Research and Projects

Background

Around 940 people in Cornwall have a stroke each year. Immediate treatment is provided at acute hospitals in Truro (Royal Cornwall Hospital), Plymouth (Derriford Hospital) or Barnstaple (North Devon District Hospital). Following this initial treatment, around 40% of patients will require follow-on care in a Rehabilitation Stroke Unit (RSU). These units are based in the community hospitals located in Camborne, Bodmin and Mount Gould (Plymouth).

The current system allows patients to choose which RSU they would like to attend. However, it has been found that patients who choose to attend Bodmin are often unable to access a free bed. These patients are either sent to an alternative RSU, resulting in increased travel times for both patients and their families, or wait in the acute hospital, which can lead to delays in transferring new patients from A&E to a dedicated stroke ward.

Project objectives

PenCHORD worked with The Royal Cornwall Hospitals NHS Trust to explore the current Cornwall acute and rehab stroke treatment system, and to determine whether ring-fencing beds in acute hospitals and RSUs would allow those requiring treatment to have a rehab bed in the location of their choice.

The aims of the project were to:

1. Map the home location of Cornwall stroke patients.
2. Determine the acute care demand for Cornwall patients in Plymouth, Barnstaple and Truro (assuming patients attend the closest hospital to their home).
3. Determine the rehab/community care demand for Camborne, Bodmin and Mount Gould (assuming patients attend the closest RSU to their home).
4. Determine the number of acute and community beds (with location) required to have a free bed in the place of choice 90% & 95% of the time.

Project activity

Using a simulation model (SIMUL8), the team modelled the flow of patients through the Cornwall stroke bed system. 

Three versions of the model were created to capture different treatment pathway options:

1. Infinite bed capacity: Patients always go to their nearest acute and nearest RSU on their desired day.
2. Capacity-restrained RSU - Version 1:  Patients always go to their nearest acute hospital, however patients can only leave the acute hospital when a bed is available in their nearest RSU.  Patients waiting for a free bed will remain in the acute hospital.
3. Capacity-restrained RSU - Version 2:  Patients always go to their nearest acute hospital, then patients will go to the closest available bed in a RSU, so patients may go to their 2nd or 3rd closest RSU. Once a day outlying patients may be repatriated to a RSU closer to home (this may still not be their closet RSU).

In addition to these three model versions, there are two further variations; beds in the RSU Mount Gould (i) may, or (ii) may not be available for Cornish patients; and changes to the order patients move through the RSUs, e.g. (iii) patients depart the RSU (and so free up beds) before new RSU patients arrive on the same day (this allows patients to arrive and take a bed that was occupied by a patient who left on the same day), or (iv) patients arrive at the RSU on the same day before patients from the RSU depart (this means that a bed occupied by a patient departing on a given day is only available for a new patient on the following day).

Findings

Based on a patient’s home location, acute care demand for each acute unit was compared to the actual emergency stroke admissions (940 per year):

• Truro – closest unit to 77% of stroke patients’ home location, received 73% of actual admissions per year
• Plymouth – 22% closest, 23% actual admissions
• Barnstaple – 1% closest, 3% actual admissions
• Other – 1% of actual admissions

The closest RSU to a patient’s home location was also compared to the actual transfer admissions (376 per year):

• Camborne – closest RSU to 51% of stroke patients’ home location, received 56% of actual transfer admissions
• Bodmin – 38% closest, 25% actual transfer admissions
• Mount Gould – 11% closest, 7% actual transfer admissions
• Other – 10% actual transfer admissions

Using a model where all patients must wait to go to their closest hospital (either Camborne or Bodmin), with beds capped at current designated levels, the team identified the following delays in the system:

• Only rare delays experienced for patients needing to go to Camborne (3%).
• For patients closest to Bodmin, 81% have to wait for a bed. The average delay for all patients is five days, whilst delayed patients wait an average of eight days for a bed).
• In Plymouth, 74% of patients are delay in the acute hospital, with an average delay for all patients of six days, whilst delayed patients wait an average of ten days.
• For Truro, 25% patients would be delayed in the acute hospital, with average delays for all patients of two days but delayed patients waiting an average of eight days for a bed.

The team concluded that:

• Current rehab bed availability does not match the home location of patients.
• ‘Ring-fencing’ stroke beds to ensure a free bed is available at a patients closest hospital 90% of the time, would require acute hospitals to run at ~70% average bed occupancy on their stroke wards and Stroke Rehabilitation Units to run at ~75% average bed occupancy.

Next steps

Initial results from the project have been shared with stakeholders via the local Stroke Partnership Board.  The results and implications of the work will be reviewed from a commissioning perspective, and will be further shared with Plymouth colleagues, so that learning can be disseminated across the areas studied.

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