NSW Stroke Reperfusion Program Evaluation Report€¦ · Health Economics and Evaluation Team –...

Collaboration. Innovation. Better Healthcare.

REPORT

NSW Stroke Reperfusion ProgramEvaluation Report

Health Economics and Evaluation Team

Health Economics and Evaluation Team – NSW Stroke Reperfusion Program Evaluation Report

AGENCY FOR CLINICAL INNOVATION

Level 4, Sage Building

67 Albert Avenue

Chatswood NSW 2067

PO Box 699 Chatswood NSW 2057

T +61 2 9464 4666 | F +61 2 9464 4728

E [email protected] | www.aci.health.nsw.gov.au

Produced by ACI Health Economics and Evaluation Team

SHPN (ACI) 150420

ISBN 978-1-76000-244-2

Further copies of this publication can be obtained from

the Agency for Clinical Innovation website at www.aci.health.nsw.gov.au

Disclaimer: Content within this publication was accurate at the time of publication. This work is copyright. It may be reproduced

in whole or part for study or training purposes subject to the inclusion of an acknowledgment of the source. It may not be

reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above, requires written

permission from the Agency for Clinical Innovation.

Version: V1

Date Amended: 29/05/2015

© Agency for Clinical Innovation 2015

The Agency for Clinical Innovation (ACI) works with clinicians, consumers and managers to design and promote better healthcare for NSW. It does this by:

• service redesign and evaluation – applying redesign methodology to assist healthcare providers and

consumers to review and improve the quality, effectiveness and efficiency of services.

• specialist advice on healthcare innovation – advising on the development, evaluation and adoption of

healthcare innovations from optimal use through to disinvestment.

• initiatives including guidelines and models of care – developing a range of evidence-based healthcare

improvement initiatives to benefit the NSW health system.

• implementation support – working with ACI Networks, consumers and healthcare providers to assist

delivery of healthcare innovations into practice across metropolitan and rural NSW.

• knowledge sharing – partnering with healthcare providers to support collaboration, learning capability

and knowledge sharing on healthcare innovation and improvement.

• continuous capability building – working with healthcare providers to build capability in redesign, project

management and change management through the Centre for Healthcare Redesign.

ACI Clinical Networks, Taskforces and Institutes provide a unique forum for people to collaborate across clinical

specialties and regional and service boundaries to develop successful healthcare innovations.

A priority for the ACI is identifying unwarranted variation in clinical practice and working in partnership with

healthcare providers to develop mechanisms to improve clinical practice and patient care.

www.aci.health.nsw.gov.au


Contents

Abbreviatons 6

Evaluation snapshot 7

Executive summary 8

Background 8

Methods 8

Key findings 8

Recommendations 9

Section 1 Introduction 11

1.1 Stroke 11

1.2 Intravenous thrombolysis for stroke 11

Section 2 Background 12

2.1 NSW Stroke Reperfusion Program 12

Section 3 Evaluation of the program 15

3.1 Purpose 15

3.2 Evaluation 16

3.3 Limitations of the evaluation 17

Section 4 Methods 18

Section 5 Stroke in NSW 21

Section 6 Key findings from site visits and interviews 25

6.1 Access to information 25

6.2 Coherent planning 27

6.3 People and engagement 28

6.4 Business processes 28

6.5 Leadership 30

6.6 Culture and values 30

Section 7 Key findings from SRAT review 32

7.1 Stroke Reperfusion Assessment Tool 32

Section 8 Discussion 41

8.1 Program fidelity 41

8.2 Barriers to program implementation and delivery 41

8.3 Factors facilitating success of the program 42

Section 9 Conclusion and preliminary recommendations 43

Section 10 Next steps 45

Section 11 References 46

Appendix I 47

Appendix II 55

Appendix III 89


Figures

Figure 1: NSW SRP Pathway 14

Figure 2: SRP site visits by participants and position 20

Figure 3: Code groupings and emerging themes 20

Figure 4: Average NWAU for SRP sites 21

Figure 5: NSW ICD-10 stroke episodes and average length of stay 2007-08 to 2012-13 23

Figure 6: SRP ICD-10 stroke episodes and average length of stay 2007-08 to 2012-13 23

Figure 7: Non-SRP sites ICD-10 stroke episodes and average length of stay 2007-08 to 2012-13 24

Figure 8: Gosford Hospital ICD-10 stroke episodes and average length of stay 2007-08 to 2012-13 56

Figure 9: Nepean Hospital ICD-10 stroke episodes and average length of stay 2007-08 to 2012-13 58

Figure 10: Campbelltown Hospital ICD-10 stroke episodes and average length of stay 2007-08 to 2012-13 60

Figure 11: Orange Health Service ICD-10 stroke episodes and average length of stay 2007-08 to 2012-13 62

