RCP: Better community care needed to help stroke victims recover

Thursday, 19 August 2010 12:00 AM

Short falls with community rehabilitation services are undermining the advances in acute medicine for patients who have suffered a stroke, according to a new report produced by the Royal College of Physicians.

For the first time the Sentinel Stroke Audit, commissioned by the Healthcare Quality Improvement Partnership (HQIP), has investigated the follow-up care that patients receive when they are discharged from hospital. It shows that while many aspects of acute care have improved, post acute services have not kept up and there is a lack of access to long term rehabilitation services, particularly to help people return to work.

Over one in ten people in the UK die from a stroke, and every year an estimated 150,000 people have a stroke. It is the third largest cause of severe disability with 250,000 people living with a severe disability caused by stroke.

100% of eligible services in England, Wales and Northern Ireland took part in the audit which is in its twelfth year. The audit shows a dramatic increase in the number of units providing 24 hour, seven day a week access to clot-busting drugs (thrombolysis). There has also been a five-fold improvement in the number of stroke patients receiving thrombolysis over last year's figures but this is still only 4% compared to the 10-15% figure being aimed for. Fast access is vital to gain the greatest benefit from this treatment which is to prevent long term disability. With further improvements in thrombolysis services, another four to five people every day could expect to survive their stroke without long term disability if they had access to the right specialist treatment at the right time.

There is a major concern that many patients are being transferred from stroke units to non specialist beds in community hospitals where there is no access to the type of specialist multidisciplinary stroke care that has been shown to reduce disability and mortality. This is presumably being done to reduce costs but is likely to be resulting in exactly the opposite with less effective rehabilitation and more long term dependency.

Fewer than half of hospitals have access to stroke-specific services known as Early Supported Discharge (ESD), despite evidence showing that patients fare significantly better when such services are available. Where ESD is in place the care being offered is not timely. Just over half of stroke units have access to longer term community rehabilitation services. Failure to support people who have suffered a stroke impacts upon the extent and speed of their recovery, putting pressure on the welfare system and causing misery to them and their family and carers.

There continues to be a problem ensuring that patients are admitted directly to stroke units instead of being treated on general wards where the care is significantly worse than on specialist acute wards. For example, patients are reviewed more frequently and nurses on specialist wards are trained to perform screening for safe swallowing after stroke which is not the case on general wards.

This report also shows there has been progress in the care given to people who have suffered a Transient Ischaemic Attack (TIA) or mini stroke, but many areas are still too slow and there is a lack of scanning to identify whether urgent Carotid Endarterectomy (CEA) is necessary as stated in NICE guidance. Many hospitals are still not achieving this standard.

The key findings of the report include:

74% of patients are now getting some access to clot-busting drugs (thrombolysis)
While 98% of hospitals now have a neurovascular clinic, the median wait from referral to being seen in one is 3 days.
36% patients are still being treated on a general assessment ward 24 hours after being admitted to hospital with a new stroke.
Almost half of sites report the need to admit patients to non-specialist wards because of bed shortages.

44% of stroke services have an available specialist ESD team.
28% of patients discharged to specialist ESD teams are still waiting over 48 hours for physical therapy, occupational therapy or speech and language therapy.
55% of stroke services have access to specialist community rehabilitation team.
43% of high risk patients with suspected TIA are seen on the same or the next day.
85% of low risk patients with suspected TIA are seen within a week.

Key recommendations include:

Patients with acute stroke should be admitted directly to a specialist stroke unit and have access to continuous physiological monitoring. General assessment units are not an adequate substitute. Standards of care offered in all specialist stroke beds should meet those defined in the National Clinical Guidelines for Stroke 2008.

Stroke services should be organised to deliver thrombolysis to all appropriate patients regardless of where they live or the time of day or week they present. Patients requiring end of life care should be able to receive such care to a high standard on a stroke unit. Vocational rehabilitation should be made available to all stroke patients wishing to return to work.

Care of stroke patients transferred to community hospitals should meet the standards defined for specialist stroke unit care set out in the National Clinical Guidelines for Stroke 2008.
All services should be able to deliver high quality specialist early supported discharge to appropriate patients.High quality longer term rehabilitation should be provided to all patients who require on-going treatment without undue delay. Facilities to investigate high risk patients after TIA should be available at all times including weekends.Information provision should be improved to provide universal access to all in-patients and out-patients.

Dr Tony Rudd, Chair of the Intercollegiate Stroke Working Party, said:

'This report shows how much progress has been made in many aspects of stroke care around the UK over recent years. I think the most concerning aspect of the report is the previously unreported heavy use of intermediate care beds instead of keeping patients in specialist stroke units or discharging them home to be managed by specialist stroke teams in the community. We should be using the processes that we know from research are effective at reducing death and disability.'

Joe Korner Director of Communications at The Stroke Association, said:

'It's fantastic to see that such positive progress has been made in acute stroke care, especially with such a dramatic increase in the number of patients getting access to clot-busting treatment. But it is of great concern that more than a third are still being treated on a general ward 24 hours after getting to hospital. They are not getting the immediate specialist treatment they need and are at risk of having much worse outcomes.

