How advanced training turned around our stroke care service
The advanced nurse practitioner programme was the key to better, more timely patient care
The advanced nurse practitioner programme was the key to better, more timely patient care
- The acute stroke service at University Hospital Southampton NHS Foundation Trust underwent a radical overhaul as it was falling short of national targets
- Nurse specialists trained as nurse practitioners and advanced nurse practitioners (ANPs), undertaking a master’s-level training programme
- ANP training allows you to practise with greater autonomy and challenge perceptions about nurses’ roles
In 2014, our acute stroke service was not meeting the required national standard.
The team of five whole-time-equivalent nurse specialists would take new referrals between 7.30am and 5pm and coordinated the stroke pathway through University Hospital Southampton NHS Foundation Trust. They were trained to do National Institutes of Health Stroke Scale assessment (NIHSS), but needed a medical review to complete their admission clerking, prescribing and requesting of further investigations.
The specialist nurse would request blood tests but doctors would request other investigations. Out of hours, intravenous (IV) thrombolysis was managed by the emergency department and the on-call neurology registrar.
What we needed to do to become a regional referral centre
We were missing the four Sentinel Stroke National Audit Programme (SSNAP) admission targets that measure the quality and standard of stroke care – a CT scan within one hour of arrival, IV thrombolysis within one hour of arrival, admitted to a stroke bed within four hours of arrival, and a swallow assessment within four hours of arrival.
To address these issues, we opened a hyper acute stroke unit (HASU) in the Wessex Neurological Centre, with the aim of eventually becoming a regional referral centre for endovascular treatments and those at risk of requiring neurosurgery due to stroke.
It was clear a more highly trained workforce was needed, so over the past five years we have developed into a team of nurse practitioners and advanced nurse practitioners (ANPs) by completing a master’s-level training programme. This has transformed the service and provided patients with prompt, expert, time-critical treatments.
Transforming the service through staff education
The team of ten whole-time-equivalent staff members, led by lead ANP for neurosciences Lucy Porter, has managed the change by developing expanded scopes of practice.
Nurse practitioners assess patients autonomously and organise their CT scans, chest X-rays, prescribing (if the nurse has completed that module) and carotid ultrasounds, which has improved the patient journey.
‘Having a nurse request CT scans was met with some negativity at first. Four years later it is the norm’
We provide 24/7 cover, coordinating IV thrombolysis, and receive every potential stroke referral for our area. Most come from paramedic crews but we also receive referrals from regional hospitals and for patients who suffer acute strokes while an inpatient.
Overnight we are the first point of contact for HASU patients who are deteriorating, whether it is from their stroke or, for example, a seizure or sepsis.
Endovascular treatment is offered 8am-5pm, Monday to Friday and we receive all referrals.
Nurses involved in creating the pathway
The stroke pathway has been developed by the nurses and the medical team. Patients are met and assessed in the emergency department assessment area, taken for a CT scan and, if necessary, straight to the HASU for ongoing treatments and investigations.
This more robust, streamlined service has reduced pressure on our emergency department and ensures patients access to specialist care. If patients deteriorate, the team is able to reassess and escalate care appropriately.
Becoming an advanced nurse practitioner: what the course involves
The Southampton team undertook the part-time master’s-level advanced clinical practice course at University of Southampton.
The first year focuses on history taking and physical assessment, while years two to three cover research methods for evidence-based practice, diagnostics and decision-making. The course looks at independent prescribing and pharmacology and applied sciences in years three to four, with year four to five covering the transition to advanced practice.
‘This involves a lot of reflection and the group includes nurses from a range of specialties,’ says advanced nurse practitioner Chris Sanders. ‘It is a safe space to discuss issues and learn from nurses in other areas. It gives you a better understanding of those issues. It also looks at clinical leadership, and how you are using research and education.’
Developing staff to develop the service
The stroke ANP team has also completed a number of courses through the trust, including a neurosciences work-based learning module, ECG interpretation, and advanced life support, as well as practical skills such as taking arterial blood gases (ABG) and interpretation of these. They have also had stroke-specific teaching sessions with stroke consultant physicians.