Figure 12: Bathurst Base Hospital ICD-10 stroke episodes and average length of stay 2007-08 to 2012-13 64

Figure 13: St Vincent’s Hospital ICD-10 stroke episodes and average length of stay 2007-08 to 2012-13 66

Figure 14: Royal Prince Alfred Hospital ICD-10 stroke episodes and average length of stay 2007-08 to 2012-13 68

Figure 15: Prince of Wales Hospital ICD-10 stroke episodes and average length of stay 2007-08 to 2012-13 70

Figure 16: Bankstown-Lidcombe Hospital ICD-10 stroke episodes and average length of stay 2007-08 to 2012-13 72

Figure 17: Westmead Hospital ICD-10 stroke episodes and average length of stay 2007-08 to 2012-13 74

Figure 18: Liverpool Hospital ICD-10 stroke episodes and average length of stay 2007-08 to 2012-13 76

Figure 19: Royal North Shore Hospital ICD-10 stroke episodes and average length of stay 2007-08 to 2012-13 78

Figure 20: St George Hospital ICD-10 stroke episodes and average length of stay 2007-08 to 2012-13 80

Figure 21: Wagga Wagga Base Hospital ICD-10 stroke episodes and average length of stay 2007-08 to 2012-13 82

Figure 22: Hornsby and Ku-Ring-Gai Hospital ICD-10 stroke episodes and average length of stay 2007-08 to 2012-13 84

Figure 23: Blacktown Hospital ICD-10 stroke episodes and average length of stay 2007-08 to 2012-13 86

Figure 24: Concord Hospital ICD-10 stroke episodes and average length of stay 2007-08 to 2012-13 88


Tables

Table 1: Key evaluation questions 16

Table 2: Summary activity by SRP site 2012-13 22

Table 3: Emerging themes 25

Table 4: Stroke Reperfusion Assessment Tool summary 47

Table 5: Gosford Hospital selected stroke DRGs 2007-08 to 2012-13 55

Table 6: Nepean Hospital selected stroke DRGs 2007-08 to 2012-13 57

Table 7: Campbelltown Hospital selected stroke DRGs 2007-08 to 2012-13 59

Table 8: Orange Health Service selected stroke DRGs 2007-08 to 2012-13 61

Table 9: Bathurst Base Hospital selected stroke DRGs 2007-08 to 2012-13 63

Table 10: St Vincent’s Hospital selected stroke DRGs 2007-08 to 2012-13 65

Table 11: Royal Prince Alfred Hospital selected stroke DRGs 2007-08 to 2012-13 67

Table 12: Prince of Wales Hospital selected stroke DRGs 2007-08 to 2012-13 69

Table 13: Bankstown-Lidcombe Hospital selected stroke DRGs 2007-08 to 2012-13 71

Table 14: Westmead Hospital selected stroke DRGs 2007-08 to 2012-13 73

Table 15: Liverpool Hospital selected stroke DRGs 2007-08 to 2012-13 75

Table 16: Royal North Shore Hospital selected stroke DRGs 2007-08 to 2012-13 77

Table 17: St George Hospital selected stroke DRGs 2007-08 to 2012-13 79

Table 18: Wagga Wagga Base Hospital selected stroke DRGs 2007-08 to 2012-13 81

Table 19: Hornsby and Ku-Ring-Gai Hospital selected stroke DRGs 2007-08 to 2012-13 83

Table 20: Blacktown Hospital selected stroke DRGs 2007-08 to 2012-13 85

Table 21: Concord Hospital selected stroke DRGs 2007-08 to 2012-13 87


Abbreviatons

ABF Activity-based funding

ABS Australian Bureau of Statistics

ACI Agency for Clinical Innovation

AH After hours

AIHW Australian Institute of Health and Welfare

ALOS Average length of stay

AR Australian-refined

ASNSW Ambulance Service New South Wales

ASC Australian Stroke Coalition

ASU Acute stroke unit

ATC Acute Thrombolytic Centre

AuSCR Australian Stroke Clinical Registry

AuSDaT Australian Stroke Data Tool

BH Business hours

BHI Bureau of Health Information

CE Chief Executive

CPDI Clinical program design and

implementation

CT Computed tomography

CTP Computed tomographic perfusion

DRG Diagnosis-related group

DTN Door-to-needle

ECI Emergency Care Institute

ED Emergency department

FAST+ Face, arm, speech, time – positive

GP General practitioner

HDU High dependency unit

HNE Hunter New England

ICD International Classification of Disease

ICU Intensive care unit

HOD Head of Department

KPI Key performance indicator

LHD Local health district

MD Multidisciplinary

MDT Multidisciplinary team

MoH Ministry of Health

M&M Mortality and morbidity

NIHSS National Institute of Health Stroke Scale

NSF National Stroke Foundation

NSW New South Wales

NWAU National weighted activity unit

PET Patient and Staff Experience Tracker

rtPA Recombinant tissue plasminogen activator

SITS Safe implementation of treatment

in strokes

SRAT Stroke reperfusion assessment tool

SRP Stroke Reperfusion Program

SSA Stroke Society of Australasia

TIA Transient ischaemic attack

TIPS Thrombolysis ImPlementation in Stroke

TGA Therapeutic Goods Administration

USA United States of America

VMO Visiting Medical Officer


Key evaluation questions Key findings

Was the program design effective in delivering the SRP program?

