Stroke Unit Access Policy

Stroke Unit Access Policy

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CONTENTS

1.INTRODUCTION

2.PURPOSE

3.SCOPE

4.DEFINITIONS

5.DUTIES AND RESPONSIBILITIES

6.PROCESS

7.TRAINING REQUIREMENTS

8.REFERENCES AND ASSOCIATED DOCUMENTATION

9.EQUALITY IMPACT STATEMENT

10.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

Equality Impact Screening Tool

Appendix 1

QUICK REFERENCE GUIDE

This policy must be followed in full when developing or reviewing and amending Trust procedural documents.

For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.

1. Duties and Responsibilities

1. Procedure for Admission to Stroke Service

1. Access to Hyper Acute Stroke Unit (HASU)

1. Access to Acute Stroke Unit (ASU)

1. Access to Stroke Rehabilitation

1. Access to Stroke Beds for Non Stroke Patients

1. Outlying of Patients

1.INTRODUCTION

Outcomes for stroke patients are improved by timely access to dedicated stroke units, and minimising door to needle times. Evidence based metrics form the basis of the Sentinel Stroke National Audit Programme (SSNAP) a national stroke database which aims to improve the quality of stroke care by auditing stroke services against evidence based standards and national benchmarks. Additionally stroke specific metrics require adherence which include ensuring90% of all patients admitted with a diagnosis of a stroke will be admitted to a stroke unit within 4 hours and patients admitted with a stroke will spend at least 90% of their hospital stay on a dedicated stroke unit (DH 2007; NICE 2008, 2010, NIII 2009; RCP 2012).

2.PURPOSE

To ensure appropriate and timely access to the Hyper Acute Stroke Unit, in line with National Standards and Clinical Guidelines, with the aim of improving outcomes for patients with a diagnosis of stroke.

3.SCOPE

All staff (both clinical and operational) directly involved in the pathway of a patient diagnosed with a stroke, from the Emergency Department to the Acute Stroke Unit, or in caring for patients who sustain a stroke whilst an in-patient.

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain on-going patient and staff safety’

4.DEFINITIONS

The Inpatient Stroke Service in Queen Alexandra Hospital

There are 3 wards within the inpatient Stroke Service:

1. Ward F4 with a mix of Hyper Acute beds for acute strokes and patients newly transferred to the service (length of stay up to 72 hours) and Acute Stroke beds for patients post 72 hours hyper acute requiring further assessment, investigation and treatment.

1. Ward F3 for patients requiring stroke specific rehabilitation.

1. Ward F1 ward for patients with complex neurological rehabilitation needs.

5.DUTIES AND RESPONSIBILITIES

Chief of Service:

Overall responsibility for the professional and medical leadership of the Clinical Service Centre (CSC), ensuring services are provided with the highest quality and fulfils the purpose of delivering safe and effective care, thus contributing to the overall strategic direction of the CSC and organisation as a whole through multi-professional collaboration.

Clinical Director for Stroke:

To work in partnership with the Chief of Service, taking accountability for the managerial, leadership and strategic development of the Stroke Service, inclusive of ensuring the delivery of agreed local and national stroke performance metrics.

General Manager:

To support both the Chief of Service and Clinical Director in the management of the Stroke Service, implementing and managing systems and processes and performance, ensuring the Stroke Service is delivered in accordance with Trust policies and local and national performance metrics.

Head of Nursing:

To provide professional leadership and strategical and operational delivery of nursing within the Stroke Service, whilst ensuring key component parts; patient experience, patient safety, clinical outcomes, performance compliance and financial balance are maintained.

Matron for Stroke Services:

To provide clinical and professional leadership whilst overseeing and having continuous responsibility for the delivery of high quality, safe and effective care, focused upon improving patient outcomes and experience within the stroke service.

Ward Manager:

To be accountable and responsible for both theprofessional and clinical leadership andmanagement of the department whilst ensuring the provision of high quality, safe and effective care.

