Safely Reducing Avoidable Conveyance Programme

Stroke Video Conferencing

Brief Description of Initiative

LAS and UCLH have set up Video Conferencing from scene to assist in the triage and treatment of patients suffering from symptoms of stroke.

Patients are assessed and triaged to either the HASU, the TIA clinic or the local ED.

Date Initiative was introduced in Trust

18th April 2020.

Date of upload or review

Uploaded to Repository 18th July 2020.
Updated on Repository 26th Feb 2021.

Introduced as part of COVID-19 response?

Yes.

Background Context

Traditionally, all FAST positive patients are taken to the HASU for further assessment. All TIA patients are taken to the Local ED for assessment.

During COVID-19 LAS and UCLH saw an opportunity to enhance the triage of these patients to ensure that they were conveyed to the best place for their presenting condition.

Which specific patient group or presenting need is this response targeted at?

Patients suffering from stroke type symptoms.

Geographical area or location covered by this response model

North Central London, population circa 1.27 million.

Key Aims
  • Ensure the right care at the right place first time for patients suffering from stroke symptoms
  • Faster door to needle times for patients requiring intervention
  • Reduction in number of stroke mimics presenting at the HASU
  • Reduction in number of patients suffering from low risk TIAs attending ED departments.
Benefits for Patients
  • Minimised exposure to Covid-19
  • Enhanced neurological assessment from a multi-disciplinary team
  • Faster treatment at a local ED if the likely diagnosis is non stroke
  • Treatment for Stroke at HASU even if FAST –VE.
Benefits for Trust or System
  • Reduction in secondary transfers
  • Reduction in Job Cycle time
  • Educational benefit for LAS clinicians
  • Reduction in number of non-stroke patients arriving at HASU
  • Increase in the number of patients who can be treated directly at the HASU with subtle signs of stroke
  • Faster door to needle time as HASU clinicians are better briefed on the incoming patient

 

Implementation

1.     How long has this initiative been operational?

Since May 2020.

2.     Days / Hours of operation:

24/7 since 15th May 2020.

3.     Which clinicians are involved in the response and how many WTEs (if a specific cohort)?

UCLH (Queens Square Stroke Consultants)

Circa 180 LAS A&E staff of all grades.

4.     Which other partners are involved in providing the response?

The Emergency Departments of North Central London. (Barnet, Whittington, Royal Free, North Middlesex, Royal Free Hospital).

The TIA clinics of North Central London.

5.     What other key resources are needed for this response to work? (vehicles, specific equipment etc)

Apple iPad / iPhone, with Apple ID.

6.     How is the initiative funded? (level of engagement/support from CCGs / COVID funding etc)

LAS use existing hardware. No additional funding was required.
UCLH (TBC)

7.     What were the main facilitators / blockers / interdependencies when introducing this response?

Facilitators: Clinical leadership from UCLH and LAS.

Blockers: Data security and risk.

Interdependencies: Technology (Apple), shared information.

Evaluation & Monitoring

1.     What are the key success measures?

  • Number of patients suffering from low risk TIA safely referred to TIA clinics
  • Number of patients suffering from Stroke mimics safely conveyed to ED
  • Improvement in call to needle time
  • LAS Job Cycle time

2.     How are these being measured / collated / monitored?  (frequency / who reported to etc)

Every patient’s outcome is being tracked. The call time for the video conference is recorded.

Feedback mechanisms have been set up between LAS and UCLH, UCLH and TIA clinics and UCLH and Local EDs.

A scrutiny board meets regularly to review the cases and the safety of the pathway.

3.     Has a formal evaluation process been undertaken (independent / inhouse)?

There is an independent qualitative evaluation being undertaken.

4.     What are the current findings in terms of the success measures?

1000+ patients
Of the 776 analysed, the pathway:

  1. Reduces the number of non-stroke conveyances by 38%
  2. Reduces AE conveyances for video triaged patients by at least 16%
  3. Allows high risk TIA cases to be managed within a few hours rather than 24 hours
  4. Appears to be safe and reliable
  5. May reduce the absolute and range of thrombolysis and thrombectomy times

 

Sustainability

1.     Does the trust intend to continue with this response for the foreseeable future?

Decisions to expand to the rest of London will be taken following an evaluation.

2.     What long-term resourcing requirements are there?

No obvious adverse impact for LAS.  UCLH will need to provide 24/7 on-call cover.

3.     What risks have been identified (for patients / trust / system) in providing this service and how have these been mitigated?

Risk: Extended on scene time.

Mitigation: call times must be kept to a minimum especially for patients who may require thrombolysis. There is a set script which is followed by the UCLH stroke consultant.  A maximum of two attempts should be made in the space of 5 minutes to contact the stroke consultant from scene.

Risk: incorrect diagnosis.

Mitigation: Any decision outside of JRCALC is the responsibility of the stroke consultant. If the LAS clinicians on scene disagree with the decision of the consultant they have been empowered to revert to their normal pathways.

4.     Is there potential to expand this response model?

There is potential to expand. Many of the HASUs in London have expressed an interest in the evolution of the pathway.

Sharing & Learning

1.     What has the trust learnt most from introducing this process?

  • Vital to have feedback mechanisms in place to address issues early.
  • Use the QSIR sustainability model before starting the pathway. It works.
  • Essential to have clinical leadership, operational leadership and executive leadership from the start.
  • Ambulance clinicians have reported feeling empowered by the pathway as they are able to discuss the case with an expert and go outside normal guidelines to achieve the best care for their patient.

2.     What might be done differently with the benefit of hindsight if implementing again? (in another part of the trust for example)

The technology existed for this to have been implemented pre Covid-19.

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Please note, this enquiry facility is for the use of NHS colleagues to find out about the set up of this initiative. Patient enquiries about a case or care experience need to go direct to the relevant ambulance NHS trust.

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