Yes, the design is supported by a clear evidence base with reperfusion being provided at all 20 of the sites prior to the official launch of the SRP. A more thorough analysis of effectiveness will be undertaken in the next stage of the evaluation.

What processes did ACI use to implement the program across sites and is it consistent with the ACI Implementation Framework?

Yes. The processes used are consistent with the ACI Implementation Framework. Implementation comprised identifiying leaders, corresponding with Chief Executives and developing tools to aid consistent implementation.

Were the processes consistent at each site? Yes. A standardised format was used by ACI accompanied by the development of a generic model of care, implementation toolkit and checklist.

Were the processes used for each component of implementation effective?

Yes. All processes were standardised and comprised site visits to review each component and documented standards for each as contained in the toolkit.

What inhibited implementation? There was a lack of access to information in terms of baseline and ongoing data collection, reporting and sharing systems to enable monitoring and evaluation, benchmarking and program improvements.

What facilitated implementation success? Leadership and champions at each site facilitated implementation success along with a team approach across SRP units (ASNSW, ED, ATC/ASU). Where several SRP sites are located within a District, a District approach to stroke care was identified as facilitaingr successful implementation.

What strategies can be used to improve the program design and implementation process?

Identification, agreement and establishment of program objectives and associated data collection methods prior to implementation to enable comprehensive monitoring, evaluation and benchmarking across sites.

Have the minimum requirements for stroke reperfusion been implemented and sustained?

Yes. Minimum standards for stroke reperfusion (pre-notification, 24/7 service, acute stroke teams) have been implemented and sustained. However, analysis is required in the next stage of the evaluation to determine if all components of the program operate within the designated time frames.

Are implementation processes in place (stroke team meetings, reviews, MD thrombolysis committee, training and education)?

Somewhat. This varies across sites with most sites using a locally-adapted, hybridised model for governance, review and training.

Are standards of care upheld (guidelines, pathways, protocols)?

Yes. All sites have appropriate guidelines, protocols and pathways in place, and regularly review and update them.

Are data collection systems in place and implemented? No. Although most sites use a local database, there is no overarching data collection method, data dictionary or agreed database for the systematic collection and use of program and outcomes data.

Evaluation snapshot


Executive summary

Background

The New South Wales Stroke Reperfusion Program

The NSW Stroke Reperfusion Program (SRP) was formally

launched by the NSW Health Minister in January 2013.

Stroke reperfusion is a clinical intervention that involves

injection of a clot-busting medication – recombinant tissue

plasminogen activator (rtPA), which can greatly improve

patient outcomes if administered in a brief time period

after the onset of an ischaemic stroke. In this report,

stroke reperfusion is referred to as thrombolysis or

thrombolytic intervention.

Central to the SRP was the establishment, within existing stroke units, of 20 Acute Thrombolytic Centres (ATCs) within

metropolitan and rural NSW. The 20 ATCs comprise specialist services to care for patients including 24/7 access to

Medical Imaging Departments, 24/7 Emergency Departments (EDs) where staff are trained in the administration of

intravenous thrombolysis and a 24/7 multidisciplinary (MD) stroke team that is based within a stroke unit with

collocated beds for monitoring.

Program objective

The objective of the NSW Stroke Reperfusion Program is to reduce the time from symptom onset to thrombolytic

intervention (onset-to-needle and door-to-needle [DTN] times) for people experiencing an ischaemic stroke. The program

is consistent with the Stroke Foundation’s Clinical Guidelines for Stroke Management 2010 (NSF, 2010) that stipulates

streamlining ambulance and hospital services to treat people experiencing the signs and symptoms of stroke, increasing

the use of thrombolysis for eligible patients from an estimated 7% in 2010 to 20%, and reducing the composite primary

end point of death or disability.

This report provides an overview of Stage one of the evaluation of the SRP. The evaluation is in three stages to enable the

identification and collection of relevant data throughout the project. Stage one is predominantly a descriptive analysis of

the program focusing on implementation processes and program fidelity.

