Partners join forces to help stroke patients

A system-wide team effort is helping patients who are admitted to hospital following a mild stroke to recover more quickly.

Partners join forces to help stroke patients
30 May 2018

A system-wide team effort is helping patients who are admitted to hospital following a mild stroke to recover more quickly.

The Cambridgeshire and Peterborough Sustainability and Transformation Partnership (STP), made up of NHS bodies and local authorities across the county, has given the green light for a new service to help stroke patients in their own homes.

It is being led by Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) which set up an early supported discharge (ESD) team to help those admitted to the stroke unit at Addenbrookes Hospital, part of Cambridge University Hospitals NHS Foundation Trust (CUH).

The team enables patients to be discharged from the hospital sooner by providing up to six weeks rehabilitation, either at their home or in a community ward such as Brookfields Hospital, Cambridge.

The team is made up of nurses and therapists trained in stroke care and since its launch in February patients have been discharged from CUH around ten days earlier than before. It has saved around 240 bed days in total and has allowed staff to admit other patients who require acute care.

Charlie Dorer, Clinical Manager (above), from the Integrated Neuro Rehabilitation and Stroke ESD Team, at CPFT, said: “Trials have previously shown that patients who receive services like the one we have set up return home from hospital earlier and are more likely to regain their independence sooner.”

“We are delighted to have put this service in place and assure patients that they receive the same care they would on a stroke rehabilitation ward, but in their own home. We work with them to develop a comprehensive rehabilitation plan and regularly visit to aid their recovery and provide expert advice on their stroke and how to prevent another one.”

Dr Liz Warburton, the STP’s Stroke Services Clinical Lead, who is based at CUH, said: “The feedback has been universally fantastic. Patients tell us they much prefer to be in their own homes and the stroke nurse provides lots of support and advice which prevents further strokes and readmissions.”

“Not only have we saved up to 240 bed days since this initiative went live, meaning that we can treat more patients in need, it is a great example of partnership working between ourselves, our colleagues at CPFT and neighbouring hospitals, the Stroke Association, and of course the patients we serve.”

Neil Chapman, Support Manager for the Stroke Association said: “Stroke survivors and their carers often tell us that they feel abandoned after leaving hospitals as they are left without any support services. ESD enables stroke survivors to leave hospital and receive their rehabilitation, with the same level of intensity and expertise their own homes. We know up to 40 per cent of people are eligible for ESD yet one in five hospitals still do not have access to a specialist ESD team.

“We’re thrilled that this service is being put in place at Addenbrookes Hospital. ESD can result in better outcomes for stroke survivors. It can reduce long term mortality, and reduced disability meaning survivors have greater independence improving overall quality of life after stroke.”

The new service is part of a package of measures to help stroke patients and follows a £1.8 million investment from the STP. The investment has seen the development of the integrated community neuro-rehabilitation and ESD service across Cambridgeshire and Peterborough.

The stroke ESD team also works with stroke survivors who are discharged from Peterborough City Hospital, Hinchingbrooke Hospital and Queen Elizabeth Hospital King’s Lynn.

They work closely with CPFT’s neuro-rehabilitation team, which supports people with complex neurological problems who need longer than six week of rehabilitation, such as more serious stroke or brain injuries, as well as those with long term conditions like multiple sclerosis and motor neurone disease.

Figures from the Stroke Association show that there are more than 100,000 strokes in the UK each year – around one stroke every five minutes – and that there are over 1.2 million stroke survivors.


Cambridgeshire and Peterborough NHS Foundation Trust
Elizabeth House, Fulbourn Hospital
Cambridge, CB21 5EF

T 01223 219400 (open 8:30am to 5pm)
F 01480 398501

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