Highly Commended in 2020 CHA Innovation and Best Practice Awards
Summary:
In February 2019 the Stroke Rehabilitation Unit at The Vale Community Hospital (Gloucestershire Health and Care NHS Foundation Trust) opened its beds to Stroke patients. It provides 24-hour specialist stroke care and rehabilitation led by therapy and nursing staff. It completes the stroke pathway in Gloucestershire by bridging the gap in post-Stroke care between the acute hospital service and Early Supported Discharge (ESD) Team for Stroke which are long-established. Evidence shows that specialist rehabilitation is an essential part of recovery after Stroke providing longer term health and social care benefits. The aim is to provide the optimal opportunity and in-patient environment in which to recover and adapt once acute medical care is no longer needed but discharge home is not yet feasible.
Patient-centered care delivered by an integrated multi-disciplinary team (MDT) is core to this service which itself is integrated with the Acute Hospital and Community ESD to form the Stroke Pathway.
Background:
Stroke features prominently in the NHS long-term plan to which the integrated One Gloucestershire is committed. The need for a Specialist Stroke Rehab Unit was recognised through findings of an NHS Gloucestershire Clinical Commissioning Group (CCG) study. The report concluded that although there were lots of elements of good service provision within the county, in order to provide a seamless pathway for stroke patients, a rehabilitation unit in addition to the hyper- and acute units in the acute Trust was necessary.
After a long process of scoping, consultation, design, and business planning the new unit within The Vale Community Hospital was selected to be the specialist, coordinated unit where resources could be centralised and dedicated. A successful business case secured funding in October 2018 to increase specialist therapy staff at the Vale and as a planned consequence the pathway change also increased the amount of therapy available per stroke bed within the acute stroke unit. Following many weeks of recruitment, building work, training, creating clinical systems, procurement of equipment and team building, the unit was ready to open. The unit had the benefit of being part of an existing well-run ward staffed by an enthusiastic and caring ward team. The hospital had the support of the local community in particular The League of Friends and the introduction of the Stroke Unit was welcomed by both. Initial training programmes were devised and implemented for those existing colleagues who were new to Stroke as a specialism and staff experienced in Stroke were recruited to the new posts.
In June 2019 representatives of the new pathway presented to the county Health and Overview Scrutiny Committee where the changes were well received.
Description:
The 14 Stroke beds are part of a 20 bedded ward. Clinical Standards of rehabilitation are applied to all patients with Stroke Specific standards applied to Stroke patients.
The MDT consists of – Nurses and Healthcare Assistants; Occupational Therapists; Physiotherapists; Speech and Language Therapists; Rehabilitation Assistants; Clinical Psychologist; Doctors including Consultant Physician; Dietitian; Discharge Co-ordinator; Administrative staff; Social Worker; Training and Development Nurse and Therapist; Hotel Services and Portering staff - together described by one of our ward Sisters as a new ‘family’.
Communication: As well as the traditional nursing handovers there is a daily board round and a weekly MDT meeting for all patients.
Within each patient’s room there is a communication board.
Each patient has individualised goals that are reviewed weekly and are accessible to them in their rehab folder along with exercise sheets and useful information.
Families and carers are involved where appropriate and patients have regular Future Planning Meetings to agree the correct discharge destination and pathway.
Environment – the ward consists of individual rooms with ensuite bathrooms affording privacy. There are specific therapy areas for exercise and rehabilitation focused activity. The unit is well equipped with a variety of specialist equipment.
Evidence based practice underpins treatment interventions which are mostly individual but group activity also takes place and is enjoyed immensely by patients and staff e.g. physical exercise, relaxation, art, singing, breakfast, garden, communication groups.
Voluntary services are involved and patients benefit greatly from befrienders and a visiting artist (ReConnect), volunteer visitors, Down – to- Earth gardening organisation and the Stroke Association for example.
The Hospital’s League of Friends continue to support us harnessing local support and fundraising for various items requested to improve quality of rehabilitation.
Patient flow through the pathway is ensured by effective communication with the Acute Stroke Unit and the Early Supported Discharge Team for Stroke on a day to day basis. Regular formal meetings are also held to monitor the pathway and quality of care given throughout.
Training and education are essential to fulfilling our purpose of being a specialist unit. This is achieved by providing regular in-service training, allowing and encouraging staff from different professions to shadow each other and providing visible resources and advice on the ward. Nurse apprenticeships have been completed and one of our Rehabilitation Assistants has just started a level three therapy apprenticeship. Staff are also encouraged to attend external courses.
Specialist nurse link roles e.g. continence, support current best practice and learning.
Provision of undergraduate training and education is also an important aspect for us looking to the long-term continuation of specialist units. We have already provided several clinical placements.
The unit has access to and support from other services e.g. orthotics; orthoptics; continence service etc., which are essential to comprehensive and holistic rehabilitation.
When and if it is safe and effective for patients to have rehabilitation in their own home, they will receive ongoing support from the Early Supported Discharge (ESD) team, including community stroke specialist nurses, specialist therapists and rehabilitation assistants.
