Linda Dobrzanska, MSc, RN, DipN, PGCert Health Care Eval, is research and development coordinator; Liz Young, BSc, RN, DipN, is community matron, both at Bradford City Teaching Primary Care Trust; Chris Patterson, BSc, MB, ChB, FRCP, is consultant stroke physician, St Luke?s Hospital, Bradford.Stroke rehabilitation in a community hospital
Dobrzanska, L. et al (2006) Stroke rehabilitation in a community hospital. www.nursingtimes.net
Stroke is the third most common cause of death in the UK, and most patients who have suffered a stroke are admitted to an acute NHS hospital for immediate diagnosis, assessment and management. This paper describes a pilot scheme that allowed the early discharge of patients from the local acute NHS trust hospital into a community hospital. A multidisciplinary approach was adopted, admission criteria were set and staff in the community hospital were given training in stroke rehabilitation.
Stroke is one of the three main causes of death and a major cause of long-term disability in the UK (Donnelly et al, 2004). Stroke patients are normally admitted into an acute NHS hospital for immediate diagnosis, assessment and management, as outlined in the National Service Framework for Older People(Department of Health, 2001a). Standard 5 of the NSF states that every general hospital caring for people with stroke should have plans to introduce a specialised stroke service from 2004.
Intermediate care has become an increasingly important aspect of health provision to ensure active recovery and rehabilitation for some patient groups and to prevent unnecessary loss of independence for older people and other care groups (DH, 2001b). The DH developed a standard definition of intermediate care, suggesting an intermediate care episode should typically last no more than six weeks. However, some patients, such as those who have suffered a stroke, may require intermediate care for longer.
Studies have shown that early discharge from a stroke unit with rehabilitation in the community (usually the home setting) leaves patients no worse off across a wide range of clinical and quality-of-life measures (Rodgers et al, 1997). Donnelly et al (2004) found a 'mixed model' approach (acute and community care) increased patient choice and satisfaction. However, comparisons between community hospital-based and home-based stroke rehabilitation are not well documented. It is against this background that the present project was undertaken, in the hope of adding to the body of knowledge and evidence to support the use of community hospitals for stroke rehabilitation.
There are three primary care trusts in Bradford Metropolitan District (population 500,000). North Bradford PCT (population 94,000) managed four community hospitals until April 2005, after which two were managed by the other PCTs, leaving North Bradford PCT with two community hospitals.
The first 18-bed community hospital (Shipley) opened in 1996. However, due to its location at one end of the area covered by the PCT, it was decided to open another (Eccleshill), also with 18 beds, at the other end, thus allowing patients choice on location for intermediate care facilities.
EccleshillCommunityHospital was opened in January 2004, providing intermediate care for patients aged 65 years and over, palliative care and admission-avoidance work with GPs accessing services for patients straight from the community. Patients are admitted for up to six weeks as outlined in the NSF (DH, 2001a). The hospital is managed on a daily basis by a local GP, and overseen on a weekly basis by a consultant specialising in care of older people from the local acute NHS trust. However, stroke rehabilitation is provided in the local acute NHS hospital's dedicated stroke unit, where the experience and training of the staff has been considered more appropriate.
Pursuing Perfection programme
The Pursuing Perfection programme was developed by the US-based Institute for Healthcare Improvement (IHI) with the aim of 'raising the bar' in healthcare to provide patients with world-class services. This international programme ran in 13 sites across the world, with four in the UK. One of these was Bradford (NHS Modernisation Agency, 2003), where it examined overall stroke services and found that some patients did not receive coordinated care.
Following the end of the Pursuing Perfection programme, a six-month pilot project was undertaken in Bradford allowing the early discharge of stroke patients from the local acute hospital into Eccleshill community hospital. Patients were to have a full assessment in the acute hospital, and those who fulfilled the strict admission criteria would be offered a choice of staying in the acute hospital or transferring to Eccleshill community hospital for their rehabilitation.
