• Implementation of a prealert to improve in-hospital treatment of anticoagulant-associated strokes: analysis of a prehospital pathway change in a large UK centralised acute stroke system

      Ashton, Christopher; Sammut-Powell, Camilla; Birleson, Emily; Mayoh, Duncan; Sperrin, Matthew; Parry-Jones, Adrian (2020-05-17)
      Intracerebral haemorrhage (ICH) has the worst outcomes of all stroke subtypes, with a case fatality at 1 month of 30%–40% and only 20% regaining independence.1 Improving the implementation of existing evidence-based and guideline-recommended interventions may lead to improved outcomes.2 10%–20% of acute ICH occurs in patients taking oral anticoagulants and this is associated with a high risk of early haematoma expansion.3 4 Rapid treatment to normalise coagulation reduces this risk and may improve outcomes.4 5 The first critical step in achieving this is for suspected stroke patients on anticoagulants to undergo immediate brain imaging, allowing ICH to be identified quickly and anticoagulant reversal therapy initiated. Our regional centralised acute stroke system within Greater Manchester and Eastern Cheshire serves a population of 2.85 million and although suspected stroke patients collected by ambulance <48 hours post onset are transported to a hyperacute stroke unit (HASU), only those within 4 hours of onset are prealerted. We conducted a service evaluation to determine whether an additional prealert and emergency transport for suspected stroke on anticoagulants 4–48 hours post onset facilitated rapid imaging and hence reversal of anticoagulation after ICH on HASU arrival. A proposed prealert for anticoagulant-associated suspected strokes was agreed by the Greater Manchester Stroke Operational Delivery Network and introduced on 13 March 2018. The change in practice was disseminated by the North West Ambulance Service (NWAS) to all prehospital clinicians. https://bmjopenquality.bmj.com/content/9/2/e000883. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ DOI http://dx.doi.org/10.1136/bmjoq-2019-000883
    • Learning from Lean: a quality improvement project using a Lean-based improvement approach to improve discharge for patients with frailty in an acute care hospital

      Rollinson, Thomas J.; Furnival, Joy; Goldberg, Sarah; Choudhury, Aklak (2021-11-25)
      A Lean-based improvement approach was used to complete a quality improvement project (QIP) focused on improving speed and quality of discharge of frail patients on two wards at a large teaching hospital in the UK. This was part of a national initiative to embed continuous improvement within the trust. The aim of the QIP was to improve the proportion of prenoon discharges to 33% of total patients discharged from the ward each day. An ‘improvement practice process’ followed, which included seven discrete workshops that took the QIP through four distinct phases—understand, design, deliver and sustain. Several improvement methods and tools were used, including value stream mapping and plan–do–study–act (PDSA) cycles. Ten PDSA cycles were implemented across the clinical areas, including improved planning and data collection of discharge, improved communication between nursing and medical staff, and earlier referrals to community hospitals for discharge. Improved performance was identified through the outcome metric prenoon discharges on both wards, with the average increasing from 8% to 24% on ward X and from 9% to 19% on ward Y, with no other significant change seen in other measures. Pettigrew et al’s context–content–process change model was used to structure the learning from the QIP, which included the impact of varying ward contexts, the format of conducting improvement with staff, the importance of organisational support, the need for qualitative measures, agreeing to an apposite aim and the power of involving service users. The original aim of 33% prenoon discharges was not achieved, yet there was clear learning from completing the QIP which could contribute to ongoing improvement work. This identified that the Lean-based improvement approach used was effective to some degree for improving discharge processes. Further focus is required on collecting qualitative data to identify the impact on staff, especially related to behaviour and culture change. https://bmjopenquality.bmj.com/content/10/4/e001393 http://creativecommons.org/licenses/by-nc/4.0/ DOI http://dx.doi.org/10.1136/bmjoq-2021-001393