Outcomes and Impact
The success of the unit depended upon having a shared vision, careful implementation of change, acceptance, collaboration and team working. It demanded new ways of working, new relationships, integration into whole of life in the community hospital.
There is continuous evaluation of the service provided through:
The Stroke Sentinel National Audit Programme (SSNAP) for which the unit achieved an overall ‘A’ on a scale of A – E for first 3 complete quarters putting the unit in the top 30%.
Quarterly internal audits are carried out using validated outcome measures to demonstrate clinical outcomes e.g. Barthel score for Activities of Daily Living, and patient confidence and experience.
Patient flow is monitored through length of stay and facilitated by the application of admission criteria.
Patient experience (Friends + Family test) highlights excellent feedback as do the great number of ‘Thank you’ cards and letters written form patients and relatives.
For example:
- § Fantastic service provided by all at this unit. My progress in 4 weeks is amazing. I can talk and walk much better compared to when I first came
- § The staff have been fantastic in caring for my mum.
- § Fantastic help from all the therapists. Couldn’t have asked for more from all the staff here. The staff were always willing to take the time to talk to me
- § I have been very happy with my stay. I have made good progress since I came to The Vale – I can now walk with a stick. The nurses and cleaning staff have all been lovely.
- § I would like to thank the staff. They have all been excellent. I feel the therapists work very hard and they have done a great job in helping me to recover.
- § Wonderful encouragement from all the staff which I feel has had a positive influence on my recovery
- § Very efficient, mostly kind and helpful. Welcoming to visitors. It is well staffed so usually people around. Good mixture of encouraging independence and providing care when needed. Everything was kept very clean and maintained to a high standard. Good activities such as art, garden and physio. There was a chance to socialise over meals.
This is all quite affirming and contributes to the positive feelings colleagues have about working here. A formal review of the redesigned pathway was carried out after 6 months the results of which were favorable. An action plan was made and again reviewed.
Good practice is shared throughout the Gloucestershire pathway and the North South West Integrated Stroke Digital Network, a regional forum that reports to the national Stroke forum. As a team we have visited and hope to visit other centres of excellence as future developments and ongoing improvements remain as important as ever. In turn we have been approached by other developing units to share our practice.
Locally, community hospitals with in our Trust have visited and taken way good ideas such the format for our MDT meeting and the development of the generic rehabilitation assistant role. The Stroke Rehabilitation Unit provides an opportunity for rehabilitation to all new, adult Stroke patients throughout the whole of the county of Gloucestershire meeting minimal criteria.
All patients are assessed and have a bespoke plan according to their individual needs to optimize their potential for rehabilitation. Patient’s wishes are always taken into consideration when planning for their future.
Another particular example is the way in which patients with communication difficulties (often caused by the Stroke) are supported on the unit through communication aids, and training of all staff by the Specialist Speech and Language therapists.
Consideration is given to accessibility of the unit in terms of location, advising families on visiting and making use of virtual technology for contact as an alternative to physical visits (particularly since the outbreak of the Corona Virus COVID-19 pandemic)
Staff take pride in their adherence to Gloucestershire Health and Care NHS Foundation Trust values: Working Together, Always Improving, Respectful and Kind, Making a Difference.
This has been a highly collaborative project and much work was done over a number of years to lay the foundations for its success. Many people are to be commended in its inception and design.
The 20 months since Feb 2019 have been very busy bringing together a new team of colleagues becoming a big part of the heart of the Vale Community Hospital.
Members of the new team feel privileged to have had this rare opportunity of being a part of setting up a new unit. Therapy staff have recently contributed to a short film for Allied Health Professional (AHP) day and are all pleased to be a part of this multidisciplinary unit. As is the case across all services within NHS organisations the unit has been affected by the pandemic COVID-19. In response to the demands on the Acute Trust, all 20 of our beds became Stroke beds. We continued to function as a specialist rehabilitation unit throughout and had the benefit of redeployed therapy colleagues coming to work here. This has been our biggest challenge and the new ways of working continues to be so. Despite this, colleagues have adapted, remained dedicated and supportive towards each other and our patients continue to benefit from their time here. We have been very well supported by our local community ever since opening but particularly throughout the pandemic.
Ongoing projects include the completion of a spasticity pathway and our future aspirations include the being involved in research trials to support the advances in Stroke rehabilitation.
By providing a community bed-based service here at Vale Community Hospital, the in-patient part of the rehabilitation journey for patients following a stroke can continue in a suitable, fit-for-purpose environment.
Quote from a physiotherapist redeployed due to the pandemic COVID-19 :
“I really enjoyed my time at The Vale during redeployment. It is a great team to work with, everyone is so supportive and approachable.
Despite it being a really tough and scary time, especially in the first few months of April-June, I felt a great sense of team spirit and that our line managers were supportive and concerned with their staff’s mental wellbeing as well as physical which was really important. I particularly felt the offer of staff “drop in” sessions with psychology was a great service to be offered to those that needed it.
It was a busy time for everybody with the increase in stroke beds on the ward, however I felt everyone had a great appreciation and respect for each other’s roles and the different pressures they were under as a result, and tried to help each other as much as they could.”