Methods

This stage of the evaluation is based on visits to each of the SRP sites, with the exception of Tamworth and John Hunter

Hospitals, both of which respectfully declined to take part in the evaluation and are advanced in practice compared with

other sites in NSW.

The site visits comprised assessing program components to test the fidelity of implementation and additional interviews

as part of the formative evaluation process designed to identify barriers and success factors for program delivery.

Key findings

• Compared with the treatment of all strokes, stroke units where SRP is provided (over 50% of all strokes) had:

° a higher complexity of patients with an average National Weighted Activity Units (NWAU) of 1.9 compared with

the NSW average of 1.5 in 2012-13

° an average length of stay of 6.9 days in 2012-13, which is only slightly higher than the NSW average of 6 days

° experienced an increased volume of 14% over the period 2007-08 to 2012-13. compared with a 3% increase for

NSW in total for the same period.

Stroke units significantly improve

health outcomes of stroke patients. Between

2007 and 2011, the number of stroke units in

public hospitals {nationally} increased from 54

to 74 and the proportion of patients receiving

stroke care increased from 50% to 60%.

“ “

AIHW, 2013


• The fastest DTN times self-reported for the past year were at Royal Prince Alfred and St George Hospitals at

17 and 18 minutes, respectively. However, there is no consistent statistical method used across sites to

analyse and compare data. Further work is required to determine median times during business hours (BH)

and after hours (AH) for each site to provide a more comprehensive understanding. This will occur at the

next stage of evaluation.

• There was fidelity in the way SRP was implemented across the sites, resulting from a consistent model of care,

the implementation approach, input from the ACI Implementation Team, implementation toolkit and

checklists. However, delivery of the SRP at sites differed, particularly between metro and rural areas.

• The need for a comprehensive data collection, reporting and knowledge exchange system in place prior to

implementing any program was raised as a major theme in the evaluation. The lack of a consistent system

resulted in barriers for local monitoring and planning, evaluation and benchmarking.

• Access to medical imaging was found to be the program component most associated with delayed treatment

times. Although most sites are actively working towards addressing this, a consistent approach to scan types

and AH access was viewed as a requirement to hasten treatment times. This was also viewed as a substantial

contributor to differences in service provision during BH and AH. A total of seven sites reported that imaging

was not pre-notified for FAST+ patients.

• Pre-notification of FAST+ patients is occurring from ambulance to EDs at all sites. However, three of the SRP sites

do not pre-notify the acute stroke team until after the patient has arrived and diagnosis is confirmed. Although

it was noted that acute stroke teams can be mobilised quickly, this has potential to slow times to treatment.

• Rural services indicated a need for flexibility in service design to enable localisation consistent with resources,

staffing and throughput. Local leaders and champions were indicated in successful program delivery,

particularly in rural sites to ensure program visibility.

• The establishment of executive sponsors and clinical champions at all sites provided leadership of the program,

effectively raising awareness of stroke pathways and emphasising the time-critical treatments.

• Where there were several SRP sites located within a District, a District-wide collaborative approach to stroke

care facilitated program success with shared medical teams, pathways, protocols and an established

knowledge-sharing environment. Similarly, a collaborative working relationship with ambulance services being

acknowledged as part of the patients’ treatment journey was seen as facilitating program success at those sites

where it occurred.

• Although most SRP sites have been thrombolysing patients prior to the official ‘‘go live’1’ date of the SRP,

anecdotal evidence suggests that improvements in pre-hospital notification and faster transfer to SRP sites has

increased rates of thrombolysis from 7% of eligible patients in 2010 (NSF, 2010) to triple that at some sites. This

will be investigated in Stage two of the evaluation when the relevant data is available.

Recommendations

The following recommendations have been made as a starting point in overall program improvement. It is anticipated

that further recommendations will be made as data is gathered and analysed at each stage of evaluation.

1 ‘Go live’ refers to the date that the NSW Health Matrix was released requiring ASNSW to transfer potential FAST+ patients to the nearest SRP site. This occurred in January 2013 and is sometimes referred to as the ‘official launch of the SRP’.


Access to information

1. Consistent data collection methods to be determined for SRP, development of a data dictionary and guidelines for

collection, access and reporting.

2. Data provided across all components of the program to SRP stakeholders (sites, Ambulance Service New South

Wales (ASNSW) and ACI), including, at a minimum, data on ASNSW FAST+ patients by site, DTS time,

scan-to-needle time, transfer times and destinations, and patient outcomes. This data will be used for monitoring,

evaluation and benchmarking.

3. ACI to continue work with the Activity-based Funding (ABF) taskforce to undertake a costing and counting study of

stroke thrombolysis treatment with a view to standardising the identification of activities and costs associated with

the provision of stroke thrombolysis services within administrative and ABF data.

