patients at recommended intervals (current RCP guidance is at four weeks).

Increase awareness of and delivery of the NHS People Plan – Our NHS People Promise. Use ISDN leadership and governance structures and the Stroke Specific Educational Framework (SSEF) to support the delivery a regional 'Stroke People Plan' to meet the needs of the stroke workforce and improve staff experience and retention. a) ISDNs to work with local services to identify the key actions required to deliver the NHS People Plan, specifically within stroke services. b) Improve the leadership culture across ISDN networks, with an emphasis on compassionate, inclusive and collaborative leadership. This should include resilience training, active learning sets, NHS policy and change management skills leading to 'learning cohorts' fostering shared development across the ISDNs. c) Further develop the Stroke Specific Educational Framework (SSEF) with support from HEE to ensure it is fit for purpose as a tool to support capability assessment, role development and structured training and career development for both the registered and non-registered workforce. d) Support and enable workforce redesign through better use of clinical and non-clinical roles, including extended and advanced roles e.g. Advanced Clinical Practice (ACP) roles. e) Ensure delivery of updated curriculum for medical specialty training in stroke medicine. f) Promote the BASP Meeting the Future Consultant Workforce Challenges paper and support the consultant job planning calculator.

Transform delivery of care and efficiency of workforce by incorporation of digital technology. a) Review the impact of virtual working, rapid adoption of technology and digital exclusion on the workforce to establish good practice. Formally evaluate and support local adoption. b) Implement digital technology at local level.

ISDNs and local providers to use NHS England and NHS Improvement's stroke bed calculator to plan bed capacity requirements in a consistent and evidence-based way. a) Calculate stroke service bed requirements, reflecting both patients in hospital and those requiring community rehabilitation at home, to inform workforce planning and funding models.

Deliver a sustainable workforce for thrombectomy. a) Thrombectomy Implementation Group (TIG) to develop options to inform an overall thrombectomy workforce strategy, in partnership with the relevant professional bodies. b) Support for GMC credentialing for non-interventional neuro-radiologists to deliver thrombectomy. c) Develop national thrombectomy training academies and community of practice. d) Ensure adequate availability of staff across the thrombectomy pathway.

Further develop the SSEF with a focus on the post-acute pathway, including life after stroke, psychological models of care, voluntary sector workforce and end of life care. a) Finalise a national service model for Life After Stroke. b) Review training requirements for current and anticipated future workforce including non-registered workers. c) Review workforce requirements across post-acute stroke pathway. d) Deliver a continuous learning framework to support extended and advanced roles.

Ensure daily MDT patient goal setting (including social care support to facilitate discharge planning). Stroke survivors and those that support them must be involved in goal-setting and discharge planning discussions. a) Ensure all stroke services have structured daily MDT board rounds. b) Consider domiciliary care as part of early supported discharge (ESD) and integrated community stroke services. c) Consider virtual MDTs between acute, community and social care teams to support discharge planning and ongoing support.

All ISDNs should ensure commissioning of a needs-based 7-day accessible Integrated Community Stroke Service, appropriately staffed with stroke specialist practitioners. This ICSS should incorporate traditional elements of early supported discharge (ESD) with more generic community-based rehabilitation for the latter stages of the stroke recovery journey. Stroke rehabilitation should be accessible to all that may benefit, this should include nursing home residents and those with severe disabling stroke cared for in their own homes. a) Discuss with commissioners, as a matter of urgency, the establishment of needs-based 7-day access to early supported discharge and community stroke rehabilitation teams, where services do not already have this in place. Use the NHSE&I National Stroke Service Model (NSSM) and ICS level commissioning to ensure equitable delivery of services for stroke survivors. Commissioners should be encouraged to agree equitable provision and ensure this activity is documented within the SSNAP national audit tool as a prerequisite for funding. b) Review funding structure for post-discharge pathways with consideration of a 'home bed' day rate. c) Review current neuro-rehabilitation commissioning within each ISDN footprint to attempt to understand where there may be opportunities to co-commission these pathways. d) Use the recommended ICSS national staffing structure, i.e. WTE/100 patients per year, when calculating staffing requirements.

