Hyper Acute Stroke Unit (HASU) patient suitability for early supported discharge (ESD): coordination and data analysis project for the North Central London (NCL) sector.

Perkins N (London North West Healthcare NHS Trust), Skrypak M (Healthcare Quality Improvement Partnership , London), Barron S (The North Central London Stroke and Cardiovascular Network), Simister R (Hyper Acute Stroke Unit, University College Hospital, London) , Walker H (NHS Improving Quality), Kilbride C (Royal Free Hospital Hampstead NHS Trust, London).

Abstract

Research has shown the benefits of Early Supported Discharge (ESD) from stroke units on patient outcomes as well as reducing bed days in hospital. This six month project identified that there are higher numbers of patients (12%) who could go home earlier from the hyper acute stroke unit via ESD services when there was an ESD coordinator role in place. In order for this to occur however there needs to be closer inter professional working relationships with social services in regards to ensuring that both patient health and social needs are met. This role could potentially increase the amount of appropriate patients being discharged to ESD teams thus allowing access to evidence based care. This short report describes how appropriate coordination can meet patient needs whilst saving the local stroke health economy over £230 000 in a 6 month period.

Keywords:

Early Supported Discharge, Stroke, Coordination, Interdisciplinary working, Social Care

Introduction

This report describes a six-month service improvement initiative funded by a local stroke network. Increasing acute care costs and perceived fragmentation of team working, including underutilisation of community services were drivers for change. A specialist stroke therapist seconded from a hospital within the network led the project, taking up the role of an Early Supported Stroke Discharge (ESSD) coordinator.

ESSD services are integrated community stroke teams (including social services), and provide similar levels of therapy as inpatient stroke units (National Institute for Clinical Excellence, 2013). ESSD services for eligible stroke survivors (i.e. able to transfer with one person) have been shown to reduce long-term dependency, institutional care, hospital stay, and use of social services care packages (Langhorne et al 2005; Clarke 2012).

Specifically the study aimed to address the following questions:

1.  Are patients from the hyper acute stroke unit (HASU) discharged to their appropriate destination?

2.  Can the timely use of ESSD services provide cost savings to the health economy?

Methods

Whilst formal ethical approval was not required for this project, the post holder adhered to the principles of non-maleficence, confidentiality and anonymity. Being from the wider organisation, there was a need for reflexivity of actions to ensure staff did not feel compromised or vulnerable by the review. Data was collected and stored according to the Data protection Act 1998.

Setting

The project took place across five metropolitan boroughs within a large English city. The stroke network consisted of a HASU, four stroke units and five EESD services (population 1.3 million).

Design

A case study design with convenience sampling was utilised.

Procedure

The project lead visited community and hospital teams in the five boroughs to introduce the study and scope existing services. Other key actions involved tracking the flow of patients through the stroke pathway, promoting collaborative inter-professional working i.e. inviting teams to undertake reciprocal visits, providing information about service provision in the different boroughs and facilitating meetings between the HASU, ESSD and local commissioners, to address administrative challenges impeding discharge to community teams.

Data Collection

To track patient flow across the pathway data were collected from stroke team meetings and patient records:

·  Borough of residence

·  Hospital number

·  Date, time and type of stroke

·  HASU arrival time

·  Discharge date/s and destination/s

·  Care package on discharge and type

·  ESSD start/end dates

·  Outcome measures: Barthel, modified Rankin scores and care package changes

·  Reasons for incorrect discharge destination i.e. patients suitable for discharge with ESSD but transferred to a stroke unit (SU)

Data Analysis

Data were entered into Excel, double checked for accuracy and analysed using descriptive statistics including totals, percentages, frequencies, means and ranges.

Project Management

A project steering group, comprising an ESSD team lead, local stroke network assistant director, HASU therapy manager met monthly with the project coordinator to discuss and scrutinise patient data flow summaries including variance in the pathway.