The project was monitored using Plan, Do, Study, Act (PDSA) cycles overseen by the PCT's PDSA leader. These cycles are a process model for quality improvement adopted by the IHI. The study aimed to determine whether a change leads to quality improvement and tested the idea in the real work setting (IHI, 2003).
A multidisciplinary approach was adopted, with team members including: The PDSA leader;
- A ward sister from the community hospital;
- A neurophysiotherapy specialist;
- A senior physiotherapist from the acute hospital;
- A community occupational therapist;
- A speech and language therapist;
- A member of the North Bradford PCT nurse case-management team;
- A consultant in care of older people;
- A social service representative;
- A dietitian.
The new service aimed to provide coordinated care to patients fulfilling the following criteria:
- Age over 55 years;
- Medically stable (due in part to limited medical cover within the community hospital);
- Requiring no more than two staff to handle;
- Registered with a GP within North Bradford PCT;
- Acute hospital therapy assessment prior to transfer;
- Receiving adequate nutrition (due in part to limited access to speech and language and dietetics service);
- Cognitive assessment prior to transfer.
The nurse case manager at this time facilitated early discharge from the two local acute NHS hospitals into intermediate care facilities for North Bradford PCT patients. Her work enabled her to visit every ward in the two hospitals and review all patients admitted with a North Bradford PCT GP. It was agreed that the nurse case manager was the best person to identify appropriate patients and liaise closely with the ward sister from Eccleshill community hospital regarding bed availability. The community hospital would take between three and six stroke patients at any one time depending on bed availability.
Education and training
Although care was to be provided by existing staff within the community hospital, they needed updating in stroke care. An awayday was organised where they would receive education sessions from the appropriate professionals on neurological rehabilitation, occupational therapy, speech and language services and nutrition. Feedback on the training was positive: staff confidence increased and relationships were built within the multidisciplinary team.
After transfer to the community hospital, each patient received a comprehensive multidisciplinary stroke rehabilitation programme. The physiotherapy team saw each patient, with enhanced support from the neurorehabilitation team. The speech and language support services also offered input in order to supply a more specialist and intensive service, which this patient group often requires. The dietitian responsible for all community hospital admissions monitored food intake, advised on nutritional supplements, had input where patients were taking an altered-texture diet and assessed patients for malnutrition using the Bradford Adult Nutrition Assessment Chart Malnutrition Quotient. This simple validated nutritional assessment tool was developed within Bradford to identify patients at risk of malnutrition by using combined scores of body mass index and mid-arm circumference, and replicates a more invasive and complicated means of nutritional assessment. Each senior nurse had an associate nurse and a team of healthcare assistants dedicated to providing stroke rehabilitation.
Seven patients were admitted into the project over a six-month period. It was considered appropriate to limit the number of patients to implement the PDSA cycle. To evaluate the project, staff were trained to record recognised, validated outcome measures for each patient on admission to the community hospital and again on discharge.
The Barthel Index was considered the best available measurement of the activities of daily living (Fig 1). This simple index of independence in the basic physical functions underlying normal living (continence, mobility, washing, dressing and diet is useful in monitoring improvement in the rehabilitation of chronically ill patients (Mahoney and Barthel, 1965).
The Waterlow score was considered an effective pressure ulcer risk assessment scoring system (Fig 2), as it is recommended a scale that has been tested in the same specialty is chosen (RCN, 2005). However, as RCN guidelines (2005) indicate, risk assessment tools should be used as an adjunct to, rather than a replacement for clinical judgement. Risk assessment is an essential precursor to pressure ulcer prevention. Scott and Newens (1999) found that the Waterlow system was used in 88% of 204 acute hospital trusts.
Rivermead Mobility Index
The Rivermead Mobility Index measures patients' ability to move independently (Fig 3). It does not measure the effective use of a wheelchair or mobility when aided by someone else. It was developed at the Rivermead Rehabilitation Centre in Oxford and is a valid score for assessing mobility in stroke patients (Collin and Wade, 1991).