4. Consider including formalised feedback loops that will provide patient outcomes to ASNSW within an agreed time

frame from patient delivery to the site to keep ASNSW staff informed.

5. ASNSW to provide weekly data of FAST+ patients taken to each site.

Coherent planning

6. Within the mandate of ACI, consideration to be given to how ACI can best support program delivery and

sustainability beyond implementation. Formalised discussions with key local health district (LHD) stakeholders

regarding their needs is suggested.

7. All models of care are to include baseline data and data collection systems prior to implementation.

8. Further discussion to occur with relevant sites about establishing adequate governance structures to oversee the SRP.

People and engagement

9. A public awareness campaign is suggested comprising stroke and time-critical aspects of treatment with a specific

focus on rural areas and cohorts with the highest stroke prevalence – Aboriginal and Torres Strait Islander people and

people from low socio-economic backgrounds. Although noted in the SRP, public awareness campaigns are outside

the remit of ACI. Therefore, it is suggested that the Stroke Network discusses potential recommendations and

forward them to the relevant bodies for consideration.

Business processes

10. The Stroke Network to convene an expert group to discuss and determine guidelines for SRP sites regarding the

relevant scan types required to ascertain eligibility for stroke thrombolysis treatment and subsequent decision-making

(remote, telehealth) and access to imaging (via ED or directly from ambulance).

11. Matrix to be reviewed in terms of providing statewide coverage and allocation of workload within catchment areas.

12. The Stroke Network to convene a forum of SRP and relevant sites to discuss issues of repatriation with the purpose of

resolution. These discussions are to include commencing rehabilitation, services and capacity at outlying sites and

assessing options for patients.

Leadership

13. ACI and Emergency care institute (ECI) to continue to discuss options for affirming thrombolysis treatment for stroke

as standard practice in stroke care.

Culture and values

14. Promote SRP as an integrated program across ASNSW and LHDs.

15. Define and promote a person-/patient-centred care focus for stroke care in NSW.

16. Further explore the areas of interest as contained in the attached Patient Experience Trackers Report at Appendix III.


Section 1 Introduction

1.1 Stroke

Stroke is the second biggest killer in Australia, after heart disease (ABS, 2009), and in 2008-09, had an estimated

financial cost of $606 billion (ICD-10 codes 160-164) (AIHW, 2013).

There are two predominant types of stroke – ischaemic and haemorrhagic. Ischaemic strokes account for up to 80

per cent of strokes in Australia and occur when a clot blocks blood flow to the brain. A haemorrhagic stroke is due

to bleeding in the brain.

During the period from July 2009 to June 2012, more than 14,200 people were hospitalised in NSW with a principal

diagnosis of ischaemic stroke and almost 5700 people admitted with a principle diagnosis of haemorrhagic stroke

(BHI, 2013). Thirteen percent of people experiencing ischaemic stroke died within 30 days. Two percent of these

deaths occurred on the first day of hospitalisation, 51% within seven days of hospitalisation and 31% occurred after

discharge (BHI, 2013).

Ischaemic strokes are amenable to intravenous thrombolytic intervention, and as documented in a Cochrane

meta-analysis of this treatment, if administered within a few hours of stroke onset, can reduce death and disability

by up to 44% (Wardlaw et al, 2009).

Ischaemic stroke is identified using a brain scan. Ischaemic and haemorrhagic strokes, and transient ischaemic

attacks (TIAs), all present as stroke, and although thrombolytic intervention is not appropriate for haemorrhagic

strokes and TIAs , patients experiencing these conditions may benefit from the intensive care received through a

dedicated stroke unit.

In providing timely thrombolytic treatment to eligible stroke patients, Lovett et al have shown that the provision of

dedicated stroke units comprising multidisciplinary teams (MDTs) and acute stroke pathways have indicated a 30%

improvement in mortality of ischaemic stroke patients in metropolitan NSW compared with stroke patients

receiving care in general wards (Lovett et al, 2003).

The National Stroke Foundation (NSF) has developed guidelines for the management of stroke patients in acute

stroke units. The guidelines comprise coordinated care by MDTs and define the need for 24/7 access to medical

imaging, EDs where staff are trained in thrombolysis for stroke and MD stroke teams within a stroke unit.

1.2 Intravenous thrombolysis for stroke

Intravenous thrombolysis is the injection of a clot-busting medication, rtPA. Administration of thrombolytic therapy

is subject to adhering to a strict criterion for administering up to 4.5 hours after stroke onset (this comprises

90-minute transfer and 3-hour hospital targets) depending upon the patients’ medical history. The earlier rtPA is

administered, the sooner blood flow to the brain is restored, resulting in more benefits being conferred in terms of

ameliorating stroke-related disability, because every 20-minute delay from stroke onset to thrombolysis

significantly reduces the benefits of this treatment. Accordingly, DTN time is a major indicator when evaluating the

clinical outcomes of intravenous thrombolysis (Wardlaw JM, 2009). The administration of rtPA in this paper is

referred to as thrombolytic intervention or thrombolysis.

