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University Hospitals Dorset: Pioneering the NHS rehab revolution with robotics

Part one: The need for technology within an NHS acute stroke unit

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“We should be looking at how we can enhance rehabilitation with robotics, and deliver rehabilitation that is enabled by technology as much as possible.”

In 2020, University Hospitals Dorset ran an award-winning fundraising campaign for a state-of-the-art electromechanical gait trainer, helping stroke patients learn how to walk again.

One year since the Lokomat was installed in the Acute Stroke Unit, Summit Medical and Scientific caught up with Dr Louise Johnson, Consultant Therapist for Stroke, and Karen Smith, Fundraising Manager, to find out how – and why – they did it.

Tell us about the Acute Stroke Unit at Royal Bournemouth Hospital.

Louise: The acute stroke service at University Hospitals Dorset is one of the biggest outside of London.

We see patients right through the early part of the pathway, so we have a hyper acute for people when they’re initially admitted to hospital and then we provide acute care and inpatient rehabilitation.

We also have an early supported discharge team, so a community team provides intensive rehabilitation when people are first discharged home. This service is for up to six weeks.

We admit around 1200 people every year with a stroke, so we have quite high numbers of people admitted through our services and obviously a high proportion of those will present with problems with mobility.

The numbers of people admitted every year is going up, and the general pattern that we are also seeing more younger people with stroke.

What is the need for robotics within the NHS?

Louise: There’s lots of ways in which robotics can support service delivery in the NHS.

The first is about delivering rehabilitation that is really evidence-based, so we know that there’s good strong evidence behind robotics – particularly for walking recovery.

It’s our role as clinicians and rehab professionals working in the NHS to be striving to deliver care that is evidence-based. So purely on that basis, we should be looking at how we can enhance rehabilitation with robotics and deliver rehabilitation that is enabled by technology as much as possible.

One of our big challenges will always be that there’s finite resources, so we have limited time and limited staffing capacity, and that will always be the case to some degree.

Robotics help to provide a solution to some of that, enabling us to provide the intensity of rehab that we know is needed to drive recovery for people in a way that is not labour intensive or resource intensive. It really helps to meet that challenge and intensity of delivery.

If it’s the right piece of tech for the right population group then it helps us to use our resources more efficiently. If we can treat somebody with one member of staff, rather than two or three members of staff to achieve the same thing, then we’re delivering more and better rehab to more people, so it provides a solution there as well.

What evidence, research and guidelines were there to support this?

Louise: We looked at the RCP national clinical guidelines for stroke, which is our go-to blueprint for the things we should be looking at for rehab delivery. They’re not extremely detailed but they do provide a list of recommendations, and for walking recovery one of those recommendations is electromechanical gait training.

For something to make it into the guidelines, it has to have a good evidence base to start with. So as a starting point, we can trust those guideline recommendations and should ask why we aren’t exploring them.

We also looked at some of the empirical evidence, and for robotic gait training the main place is the Cochrane review. This is a very comprehensive and regularly-updated systematic review around gait training. We particularly looked at the studies included here, and the evidence is really compelling so we didn’t need much more convincing than that.

Why did University Hospitals Dorset want to fundraise for a Lokomat in your “Walkerbot campaign” and how did you get to the point where you could fundraise for it?

Louise: The reason why goes back to the evidence and the guidelines, so we are always striving to make sure that we are progressing the way that we deliver rehab and keeping the profile of rehab high.

I think as a service we are quite proactive at thinking about how we can do things better, how we can integrate research evidence into practice, and make sure the evidence is translated into practice. I’d been to a few conferences where robotic gait training was talked about, so over time we felt we shouldn’t ignore it. We shouldn’t skim over it in our national guidelines just because we feel it might be out of reach, or too difficult, or too expensive for us to be able to offer.

We didn’t know that we would end up getting an electromechanical gait trainer like the Lokomat, and that our Walkerbot campaign would be successful, but we wanted to make sure that we had at least considered it for our patients.

Another reason was that the evidence around robotic gait training is strongest for people who are more impaired after stroke, and who are in the early phase after stroke. That’s exactly the group of patients that we see on our units, day in and day out. These patients are hard to deliver good rehab to because it’s difficult and resource-intensive to achieve intensity with patients who are really impaired.

So it seemed like a really good fit and a really good solution to a challenge we have in our day-to-day clinical practice.

We just started chatting about it with the team and tested the water, and then we started chatting to the charity team, and then it snowballed from there.

Karen: I think it resonated with me that you can save someone’s life from a stroke, and we focus a lot of time and resources and energy on this primary goal, but we also want to invest time and money and effort into funding rehabilitation. So not only have those people had their lives saved, but their quality of life moving forwards will be significantly better as a result of this piece of equipment.

What was the procurement process for you and how did you navigate it?

Karen: Well from the charity’s perspective, we operate under the charity commission rules and regulations, and we also sit under finance, so we have a process that we operate through.

So even for a fundraising project it has to have a full business case if it’s over £25,000, and we have to make sure medical devices adhere to the regulations and rules in order for that equipment to come into the Trust.

We also had to consider the practical elements with estates, as we had to make changes switching our day room with the garden room.

Then we worked with Summit Medical and Scientific, who were the UK supplier for the Lokomat.

Overall it was a complete team effort, and we had fortnightly meetings including estates, procurement, the clinical team, and the charity. This made sure as the fundraising gathered momentum, all of the procurement and finances processes were aligned to progress it in a timely manner.

Louise: I think it’s just about getting people involved early and knowing who those people are, getting them on board as part of the project. We can’t come up with a clinical idea, agree with the charity to fundraise it, and then at some point further down the line talk to procurement and estates.

We created such a buzz that everyone felt like part of the project, and this all helps within an organisation.

Karen: Everyone was emotionally invested. Louise is so engaging and passionate about her work, and that really resonated with the whole team. This is what made it possible. When we brought the Lokomat onsite, which had travelled from Zurich, everyone was there.

When we were awarded the NHS Charities Together award, we were credited for the fact that it was a small marketing investment but we brought everyone on that journey with us. The Walkerbot campaign became everyone’s Walkerbot.

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