Results

During this six-month study, 52 stroke survivors were unnecessarily transferred from the HASU to a local SU despite meeting the ESSD criteria for discharge home. Specifically, 13 waited for two days or less to on the SU before going home , two more stayed another 2-4 days, the remaining 37 were inpatients for four days. Table 1 shows between 9-15% (n=5 -11) patients were incorrectly discharged each month. Patients incorrectly admitted to a SU for over 48 hours, carried the full tariff of £5850, patients staying under 2 days had a tariff of £548 applied. In total, a potentially avoidable cost of £235 274 was incurred across the sector (Healthcare for London 2009). Care packages took an average two days to organise,

Table 1- Cost implications of unnecessary stroke unit transfers

Month / Total number of admission to HASU with stroke per month / Numbers (%) of patients who go home with ESSD / Number (%) of patients who went to a SU but met ESSD criteria
January / 72 / 10 (14%) / 8 (11%)
February / 54 / 10 (19%) / 5 (9%)
March / 74 / 19 (26%) / 8 (11%)
April / 78 / 16 (21%) / 10 (13%)
May / 89 / 19 (21%) / 10 (11%)
June / 71 / 13 (18%) / 11 (15%)
Total / 438 / 87 (mean= 20%) / 52 (mean= 11%) Total cost = £235, 274

Discussion

In addressing the aims, results from this service improvement project showed 12% (n=52/438) of HASU patients were unnecessarily transferred to a SU despite being eligible for discharge home with an ESSD. Examination of patient flow data revealed delays in care packages were the main cause of variance and by default patients were transferred to stroke units rather than home. This system inefficiency and inability to meet patient needs not only led to costly hospital repatriation and financial tariffs being incurred (£235, 274), but importantly could lead to poor patient experience and demotivation (Holmqvist, 2001).

Actions to arise from study findings included the introduction of rapid assessment processes for social services in the two boroughs where delays were especially problematic. The upward trend of ESSD referrals during the six month project period and anecdotal positive feedback from staff across the stroke pathway highlighted the value of the ESSD coordinator. In particular, staff commented on the facilitation of inter-professional collaboration and the ESSD role of acting as a “go- between” (Day 2006 p.84), spanning boundaries between the teams at the HASU, local SUs, and ESSD community services. Strengthening networks with local commissioners and social service providers to promote mutual understanding and positive working were likewise fundamental in the overall process.

Conclusion

During this six-month project 52 (12%) patients could have gone directly home from the HASU with ESSD services; instead they went to SUs incurring unnecessary costs to the health economy. Findings showed patients with moderate disability incurred waits to going home primarily due to delays in care packages, as a result two boroughs developed rapid social service assessments. While project results support the economic case for an ESSD coordinator, further in-depth investigation into the effects of the role as a boundary spanner to help coordinate teamwork across the continuum of the stroke pathway, including social services is needed.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

References

Clarke, DJ. (2013). The role of multidisciplinary team care in stroke rehabilitation. Prog. Neurol. Psychiatry.17: 5–8.

Day, J. (2006). Interprofessional working. An essential guide for health and social care professionals. Nelson Thomas Ltd: London.

Healthcare for London. (2009). Stroke acute commissioning and tariff guidance. Retrieved from http://www.londonhp.nhs.uk/wp-content/uploads/2011/03/Stroke-Commissioning-and-Tariff-Guidance.pdf [Accessed 17 Oct 2015].

Holmqvist, Lotta. (2001) Environmental factors in stroke rehabilitation: being in hospital itself demotivated patients. BMJ. 322 (7301), 1501-1502

Langhorne, P., Taylor, G., Murray, G., Dennis, M., Anderson, C., Bautz-Holter, E., Dey, P.,Indredavik, B., Mayo, N., Power, M., Rodgers, H., Ronning, OM., Rudd, A., Suwanwela, N.,Widen-Holmqvist, L., Wolfe, C. (2005). Early supported discharge services for stroke patients: a meta-analysis of individual patients' data. Lancet 5-11: 365(9458), 501-506.

National Institute for Health and Care Excellence. Stroke Rehabilitation: Long term

rehabilitation after stroke. London: NICE, 2013. Retrieved from http://www.nice.org.uk/guidance/cg162/resources/cg162-stroke-rehabilitation-full-guideline3 [Accessed 14 Oct 2015].