ISDNs should work with stroke teams to review current provision of Life after Stroke pathways. This should include access to psychological care, voluntary sector support and appropriate patient directed follow-up. a) Review current models of service delivery across providers and consider ISDN footprint commissioning with single lead commissioner and service specification. b) Finalise the Life After Stroke service model. c) Consider a 'blended' approach to service delivery with a mixture of face to face, telephone/video call, voluntary-led and peer-to-peer support groups. d) Review delivery models of psychological care post-stroke and work with ISDNs to improve access. e) Introduce my stroke record - a stroke patient passport (personal stroke information) system, initially in paper format, moving to electronic, to facilitate education, self-directed care, and follow-up.

Review stroke data collection, data fields and links to other registries, reflecting feedback from acute and community teams. This will ensure units continue to receive high-quality and actionable insights from the national audit. This must include more real-time reporting and an ability for local ISDNs to interrogate data and produce their own bespoke reports based on their own priorities and challenges. a) Review questions within the SSNAP dataset to reflect changes in care delivery pathways e.g. thrombectomy patient flows and metrics, delivery of virtual models of care and rehabilitation pathways. b) Continue the commissioning of national audit including formal review of contract and prioritisation of work plan. c) Ensure the longevity and sustainability of a national stroke audit that links with other registries so that data is collected only once, is linked and accessible. d) Provide data reported at network level so that ISDNs and regions can take ownership. A dashboard that is developed nationally and made available to ISDNs can inform local quality improvement activities. e) Enable real time linkage of SSNAP data to increase timeliness of mortality data reports. f) ISDNs to work with local units to ensure completion of data entry from all providers across the stroke pathway.

Formalise the ISDN assurance process for quality of SSNAP data entry and performance. There should be regular meetings between clinical and coding teams to ensure alignment with HES data and SSNAP. a) Establish quarterly independent verification of SSNAP attainment score via independent assessors. b) Stroke teams and coding teams to engage in continuous review of the coding of patients with stroke in HES and SSNAP. This will ensure that data is accurate and comparable. Data must be available to teams in a timely to allow for case review and improvement actions.

Use PROMs and PREMs collection to understand the impact and outcomes of enhanced rehabilitation and life after stroke services. a) Develop a national PREMs questionnaire with supported analysis and reporting. b) Integrate PROMs questions within national audit and introduce into national data set within SSNAP after initial testing in rehabilitation pilots.

Reduce litigation costs by application of the GIRFT Programme's five-point plan. Although claims relating to stroke have not been directly identified in the GIRFT litigation data pack as a separate specialty, trusts can ensure they learn from claims relating to stroke by following the five-point plan for all claims listed for both medical and surgical specialties, as a proportion of these relate to patients with stroke. a) Clinicians and trust management to assess their benchmarked position compared to the national average when reviewing the estimated litigation cost per activity. Trusts would have received this information in the GIRFT Litigation data pack. b) Clinicians and trust management to discuss with the legal department or claims handler the claims submitted to NHS Resolution included in the data set to confirm correct coding to that department. Inform NHS Resolution of any claims which are not coded correctly to the appropriate specialty via CNST.Helpline@resolution.nhs.uk c) Once claims have been verified clinicians and trust management to further review claims in detail including expert witness statements, panel firm reports and counsel advice as well as medical records to determine where patient care or documentation could be improved. If the legal department or claims handler needs additional assistance with this, each trusts panel firm should be able to provide support. d) Claims should be triangulated with learning themes from complaints, inquests and serious incidents (SI) and where a claim has not already been reviewed as SI we would recommend that this is carried out to ensure no opportunity for learning is missed. The findings from this learning should be shared with all front-line clinical staff in a structured format at departmental/directorate meetings (including multidisciplinary team meetings, morbidity and mortality meetings where appropriate). e) Where trusts are outside the top quartile of trusts for litigation costs per activity GIRFT we will be asking national clinical leads and regional clinical teams to follow up and support trusts in the steps taken to learn from claims. They will also be able to share with trusts examples of good practice where it would be of benefit.

NHS Resolution to develop its clinical coding to enable the identification of all claims that relate to stroke as either a primary or secondary factor in a claim. a) Code claims related to stroke separately to allow identification of the true prevalence of stroke in clinical negligence claims.

Full addressee: NHS Resolution