Thrombolytic intervention administered within 3 hours of the onset of stroke symptoms was licenced for use by the

Therapeutics Goods Administration (TGA) in Australia in 2003. The TGA has since reviewed the evidence and has

licenced its use up to 4.5 hours after symptom onset based on more recent evidence. From 2007 to 2010, patients

admitted for ischaemic stroke who received thrombolysis increased from 461 per year to 1,170 in Australia (AIHW,

2013). This increase is indicative of the increase in stroke units offering the treatment. However, the use of

thrombolysis intervention for stroke is still relatively low in Australia, with the treatment being used for an

estimated 7% of patients presenting with ischaemic stroke nationally (Hoffman T, 2013).


Section 2 Background

In 1998, the Helsinki University Central Hospital began thrombolysing patients for ischaemic

stroke using a specific protocol to ensure that the treatment could be administered safely in a

time-critical manner.

The protocol encompassed the key components of:

• ambulance pre-notification

• the transfer of patients directly from triage to radiology for scans; and, if eligible

• administering of thrombolysis in radiology (Lindsberg et al, 2006).

The key components of the Helsinki model have been successful in reducing DTN time to approximately 20 minutes.

It has since been implemented in several other countries including European nations, the United States of America

(USA), Canada and Australia.

The model has been adapted and implemented on a large scale in the states of North Carolina and New York in the

USA (Asimos et, 2014; Goldstein, 2010; Jaunch et al, 2013), in two centralised metropolitan areas in the United

Kingdom – Greater Manchester and London (Morris, 2014), and in Ontario, Canada (Merino et al, 2014).

In Australia, increasing access to thrombolysis forms part of the Victorian statewide and Western Australian Stroke

Care Plans (WA Gov, 2012; Vic Gov, 2013).

In Victoria, the model has been successfully operating at the Royal Melbourne Hospital, achieving a median

20-minute door-to-needle time (Meretoja et al, 2013). Hunter New England (HNE) was the first place in NSW to

adopt the key components of the model in the early 2000s.

Using the formal definition of program innovation as defined by Wyatt Knowlton and Phillips, innovation occurs

as a result of programs designed from hypotheses derived from research synthesis, whereas benchmark

programs are those based on the evidence of existing and similar programs (Wyatt Knowlton et al, 2013). Thus,

although the NSW SRP is not an innovation, it is based on sound evidence, with its foundations in well-

researched and successful programs.

2.1 NSW Stroke Reperfusion Program

The NSW Stroke Reperfusion Program was formally launched in January 2013 by the NSW Health Minister along

with the formal establishment of 20 ATCs within metropolitan and rural NSW. The ACI Stroke Network Manager,

Clinical Program Design and Implementation (CPDI) Team within ACI and a project officer from ASNSW have

worked collaboratively with LHDs to establish the program across NSW. Throughout this report, ATCs and SRP sites

are used interchangeably.

ATCs are located within existing stroke units and include several key components, as detailed below.

• They have specialist services to care for patients including 24/7 access to medical imaging departments, EDs

where staff are trained in the administration of intravenous thrombolysis and a MD stroke team within a stroke

unit with collocated beds for monitoring. The stroke team members are expertly trained in the management of

people experiencing stroke.

• They are required to undertake a robust process to demonstrate ability to safely and competently deliver 24/7

intravenous thrombolysis and provide the hyper-acute care needed for these patients.

• They have collocated monitored beds and staff facilitate timely transfer of care (ACI, 2013). Each ATC

underwent a pre-implementation process, which included ongoing monitoring and governance processes. An

important element of the program is a well-defined process of transfer to appropriate post-thrombolysis and

post-acute care.


The objective of the NSW SRP is to reduce the time from symptom onset to thrombolytic intervention (onset-to-

needle and DTN times) for patients with an ischaemic stroke. The program is consistent with the National Stroke

Foundation’s Clinical Guidelines for Stroke Management 2010 (NSF, 2010) that stipulates streamlining ambulance

and hospital services to treat people experiencing the signs and symptoms of stroke, increasing the use of

thrombolysis for eligible patients and reducing the primary composite end point of death or disability.

Through the program, all paramedics in NSW have received training in the nationally recognised and validated

FAST+ tool. Paramedics use this tool and their clinical skills to:

• rapidly assess and identify patients with the signs and symptoms of stroke

• transport these patients with onset under 3 hours to the nearest ATC (within a 90-minute drive time), pre-notifying

en route to mobilise the stroke team on pre-arrival through what is often called a stroke code or ‘bat call’.