Stroke Nurse Specialist:

To provide skilled assessment and guidance for patients presenting with a suspected stroke and as they progress though thrombolysis, hyper acute care and recovery in collaboration with both Medical and Allied Healthcare professionals.

Ward Shift Leader

To be responsible for the assessment of potential Thrombolysis patients Out of Hours, in addition to other shift leader responsibilities, and for maintaining Stroke access beds and escalating when these are potentially compromised.

6.PROCESS

Procedure for admission to the Stroke Service

• All new acute stroke admissions should be admitted directly to HASU within 4 hours of arrival at hospital.
• All requests for admission to HASU should be made by contacting the Stroke Nurse Specialist (08:00hrs to 20:00hrs) or Out of Hours (20:00hrs to 08:00hrs) the Ward shift leader, both on bleep 1788.
• Referrals received from the community will be pre-alerted by the ambulance services via the Mobimed system or HASU emergency red phone. On receiving the referral the stroke team will contact the Emergency Department with the details of the expected stroke admission.
• For potential thrombolysis patients (FAST / ROSIER positive or with symptoms strongly suggestive of a posterior circulation stroke and within 4.5 hours of clear time of onset), the following algorithm should be followed:

-Immediately contact the Stroke Team on bleep 1788

-For Emergency Department patients, the department is to facilitate a rapid assessment, obtain intravenous access (IV), take bloods and perform an electrocardiogram (ECG)

-Stroke Team to contact Medicine for Older People, Rehabilitation and Stroke (MOPRS) Specialist Registrar on bleep 1644

• For patients who are not considered suitable for thrombolysis but have a probable diagnosis of a stroke (FAST / ROSIER positive or with symptoms strongly suggestive of a posterior circulation stroke) bleep 1788 immediately. If assessment by the Emergency Department confirms a probable acute stroke, the Stroke Team will organise the appropriate transfer to HASU.
• All inpatient strokes should be referred to the Stroke Team on bleep 1788. If there is a clear time of onset, then bleep 1788 immediately for potential thrombolysis assessment. Where the diagnosis of a stroke is unclear, discussion with a Senior Medical colleague should be undertaken and referral made to the Stroke Service if appropriate.
• Where stroke patients have other overriding clinical needs, i.e. requiring clinical transfer to the Wessex Neurological Centre or the Department of Critical Care, the Stroke Team on bleep 1788 will require notification if remaining inter-departmental to facilitate stroke specific clinical input.
• A Stroke Access bed (1 male and 1 female) must be maintained whenever possible for direct access to the service.
• A clear overnight plan for managing stroke demand will be developed and agreed by the Stroke Consultant, Stroke Co-ordinator, Older Persons Nurse Specialist (OPNS) and Nurse in Charge for wards F4 and F3 at the 1600hrs ward meeting.
• When Stroke beds are occupied by non-stroke or acute MOP patients then the appropriate specialty/specialties are to identify suitable patients to be outlied from their respective wards in order that their patients can be moved back to their care to create Stroke bed capacity.
• At times of competing admission priorities, the On Call Stroke Consultant will have the final decision on any admissions to the Hyper Acute Stroke Unit (HASU).

Access to the Hyper Acute Stroke Unit (HASU)

• Direct access to HASU beds should be made available for all new acute stroke admissions.
• A minimum of 2 HASU access beds should be readily available at all times (one male and one female), to facilitate direct admissions and thrombolysis.
• Patients suitable for transfer from HASU after 72 hours of admission must be identified clearly on the patient journey board to facilitate out of hours decision making concerning capacity.
• All out of area patients are to be repatriated within 24 to 72 hours of admission if medically stable for transfer. If a delay to transfer ensues, the Senior Management Team or Duty Director should be informed to assist repatriation.
• Repatriation of patients found to be either inter-hospital or inter-departmental is required to be facilitated where able within 24 hours of receiving a referral. To ensure a seamless transition of repatriation, co-ordination will be led by the Stroke Team

Access to the Acute Stroke Unit (ASU)

• All admissions to ASU will be the direct result of transfer from HASU dependent on the clinical stability of a patient post 72 hours of admission.

