CRHFT ESD Service, January 2015

STROKE SERVICESEARLY SUPPORTED DISCHARGE (ESD)

OVERVIEW REPORT – QUARTER 1

OCTOBER – DECEMBER 2014

CONTENTS

Executive SummaryPage 1

Part 1: Monthly Figures AnalysisPage 2

Part 2: Patient Survey Overview ReportPage 12

Part 3:Observations of ESD TeamPage 17

Part 4: Case StudiesPage 19

AppendicesPage 23

Executive Summary

The stroke services Early Supported Discharge team (ESD)commenced 6th October 2014, funded nonerecurrentlyby commissioners, for one year. The service will be reviewed on the 21st April 2015. During the first quarter 34 percent of stroke patients discharged from Stroke Services at ChesterfieldRoyalHospital were seen by the ESD team, and a further patient discharging from another hospital accessed the service. High levels of satisfaction have been reported by patients. Therapy and nursing staff report considerable benefits to the quality of care and discharge processes, since its implementation

Report prepared by:

Lucy Boden, Clinical Quality Facilitator

Ann Godfrey, Lead Senior Occupational Therapist

Grace Walton, Senior Physiotherapist: case study one

Rachel Gavan, Highly Specialist Speech and Language Therapist, Jennie Boden, Specialist Speech and Language therapist, Wendy Elliott Senior Occupational Therapist: case study two

Donna Evans, Senior Nurse

Draft written: January 2015

Report finalised: February 4th2015

Page 1 of 25

CRHFT ESD Service, January 2015

PART 1: MONTHLY FIGURES ANALYSIS – QUARTER 1

1. Introduction

In October 2014, the early supported discharge (ESD) service for stroke patients was implemented at Chesterfield Royal Hospital NHS Foundation Trust (CRHFT). The aim of this service is to help patients get home more quickly from hospital whilst continuing with their therapy at home. In evaluating the new ESD service, we collect monthly figures on a number of key indicators.The ESD team consists of nursing, speech and language therapy, physiotherapy, occupational therapy, and consultant physician support.

The project aim is to provide a stroke specialist rehabilitation service at home following discharge. The objectives are for patients to be able to live safely at home, earlier than they would have done under normal service provision, thus reducing length of stay in hospital. The objectives are also that ESD will improve the functional abilities and quality of life of patients, and assist patients to work towards achievable goals.

2. Method

Monthly figures are collected on a number of key performance indicators (listed in appendix A),as agreed with commissioners. Data is put together by the ESD team, Admin staff, data services and the Clinical Quality Facilitator – Clinical Specialist Services Division. The data for quarter 1 (October – December 2014) was analysed by the Clinical Quality Facilitator and the ESD team. The results are detailed in the following section.

3. Findings

3.1 Stoke patients discharged from CRHFT

Over quarter 1, the average number of stroke patients discharged from CRHFT was 38 patients a month.

Graph1. Number of stroke patients discharges

As shown in graph 1 above, a total number of 35 patients were discharged from Eastwood ward in October, 33 in November and 45 December.

The average (mean) length of stay (LoS) for all stroke patients on Eastwood ward, over quarter 1 was 20 days. As shown on graph 2 below, both October and December were within one standard deviation of the mean whereas November was just outside.

Graph 2. Average length of stay for stroke patients

During quarter 1, the % of patients spending ≥ 90% of their stay on stroke unit was 93%. The pattern of change for this indicator over October to December 2014 is illustrated in graph 2 below). The national target is that patients spend 90 percent of their stay on a stroke unit.

Graph 3. Patients spending 90% of their stay on stroke unit

Over quarter 1, the average available bed days per month for Eastwood Ward were 491 days (acute stroke referrals) and 613 days (stroke rehabilitation referrals). The available bed days for Eastwood Ward during October – December 2014 are shown in graph 4 below. Currently funded are 20 rehabilitation beds and 16 acute beds, 6 beds on Durrantward are also protected stroke beds. Patients who move onto Durrant ward are considered as staying on the stroke unit.

Graph 4. Available bed days

The average occupancy rate during quarter 1 was 99% for acute stroke referrals and 90% for stroke rehabilitation referrals. Graph 5 below illustrates the change in occupancy rates over October – December 2014 on Eastwood Ward.The acute occupancy rate in October of 116.3% was as a result of rehab beds being used by acute patients.

Graph 5. Occupancy rates

3.2Patients discharged with ESD service

The total number of patients who were eligible for the ESD service at CRHFT over quarter 1 was 44. Whilst the number of eligible patients remained the same over October and November, it reached a peak in December with 18 patients being deemed eligible for discharge with ESD. This is illustrated in graph 6 below.

Graph 6. Patients ESD eligible

This translates in percentage terms to 39% of stroke patients who were discharged between October and December 2014 were eligible for the ESD service. As shown in graph 7 below, the percentage of stroke patients discharged from CRHFT being considered for the ESD service has risen from 37% in October to 40% in December during quarter 1.