Figure 1 shows the pathway for the NSW SRP. Through the pre-hospital-led redesign, the NSW Health Matrix (the

Matrix) was reviewed with an additional category of Stroke FAST+ positive created by the NSW Ministry of Health

(MoH). This helps ensure paramedics take patients who meet the criteria to one of the 16 metropolitan ATCs for

definitive treatment.

The program includes protocols on the repatriation and transfer of care for people experiencing stroke back to

their local hospital, as appropriate. Rural hospitals (and Wollongong Hospital) do not operate under the Matrix

system. However, hospitals are still pre-notified of FAST+ patients irrespective of whether an ATC is present.

Patients arriving at a hospital with an ATC by transport other than ambulance are assessed using relevant

assessment tools and if identified as experiencing stroke, the stroke team is notified and mobilised immediately.

The stroke team provides intensive and timely assessment and monitoring to patients while determining eligibility

for thrombolytic intervention (the type of stroke is identified through scans). Once eligibility is confirmed, these

patients are treated, and those not considered eligible are transferred to the relevant units for treatment, i.e.

intensive care, high dependency or stroke units.


Source: ACI Stroke Reperfusion Program evaluation plan, 2014

NSW Ambulance - use FAST+ to

identify people experiencing stroke

NSW Ambulance-determine time of

onset (or last seen well) of stroke

FAST positive patients

Stroke FAST positive, patient trans

ported to nearest Acute Thrombolysis

Centre if within 3 hour clinical time

Eligible patients receive

thrombolytic intervention

Patients arriving to

Emergency Department by

non-Ambulance transport

Non-eligible patients are transferred

to ward (ICU, HOU, stroke care beds)

Pre-notification of FAST positive

patient to Acute Thrombolysis Centre

or hospital if no ATC

Patients transferred to ICU, HDU,

acute stroke care beds with in 3 hours

Staff identify patients

experiencing stroke

Discharge (including rehab, local

hospital, home, aged care facility)

Stroke team mobilised (24-hour service)

Bedside patient assessment with completion of IV

thrombolysis and acute clinical management checklist

Eligibility for thrombolysis determined by checklist, general

assessment and brain scan

3 hours

4.5 Hours

CUMULATIVE TIMELINE

Stroke onset

Figure 1: NSW SRP Pathway


Section 3 Evaluation of the program

3.1 Purpose

The overall purpose of the evaluation of the SRP is to:

• examine whether the aims of the program have been achieved at a system, staff and patient level

(a process-outcome evaluation)

• determine if the implementation approach has been effective, well-designed and appropriate.

As the SRP has several components, and given the lack of inclusion of stroke reperfusion in administrative

datasets, the evaluation will be undertaken in three stages as follows:

3.1.1 Stage one

Stage one will comprise a review of the program design and components implemented across the SRP sites and

within ASNSW. The aim is to identify what aspects of the program have been implemented and delivered and

what inhibits or facilitates program success.

This stage will examine the fidelity of the implementation approach by examining the intent and design of the

program and how this relates to the implementation processes and subsequent program delivery. This

descriptive study will examine various design elements and link to specific implementation strategies and

program delivery to determine success factors that can be adopted at a generic program design level and those

that are specific to the SRP. The results of this part of the study will be used to inform ACI of areas that can be

improved in future design and implementation activities.

The first stage will use a variety of methods and instruments including surveys, interviews and audits – including

the Stroke Reperfusion Assessment Tool (SRAT) and the collection of a minimum dataset around stroke

thrombolysis process – and observation. The SRAT tool and datasets are to be routinely used in the governance

of the program.

3.1.2 Stage two

Stage two of the evaluation will examine outputs and subsequent outcomes of the program at SRP sites compared

with non-SRP sites being assessed before and after inception of the program. Where data are available, this will

comprise DTN time, whether the patient received thrombolytic intervention, and death and disability rates. Stage

two will investigate reasons why eligible patients experiencing ischaemic stroke did not receive thrombolytic

intervention, and why ineligible patients receive intervention and their clinical outcomes in all participating SRP

sites. Examination of changes in clinical outcomes for patients experiencing non-ischaemic stroke and receiving the

intensive assessment, monitoring and care provided by the stroke teams until eligibility is determined will occur.

Stage two will comprise audits of data systems, and linked administrative ambulance, inpatient and death data.

Patient and Staff Experience Trackers (PETs) will be used to examine changes in the experience of staff and

patients. The PET analysis will be undertaken in Stage one of the evaluation to establish a baseline of the staff and

patient journey, and continue at intervals throughout the evaluation. It is anticipated that the PETs will provide

qualitative assessment linked from ambulance to ED (commencing at ED for those patients not arriving by

ambulance), SRP site, transfer destination and at discharge.