Trunk Control Test
The Trunk Control Test (Fig 4) evaluates patients' trunk control following a stroke and examines their ability to roll from a supine position towards the 'weak' and 'strong' sides, and to transfer from supine to sitting position (Franchignoni et al, 1997).
All the outcome measures showed positive results, and have enabled the project team to demonstrate the success of coordinated care patients in the community hospital environment who have mild-to-moderate rehabilitation needs
The PDSA team leader held focus groups throughout the project asking for feedback from patients and their carers. Informed consent was obtained from the patients who transferred to Eccleshill community hospital and the team leader ensured they had a full understanding of the project. The focus groups were patient-led and highlighted patients' desire to be offered a choice of location for their stroke rehabilitation. Comments from the seven patients also suggest that the introduction of community hospitals has been successful. Examples of comments received were:
Patient 1: 'So much easier for my husband to visit.'
Patient 2: 'It's easier for all my family.'
Patient 3: 'Easier for friends to visit? nice nurses? near home.'
Patient 4: The patient's main carer, a daughter, stated she could come and go as she pleased.
Patient 5: 'Provided smaller, safer environment.'
Patient 6: 'Local to area.'
Patient 7: 'Provided less confusing surroundings.'
Before the project the different professions worked independently of each other, but this has shown that close multidisciplinary working can work well. The team in Eccleshill community hospital had the opportunity to work alongside specialist therapy staff, which enabled them to develop skills in stroke care and to build their confidence in caring for patients who have had a stroke. Other PCTs in the area have shown interest in transferring the project into their own community hospitals. The way the initiative was set up meant it had no financial implications for the PCT.
The patients have all benefited from the community hospital's proximity to their own homes, family and friends, which allowed them to receive more appropriate and timely stroke care within the community setting.
This pilot has demonstrated that patients who have had a stroke can be rehabilitated successfully in a community hospital setting, with support from specialist stroke teams. Further randomised controlled trials could explore whether such intermediate facilities could provide equivalent care to organised rehabilitation units.
Since the pilot project scheme in 2004-2005, community hospitals throughout the Bradford area are working towards identifyingstroke patients who are suitable under the criteria mentioned earlier. This will involve providing specialist outreach services including physiotherapy, occupational therapy, speech and language services and dietetic services.
To improve the standard of stroke services provided to patients, courses are currently being devised for staff from all areas of stroke care, which will continue to develop cross boundary, multidisciplinary working.
Collin, C., Wade, D.(1991) The Rivermead Mobility Index: a further development of the Rivermead Motor Assessment . International Disabilities Studies; 13: 50-54.
Department of Health(2001a) National Service Framework for Older People.London: DH.
Department of Health(2001b) Health Service Circular 2001/01: LAC (2001)1. Intermediate Care.London: DH.
Donnelly, M. et al(2004) Randomised controlled trial of an early discharge rehabilitation service: the Belfast Community Stroke Trial. Stroke;35:1, 127-133.
Franchignoni, F.P. et al(1997) Trunk Control Test as an early predictor of stroke rehabilitation outcome. Stroke;28: 1382-1385.
Institute for Healthcare Improvement (2003) A Resource From the Institute for Healthcare Improvement. Available from: www.ihi.org.
Mahoney, F.I., Barthel, D.W.(1965) Functional evaluation: the Barthel Index. MarylandStateMedical Journal;14: 56-61.
NHS Modernisation Agency(2003) Pursuing Perfection. Available online from: www.modern.nhs.uk.
Rodgers, H. et al(1997) A randomised controlled trial of early supported discharge following acute stroke comparisons at discharge. Age and Ageing; 26: (Supplement 1), 28.
RoyalCollegeof Nursing(2005) The management of pressure ulcers in primary and secondary care. A Clinical Practice Guideline. London: RCN.
Scott, F., Newens, A.(1999) Hospital monitoring of pressure ulcers in the UK. Journal of Wound Care; 8: 5, 221-224