Graph 7. % of stroke patients who were referred to ESD

In total, 39 stroke patients (34 %) were discharged with ESD from CRHFT during quarter 1 and one further patient (a North Derbyshire resident) was discharged with ESD from Kingsmill hospital. The criterion of the ESD service was modified at this time to allow for referrals into the service from patients discharginghome to north Derbyshire, from hospitals out of area.

Graph 8. Patients discharged with ESD from CRHFT

As shown in graph 8 above, the number of patients discharged from CRHFT with ESD has risen from 11 patients in October to 16 in December 2014. These figures are not cumulative. This equates to a total of 39.

However, the % of eligible patients discharged with ESD has not followed this pattern (illustrated in graph 9 below).

Graph 9. % eligible patients discharged with ESD

The % of eligible patients discharged with ESD peaked in November at 100% and was at its lowest in October with 85% of patients.

In October, two patients were deemed eligible for ESD in October but were not discharged until November because their care package was not in place. In November all patients deemed eligible for ESD were discharged with the service, there was one patient whose discharge was delayed by two days as the capacity of the ESD team was not sufficient enough to meet the immediate need over the weekend period.

In December, two patients deemed eligible for ESD were not discharged with the service due to the need to manage potential demand onthe ESDservice over the Christmas period. One of these patients would have benefited from follow up therapy, he lived in a nursing home but lived on the border of the catchment area and their needs could equally be met by the existing community services. The second patient met the criteria for ESD, their needs were not intensive and could be met by the community rehab team. This patient had also specified that they did not want input immediately on discharge. A further four patients who were discharged with ESD in December were delayed by 2 - 4 days whilst waiting for reablement care capacity to be available to meet their needs. One additional patient in December was discharged to Mansfield ESD service.

Over the three months in quarter 1, the average waiting time for initial assessment for ESD has remained at 0 days. In relation, there have been no patients on a waiting list for the ESD service. Furthermore, 100% of patients discharged with ESD were seen within 24 hours.

Graph 10. Estimated average bed days saved

The estimated average bed days saved per patient discharged with ESD during quarter 1 was 3.8 days. Graph 10 above illustrates that this figure has remained between 3.25 and 4 for October – December 2014. Narrative regarding the estimated average bed days saved for some of the patients discharged with ESD during quarter 1 is detailed below.

  • 7 days – Patient would have taken a further week to link up with, and secure, the high levels of support necessary on discharge

  • 14 days – Patient had dyspraxia and complex communication difficulties. The patient’s wife was at home to provide support. Patient would have needed to stay in for ongoing SLT

  • 14 days – Patient had communication difficulties and would have needed to stay in for input

  • 3 days – Patient was highly anxious and had difficulties taking medication. It was difficult to predict how this patient would have been supported without ESD

  • N/A as discharged from Kings Mill

  • 4 days – The SLT would not have agreed to discharge the patient had they not been able to follow up with ESD

  • 0 days - Patient had a prolonged stay due to new severe visual difficulties. It is difficult to predict how this patient could have been supported to return home without ESD

  • 7 days - Family needed high level of support on discharge. It would have taken longer to organise and reassure, as needed, without the ESD service

  • 0 days - Discharged to family and partners care. This patient could have returned home a week sooner, but their family were finalising their own support plans for the patient

  • 0 days - Discharge would have been with increased risk without ESD, and pressure would have been increased for the family.

  • 0 days – Patient could have discharged 9 days sooner but their partner was not agreeable to the rehab process carrying on at home at the time.

  • 4 days - Patient would have needed further SLT advice and input in hospital

  • 0 days - Waited for care package to be set up

  • 7 days - Patient had dense upper limb weakness and inattention

  • 7 days - Patient would have needed to stay in for further SLT

  • 0 days - Waited for care package to be put in place

  • 2 days - Patient would have stayed in for further cognitive assessment

  • 0 days - Waited for 2- 3 weeks for family agreement for rehab to carry on at home

  • 7 days – Patient would have needed to have had improved mobility prior to discharge without the ESD service

  • 0 days - Waited for care

  • 14 days – Patient would have needed to stay in for SLT

  • 2 days - Elderly parents were caring for the patient and not able to support them at home any earlier

  • 4 days - Patient would have needed a home visit and link up with community team without ESD

  • 3 days - Patient would have needed a home visit without ESD - concerns regarding shower and meal prep

  • 0 days – The patient’s family were intending to take them home on day of discharge

3.3Patients discharged from ESD service

During quarter 1, the total number of patients discharged from the ESD service was 27. As shown in graph 11 below, this figure has steadily risen from 2 patients in October to 16 patients discharged from ESD in December. These monthly figures are not cumulative.

Graph 11. Patients discharged from ESD

Of the patients discharged from ESD during quarter 1, 78% met their rehabilitation goals.

Graph 12. % patients discharged from ESD whose rehabilitation goals were met

Illustrated in graph 12 above, this figure has risen from 50% (frequency = 1) of patients in October to 89% (frequency = 8) in November and finally 94% (frequency = 15) in December.