'It's clear that a large number of stroke survivors being discharged from stroke units aren't receiving the specialist community care that they need. It is vital that when stroke patients are discharged they receive this specialist care to ensure they are given the best possible chance of regaining their lives after stroke.'

Kamini Gadhok, Chief Executive of the Royal College of Speech and Language Therapists (RCSLT) commented:

'Access to timely and appropriate care following a stroke is vital. As the Department of Health pointed out in 2007, over one in three people who have had a stroke will suffer problems with their speech, language and communication. In 2005, the National Audit Office highlighted how 'Early Supported Discharge (ESD), facilitated by a multi-disciplinary team, reduces length of stay, thereby increasing inpatient bed capacity and can help the patient adapt to life at home'.

'The 2010 Audit's findings are deeply concerning - that only half of all post stroke patients are seen by a speech and language therapist within 48 hours of referral, when it is integral to the definition of a ESD team, that appropriate therapy is provided within two days of the transfer of care from hospital.

'In addition, stroke survivors who are inpatients at one of the UK's 298 community hospitals are also unable to access the level of speech and language report they require, with only 55% having five-day-a-week access to speech and language therapy, potentially putting their long terms recovery at risk.

'Stroke is the leading cause of disability in the UK, with 300,000 people living with some of disability as a result of stroke. Speech and language therapy is essential to helping stroke survivors to live an independent life and through early intervention we can not only help people rebuild their lives but also reduce their long term dependency on NHS services. The RCSLT is working to ensure everyone who needs access to this kind of essential support can receive it.'

Natalie Beswetherick, Director of Practice and Development at the Chartered Society of Physiotherapy (CSP), said:

'This audit again shows the difficulties that exist in providing patients with the ongoing specialist support they need after being released from hospital. There is real frustration among physiotherapists at the lack of progress on this front. Early access to physiotherapy and ongoing, tailored rehabilitation can play a key role in helping stroke survivors maximise their mobility and independence.

'It is important to remember that any money saved by not extending treatment is lost many times over in the wider economy by preventing the patient from recovering sufficiently to return to work or to live independently. 'We need to ensure that the progress achieved in acute care for stroke survivors is replicated in terms of better access to physiotherapy after leaving hospital.'

A joint CSP-Stroke Association survey released in March this year revealed that 83% of physiotherapists believed the process of transfer of care for stroke patients from hospital to home could be tailored to each patient's needs.

Nearly two thirds of physiotherapists felt that current systems and resources limited what they could achieve with their stroke patients. Amy Edwards, professional affairs officer for long term conditions at the College of Occupational Therapists, commented:

'This report shows the need to ensure adequate provision of care for stroke patients for the whole of the care pathway, so that the improvements which have been made in acute management are not subsequently offset by a lack of on-going and timely rehabilitation.

'Occupational therapists have a key role to play in ensuring that patients return to the best possible quality of life following stroke, whether this is through intervention at the acute phase, through making provision for early supported discharge (for appropriate patients), or through providing on-going rehabilitation in the community. Obviously such provision requires adequate numbers of trained healthcare professionals, including occupational therapists. Although the findings from this audit show that there is room for improvement in the follow up care that patients receive when they are discharged from hospital, it is welcome that this aspect of care has been investigated; it is only by clearly demonstrating shortfalls in provision that these can begin to be addressed.

'Some of the findings of the report echo those of the National Audit Office Progress in improving stroke care It is hoped that some of the specific measures in the 'Accelerating Stroke Improvement' initiative which, for example, target early supported discharge and follow up in the community will help to address some of the recommendations made in this report.'

Julia Skelton, chief executive at the College of Occupational Therapists, commented:
'Access to good quality and on-going rehabilitation is critical for stroke patients, especially given the sudden decline in functioning which many of them will have undergone. The findings of this report highlight the need for good quality, ongoing and timely rehabilitation, both to ensure maximum independence and quality of life for patients and their carers, and to reduce the overall costs of ongoing support.

'It is particularly welcome that the need for vocational rehabilitation has been highlighted. Occupational therapists working in various settings, such as occupational health teams, Access to Work and Pathways to Work schemes, as well as those working in health and social care, are well placed to advise on or provide such rehabilitation. There is a need however for collaboration and good inter-agency working to ensure that those who need specialist vocational rehabilitation receive this.'

ENDS

Notes to Editors

The Healthcare Quality Improvement Partnership (HQIP) is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its aim is to promote quality improvement, particularly the impact clinical audit has on healthcare quality in England and Wales. HQIP manages and develops the National Clinical Audit and Patient Outcomes Programme (NCAPOP), which currently comprises 30 clinical audits covering an extensive range of medical, surgical and mental health conditions.

The full report can be found here: www.rcplondon.ac.uk.

For further information, pleas contact Linda Cuthbertson, PR manager, at the Royal College on Physicians on 020 3075 1254 or linda.cuthbertson@rcplondon.ac.uk.

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