St Richards Hospital

Clinical challenge
Until June 2018 St Richards hospital (part of Western Sussex Hospital NHS Trust ) had been providing a 5 day  ‘in hours’ stroke thrombolysis service operating Monday to Friday 9-5 covered by Stroke Specialist Nurses and on-site Stroke Consultants  with a divert agreement in place with Portsmouth Hospitals NHS Trust out of those hours.  The reasons behind this were historic based on Stroke Consultant availability to cover a 24 hour rota and lack of availability of Stroke Nurses.

SSNAP data showed a thrombolysis rate Jan to March 2018 of only 7.3%. Local data showed that nearly 50% of our stroke admissions were occurring out of hours (ie, not Monday to Friday 9-5 ) and, due to staffing, those  patients who arrived at the hospital out of hours could only be seen by a nurse trained in stroke management once they arrived on the Stroke Unit.  The Stroke Team were keen to offer thrombolysis to all our patients 24 hours a day on the St Richards site.

Solution
St Richards and Worthing Stroke Consultants already shared cover for 24 hour thrombolysis provision at the Worthing Hospital site.  An agreement was made that they would now share cover for the stroke thrombolysis service out of hours, providing 1 in 7 weekend and overnight cover to both sites using telemedicine.

A close working relationship with A+E and Radiology was already in place at St Richards to provide in hours thrombolysis cover. Reviewing nursing numbers on the stroke unit showed that providing 24 hour stroke nurse cover using current numbers was not possible since active recruitment to create 3 band 6 nurses had resulted in 2 posts coming from within the current establishment.  A+ E were keen to be involved in extending the stroke thrombolysis service: “if we are going to provide 24 hour thrombolysis in A+E then we want to do it”.  Following discussions around logistics and training needs it was agreed that stroke nurse cover would be shared between A+E and the Stroke Unit with a plan that  A+E would have a stroke trained nurse available to cover 8pm to 8am 7 days a week and the Stroke unit to cover 8am to 8pm 7 days a week.

A training programme was put in place to train Stroke Unit and A+E Nurses (all band 6 and above or senior band 5s in A+E ) to:

• have an understanding of acute stroke and indications for thrombolysis
• be aware of stroke mimics
• be able to perform the NIHSS, operate the telecart, draw up and administer alteplase
• provide post-thrombolysis care until the patient reached the stroke unit.
• perform a swallow screen

Impact

1. 24 hour thrombolysis was implemented on 4^th June 2018. There was an immediate significant increase in the % of our stroke patients who were thrombolysed . This has been sustained and in July 2018 a thrombolysis rate of 30% was achieved.  Overall, since June an average thrombolysis rate of 18.25% has been achieved
2.  In addition since June  median time to Nurse trained in stroke management has significantly decreased  to 20.25  minutes.
3. Since starting 24 hour thrombolysis in June an average of 71% of patients have been thrombolysed within one hour (SSNAP National  % Apr to Jun = 63.6%) and a median door to needle time of 49.75 minutes June to September has been achieved ( SSNAP National median April to Jun =50 minutes) This demonstrates there has been no detrimental effect from using Stroke Unit and trained A+E Nurses to provide this service.

Reflection
Providing this service would not have been possible without the agreement of  the Stroke Consultants to cover both sites when on call. Training up A+E Nurse was a practical solution to a shortage of stroke nurses on the stroke unit, but was only possible because of the enthusiasm and commitment from the A+E staff to engage in training and the willingness of the Stroke Unit nurses to work together to provide 24 hour cover.

In practice there has been give and take with swapping of shifts when necessary and occasions when, even with support from A+E, having a stroke trained nurse available to see every stroke patient has not been possible. However all thrombolysis calls can now be responded to immediately 24 hours a day and we are able to sustain a high quality thrombolysis service using either Stroke unit Nurses or A+E stroke trained nurses.

New nurses to A+E and the Stroke Unit are receiving stroke training as an ongoing programme. However, in order to maintain this service, regular review, audit and ‘top up’ training will also be implemented.

A shortage of A+E nurses and winter pressures may affect the availability of A+E staff to continue to support this service in the longer term.