In October, one patient was readmitted to hospital after becoming unwell and sustaining a fall. This patient moved from CRHFT to a community rehab hospital. In November, one patient was not able to set rehabilitation goals with the Speech & Language Therapist (SLT) on their first visit following discharge, despite agreeing to the service on the ward prior to leaving hospital. The patient stated that they would like to continue to recover in their own time, without ongoing SLT input. For this patient, only advice was given. In December, one patient was unwell and admitted to the Northern General hospital on 13th December before being discharged and admitted to CRHFT on 17th December. This was not stroke related.

Graph 13. Patients discharged from ESD not referred for ongoing therapy

During quarter 1, a total of 14 patients were discharged from ESD and not referred for ongoing therapy. This figure has risen from 2 patients in October to 8 in December 2014 (illustrated in graph 13 above), as the overall number of patients discharged from the services has increased.

A total of 14 patients discharged from ESD were also referred to community follow up therapy services during quarter 1. Again, this figure has risen from October to December with 0 patients discharged from ESD being referred to community follow up therapy services in October to 9 patients in December 2014 (illustrated in graph 14) The number of patients increased as more patients were discharged from the service.

Graph 14. Patients discharged from ESD referred to community follow up therapy services

During quarter 1, no patients who were discharged from ESD were seen after ESD goals were met, whilst waiting for community therapy input. Narrative regarding referral from ESD to other services is detailed below.

In November, no delays incurred for the five patients requiring ongoing Occupational Therapy (OT) and Physiotherapy (PT). Two patients were referred to Bolsover therapy unit; a joint visit took place with OT from therapy unit to handover. One patient was referred to Dales Community rehab team (CRT) for upper limb followup. Another patient was referred to Dales CRT. A joint visit took place with PT from Dales CRT. One patient was referred to Clay Cross Intermediate care team and a joint visit took place with the Physiotherapist.

In December, one patient was referred to Eckington ICT, and community SLT. A second patient was referred to the outpatient Physiotherapy service at CRHFT, a third to the Clay Cross Therapy Unit, a fourth to Bolsover ICT, a fifth to Dales Community rehab team, a sixth to Eckington ICT, a seventh to Community PT at Eckington, an eighth to Walton CRT for input to commence when moving to a new property and a ninth patient was referred to community SLT.

Analysis of the 25 patient surveys received during quarter one is discussed in part two of this report.

4. Summary and recommendations

  • To continue to collect data over 2nd quarter and review at 6 months
  • Review and report on SSNAP data. The first SSNAP report since commencing ESD is still pending. This will provide additional information on therapy time spent with patients, and will allow for benchmarking against other services.
  • Work on promotion of theESD service and raising awareness with patients and families, whilst inpatients,early in the stroke pathway
  • To explain details of the ESD service in the eastwood ward information leaflet

Page 1 of 25

ESD Patient Survey, January 2015

STROKE SERVICES EARLY SUPPORTED DISCHARGE (ESD)

PART 2: PATIENT SURVEY SUMMARY REPORT – QUARTER 1

OCTOBER – DECEMBER 2014

1. Introduction

In evaluating the new ESD service, we asked patients discharged with the service to complete a short questionnaire.

2. Method

All patients (where appropriate) who were dischargedwith the ESD service were given a copy of the questionnaire (questions listed in appendix B), on their final visit completed questionnaires were collected returned to the Clinical Quality Facilitator – Clinical Specialist Services Division for analysis. Free text comments were themed using the CRHFT theming guide in appendix C.

A total of 27 patients were discharged from the ESD service in quarter 1 (October – December 2014) and all were given a patient survey. 25 surveys were returned during quarter 1 giving an espouse rate of 93%. The results are detailed in the following section.

3. Findings

3.1 How confident did you feel about managing at home after you were discharged from hospital?

Graph 1. Patient’s confidence in managing at home after being discharged from hospital

Of the 24 responses to question 1, 67% reported that they felt ‘fairly confident’ about managing at home after being discharged from hospital, 21% reported feeling ‘completely confident, 13% ‘not very confident’ and no respondents reported feeling ‘not at all confident’.

In order to assess the effectiveness of the ESD service, it may be useful to amend the current patient survey and add in a question which asks ‘how confident do you feel about managing at home now?’

3.2How confident did your family/carer feel about helping you to manage at home after you were discharged from home?

Graph 2. Family/carer’s confidence in the patient managing at home

Replicating the spread of answers for question 1, the most popular response in answer to question 2 was, ‘fairly confident’ (46%), followed by ‘completely confident’ (33%) and ‘not very confident’ (13%) respectively. However, a higher proportion of respondents believed their family/carer felt ‘completely confident’ regarding their ability to manage at home (33% compared to 21%).

For two (8%) respondents, this question was not applicable as they were managing alone at home.

3.3Did you know how to contact someone from the ESD team if you needed to?

96% of respondents reported that they did know how to contact someone from the ESD if they needed to. Just one patient (4%) did not know.