Consultant physicians working with patients - Royal College of ...

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2 Specialties Stroke medicineResearchStroke medicine is founded on an increasing evidencebase of high-quality international randomisedcontrolled trials and was represented early in theCochrane Collaboration (www.cochrane.org). TheNational Institute for Health Research Stroke ResearchNetwork (NIHR SRN) is one of the five main UKclinical research networks (www.uksrn.ac.uk).Specialty guidelines, audits andquality toolsSpecialty guidelines, audits and quality tools arepresented in Box 2.Regional and national workStroke physicians work within local clinical networks.Many are involved in the RCP Stroke Programme(Clinical Effectiveness and Evaluation Unit, RCP), theIntercollegiate Stroke Working Party (ICSWP, RCP),and with BASP and the NIHR SRN. Current strokephysicians are the founder members of a new nationalspecialty and continue to work together to developnational service specifications, deliver integratedservices and train future specialists.6 Clinical work of consultantsHow a specialist works in this specialtyConsultant stroke physicans are expected to providedaily assessment of new confirmed and suspected strokeand TIA patients, including at weekends and bankholidays. Weekly acute and rehabilitation MDTmeetings and twice-weekly ward rounds ofrehabilitation patients are specified. 4Outpatient reivew of high-risk TIA patients within24 hours and low-risk TIA patients within 7 days, and atleast two outpatient review opportunities afterdischarge from a stroke unit, must be provided. Strokespecialists will participate in clinics for spasticity, painand other stroke-related complications.Specialist on callTwenty-four-hour availability of an experienced strokephysician for diagnosis and opinion on thrombolysistreatment is mandatory. Few hospitals currently havesufficient experienced consultants within stroke/neurology to provide cover within the EuropeanWorking Time Directive criteria. Hyperacute centresand telemedicine are possible methods of achieving a24-hour service.Other specialist activity including activitiesbeyond the local servicesMany stroke physicians play an active role in provisionof tertiary services, research and service development(see above).7 Opportunities for integrated careThe NICE Quality standard for stroke 14 requires thatstroke services are commissioned from and coordinatedacross all relevant agencies to encompass the wholestroke pathway.8 Workforce requirements for the specialtyClinical developments in UK stroke services haveovertaken the specialist resource needed to supportthem. Using nationally approved clinical standards, it iscalculated that 20 direct clinical care (DCC) programmedactivities (PAs) are required to support a serviceadmitting 500 patients per year (approximately 300,000population). A population of 60 million requires 2,800DCC PAs from stroke specialists. This is equivalent to350 whole-time equivalent (WTE) consultants.However, (RCP) census data indicate that most strokephysicians also provide input into another specialty(www.rcplondon.ac.uk/resources). It is acknowledgedthat some aspects of stroke care are currently providedby consultants who are not stroke specialists accordingto BASP criteria. Allowing for such subspecialistsupport, it is calculated that the stroke specialistshortfall is currently 163 posts, ie 513 stroke specialistsare required in the UK. In 2011, 40 stroke trainees wereexpected to complete specialist training by 2014.BASP recommended that an extra 30 stroke medicinetrainee places are created per year in the UK for the next4years. 49 Consultant work programme/specimenjob planStroke specialists should provide a mimum of 5 PAs intostrokecare,usually4DCCPAsand1SPA.Theremaining 5 PAs can support a parent specialty.However, consultants may provide more or less timethan this into stroke care, eg a full-time stroke specialistcould provide 8 DCC PAs and 2 SPAs but would notprovide any input into a parent specialty. 4 For thepurposes of this example it is assumed that a 1.0 WTEstroke consultant provides 2.5 DCC PAs into the parentspeciality (Table 1).C○ Royal College of Physicians 2013 259
Consultant physicians working with patientsTable 1 Specimen job plan for a consultant stroke physicianActivityPAsAcute stroke unit (ASU) ward rounds (7-day service) 1ASU MDT meetings/relatives clinics or meetings 0.25Neuroradiology meeting 0.5Neurovascular clinic (7-day service) 1.25Rehabilitation stroke unit (RSU) ward rounds 1RSU MDT/relatives clinic or meetings 0.5On-call for stroke/TIA/thrombolysis (24-hour service) 1Direct clinical care (DCC) stroke 5.5DCC parent specialty 2.5Supporting professional activities (SPAs) 2.0Total PAs 10In this example, a total of 20 DCC PAs are needed to support a stroke service.PAs for each activity are as follows:Hyperacute/Acute stroke service: 10.0Rehabilitation stroke service: 2.5Outpatients including 7-day neurovascular service: 7.5Depending on the amount of work in parent specialties, between 4 and 8 stroke consultants are needed in this hospital (maximumon-call frequency 1:4).The British Association of Stroke Physicians (BASP) have produced a template for the amount of stroke consultant sessions neededaccording to the size of the service and the amount of work done in parent specialties. 4MDT = multidisciplinary meeting; TIA = transient ischaemic attack.10 Key priorities for commissionersThe key priorities listed below are adapted from NICE’sQuality standard for stroke. 101 People seen by ambulance staff outside hospitalshould be screened using a validated tool, todiagnose stroke or TIA, and transferred to aspecialist acute stroke unit within 1 hour.2 Patients with acute stroke who meet any of theindications for urgent brain imaging should receivethis within 1 hour.3 Patients with suspected stroke should be admitteddirectly to a specialist stroke unit and receivethrombolysis if clinically indicated.4 Patients with acute stroke should have theirswallowing screened within 4 hours of admissionby a specially trained professional before beinggivenoralfood,fluidormedication,andhaveaplan for the provision of adequate nutrition.5 Patients with acute stroke should be assessed andmanaged by stroke nursing staff and at least onemember of the specialist rehabilitation team within24 hours of admission, and by all relevant membersof the team within 72 hours. Documentedmultidisciplinary goals should be agreed within 5days.6 Patients who need ongoing inpatient rehabilitationshould be treated in a specialist strokerehabilitation unit.7 Patients should be offered a minimum of45 minutes of each active therapy that is required,for a minimum of 5 days a week.8 Patients who have continued loss of bladder controlafter 2 weeks should be reassessed to identify thecause and have a treatment plan involving bothpatient and carers.9 All patients should be screened within 6 weeks,using a validated tool, to identify mooddisturbance and cognitive impairment.260 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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