The university’s model requires a medical sign off and the nurses have a medical mentor. ‘We are assessed under their supervision to start with,’ says Mr Sanders. ‘Now we have achieved a more advanced level we are able to sign off junior members of the team.
‘The way in which we have developed has meant that our service is able to develop rapidly.’
Changing the culture and perception of nurses’ roles
We organise education for staff on the stroke units, as well as in the emergency department, other areas of the hospital and on work-based university-accredited modules in neurosciences. We have also worked with speech and language therapists so staff can carry out swallow assessments; this has reduced the time that patients are kept nil by mouth and the incidence of stroke-related aspiration pneumonia.
The medical team has supported us from the start, but transitioning the team from specialist nurses to ANPs, and having a more autonomous and decision-making role acknowledged, was a challenge. For example, having a nurse request CT scans was met with some negativity at first. Four years later it is the norm.
Negativity was overcome in time as we completed our courses and formal governance was established.
What the data show: patients receiving scans more promptly
Our team is alerted and a member is present in the emergency department when the patient arrives – the quicker they get the scan and we can formulate a diagnosis, the better the outcome. It took a great deal of work and meetings over a lot of months, but the team could see that more patients were receiving CT scans more promptly.
Expanding the service could have been difficult, but due to the career development on offer we have managed to recruit members with a variety of clinical backgrounds and build a strong team.
The data show us the difference we have made, and that we are now exceeding national targets. We achieved our first top SSNAP score of A in 2018 and have managed to maintain this.
The number of patients who received a CT scan within one hour of arriving at the hospital has increased from 31% in 2015 to 63.5% by March 2019, with 96.5% now scanned within 12 hours.
In 2014 we were behind the national average in delivering thrombolysis within one hour of arrival, achieving the target in only 49% of cases. This has now risen to 76%, against a national average of 61%. We achieve the four-hour target for admission to a stroke unit in 77% of cases, compared with the national average of 58.8%.
We are especially proud that the median time in which a patient is seen by a stroke nurse practitioner has fallen from one hour 56 minutes in 2014 to 13 minutes in March 2019, with 95% of patients having been assessed by a stroke nurse practitioner within 24 hours of the onset of symptoms.
Future plans to improve the acute stroke service
While we are finally seeing the rewards of years of hard work, we are not complacent and are always looking to improve. We have developed weekly ‘huddle’ meetings, at which we scrutinise each patient’s admission data to look for possible improvements and where we can do better.
We are piloting the Helsinki Stroke Model – a pathway in which paramedics alert the stroke nurse so the patient can be taken directly from the ambulance to a CT scan to reduce delays in diagnosis and increase access to treatments. We are also writing an expanded scope of practice so we can request MRI scans, rather than waiting for the medical ward round to do this.
Our future plans are focused on developing the service to offer a mechanical thrombectomy service 24/7 within the next few years; the work that has already taken place has given a strong foundation to be able to achieve this.
About 10% of patients will be eligible for the procedure, through which the blood clot in the brain causing the stroke is removed with a stent device by an interventional radiologist.
This is a game-changer. Patients who would have returned home with complex care needs or may have suffered a fatal stroke can potentially leave hospital within a couple of days with minimal or no disability if all goes well. We offer the procedure 8am-5pm, Monday to Friday, and it is a challenge outside these hours.
The motivation to become a flagship stroke care team
On occasion, we have managed to pull together a team out of hours, with fantastic results, especially in young patients whose stroke would have been life-changing. We want to be able to do this every time. Every patient we have to say no to motivates us to improve and expand the service.
We are aiming to be a flagship team: we want the ‘Southampton way’ to demonstrate how an ANP team can enhance the patient experience and improve outcomes.
By reviewing our data we can work out how to make marginal gains – a 1% improvement here and there. We have a team of fantastic individuals, each bringing their unique skills and experience, and this makes all the difference when striving for improvements and success.
We might be a much-improved service, but our patients drive us to keep pushing on to do even better.