Access to Stroke Rehabilitation

• Stroke rehabilitation services within the organisation are divided into threedepartments;Ward F3 Inpatient Stroke Rehabilitation unit, Ward F1 Complex Neurological Rehabilitation and the Community Stroke Rehabilitation Team.
• Patients found to be suitable for rehabilitation will be appropriately assessed and identified by the multi-disciplinary team within the Stroke Service / Acute Neurological Team, with a view to commence rehabilitation within a suitable environment as capacity allows. In the event of delay to transfer, the multi-disciplinary team is to outreach and ensure the commencement of rehabilitation as appropriate in their current location until transfer occurs.

Access to stroke beds for non-stroke patients

• In the event of high activity across the organisation and at times when capacity within the Stroke Service exceeds that of demand, patients with a non-stroke diagnosis from within MOPRS, with a predicted discharge of less than 24 hours may be admitted to the Stroke Service after the appropriate identification by a member of the Stroke Team or Older Persons Nurse Specialist Team (OPNS).

Outlying of patients

• In the event of high demand within the Stroke Service, patients identified as non-stroke should be outlied (if clinically suitable for transfer) in preference to a stroke patient, to allow for the direct admission of a new stroke patient to the Stroke Service.
• Patients deemed clinically stable and whereby 90% of their hospital stay has been maintained, are required to be identified by the MDT and outlied accordingly.
• In the event of stroke capacity outweighing demand, stroke patients previously outlied should be repatriated back to the Stroke Service preferentially before admitting non-stroke patients.
• Should the above protocol be breached, immediate discussion is required to take place with either the Senior Management Team (in-hours) or On-Call Stroke Physician.

7.TRAINING REQUIREMENTS

Nil training requirement is appropriate to this access of unit policy.

8.REFERENCES AND ASSOCIATED DOCUMENTATION

Department of Health. 2007. English National Stroke Strategy [Online]. [Accessed 18 January 2015]. Available from:

National Institute for health and Care Excellence. 2008. Stroke Guidelines [Online]. Manchester, National Institute for health and Care Excellence. [Accessed 18 January 2015]. Available from:

National Institute for health and Care Excellence. 2010. Stroke Quality Standards [Online]. National Institute for health and Care Excellence, Manchester. [Accessed 18 January 2015] Available from:

NHS Institute of Innovation and Improvement. 2009. Stroke Pathway -Delivering through Improvement. [Online]. NHS Institute Innovation and Improvement, (no place). [Accessed 18 January 2015]. Available from:

Royal College of Physicians of London – RCP. 2012 National clinical guideline for stroke: 4th edition [Online]. [Accessed 16.04.15]. Publisher: Royal College of Physicians (RCP). Available from:

An Organisation-Wide Policy for the Development and Management of Procedural Documents: NHSLA, May 2007.

9.EQUALITY IMPACT STATEMENT

Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.

This policy has been assessed accordingly.

Our valuesare the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace.

Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do.

We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:

Respect and dignity

Quality of care

Working together

No waste

This policy should be read and implemented with the Trust Values in mind at all times.

10.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

This document will be monitored to ensure it is effective and to assurance compliance.

• Operational Stroke Group

Equality Impact Screening Tool

To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval for service and policy changes/amendments

• Age

• Disability

• Ethnic Origin (including gypsies and travellers)

• Gender reassignment

• Pregnancy or Maternity

• Race

• Sex

• Religion and Belief

• Sexual Orientation

Stroke Unit Access Policy
Version:1

Issue Date: 15 February 2016
Review Date: 15 February 2018 (unless requirements change)Page 1 of 13

Stroke Unit Access Policy
Version:1

Issue Date: 15 February 2016
Review Date: 15 February 2018 (unless requirements change)Page 1 of 13