3.1.3 Stage three

A third stage of evaluation of the program will occur at a later date once the program is considered settled and

there is adequate data available to examine long-term clinical outcomes. This stage will also comprise a system-

wide analysis and economic appraisal.

Currently funding contained in ABF datasets is based on costs that reflect the more “traditional” treatments for stroke.

This means that the prices paid for the treatment of stroke with thrombolytic intervention may not capture the costs


associated with determining whether a patient is a suitable candidate for thrombolytic intervention and for undertaking

the intervention. Additional separate work is underway to establish realistic costings and ABF pricing for stroke

intervention and care. The development of the ABF platform is considered to be the preliminary phase of the economic

component of the evaluation. Full scoping of this stage will occur once comprehensive ABF stroke reperfusion data are

available to inform the analysis.

In the interim, ABF data concerning the treatment of ischaemic stroke will provide an indicative guide to potential costs of

the program.

This report documents the findings of the first stage of the evaluation only. As subsequent stages are completed,

additional chapters will be added to this document. The information gathered at each stage of the evaluation will be

triangulated to form a comprehensive assessment of the impact of the program.

3.2 Evaluation

This first stage of the evaluation is primarily a descriptive, qualitative study that will assess implementation, function and

fidelity of the program at the participating sites. This is aimed at identifying what aspects of the program have been

implemented and delivered and what inhibits or facilitates program success.

This stage examines the fidelity of the implementation approach by examining the intent and design of the program and

how this relates to the implementation processes and subsequent program delivery. This includes assessment of various

design elements and links to specific implementation strategies and program delivery to determine success factors that

can be adopted at a generic program design level and those that are specific to the SRP. The results of this part of the

study will be used to inform ACI of areas that can be improved in future design and implementation activities.

This first stage has used a variety of methods and instruments including surveys, interviews and audits – including the

SRAT – to collect data. As discussed further in the limitations section, it is not known what data are collected at sites,

therefore it was unknown prior to Stage one what data was available for further investigation. This includes whether data

concerning time of stroke onset, rates of thrombolysis intervention and protocol compliance or violation is available. A

component of the first stage has been to identify data that is collected at each site required for output (key indicators)

and outcome measures that will be used in the proceeding stages of the evaluation.

The key evaluation questions for Stage one comprise:

Table 1: Key evaluation questions

Fidelity Process, quality and quantity

Was the program design effective in delivering the SRP program?

Have the minimum requirements for stroke reperfusion been implemented and sustained (staffing / protocols)?

What processes did ACI use for program implementation across sites and is it consistent with the ACI Implementation Framework?

Are implementation processes in place (stroke team meetings, reviews, MD thrombolysis committee, training and education)?

Were the processes consistent at each site? Are standards of care upheld (guidelines, pathways, protocols)?

Were the processes used for each component of implementation effective?

Are data collection systems in place and implemented?

What inhibited implementation?

What facilitated implementation success?

What strategies can be used to improve the program design and implementation process?


3.3 Limitations of the evaluation

1. There are several gaps in data that limit knowledge in several areas of stroke care and thrombolysis treatment

for stroke. A major limitation of the SRP evaluation was the unknown nature of data collection systems and

availability at sites. To address this, the evaluation of the SRP has been staged and part of this first stage was an

investigation of the local data sources to inform analysis at Stage two.

2. There is no defined coding system used consistently for thrombolytic treatment for stroke. This means that

treatment cannot be identified and analysed at each site through administrative data. To address this, stroke

episodes have been used to provide a general overview of trends and provided in this report, with further

analysis to occur in subsequent evaluation stages. This has prompted additional work with the ABF Unit in the

NSW MoH to define costs associated with thrombolytic intervention and potential identification through

improved coding.

3. Sites visited were asked to include staff from ED, stroke units, imaging and stroke committees in the interview

process, as well as executive sponsors, clinical leaders and project officers. Participation varied across sites and

this may have impacted on the information gathered and subsequently reported in this document. The reader

should therefore be mindful of interview participation when reading findings.

4. Several sites raised issues of program resourcing in the course of interviews. Although ACI acknowledges that

there may be local issues with regards to program funding, stroke reperfusion is considered the standard

practice of stroke treatment rather than an additional program, and therefore, local resourcing is not within

the scope of this evaluation.


Section 4 Methods

The Stage one evaluation of the SRP is a descriptive, qualitative study based on assessment of the SRAT and a series

of interviews. All 20 sites delivering the SRP were invited to participate in the evaluation, with all but two accepting.

The HNE LHD respectfully declined the invitation for the John Hunter and Tamworth Hospitals to participate.

Descriptive statistics for stroke separations in NSW (for patients 18 years and older) have been included in this

report (in Attachment II) to contribute to the overview of stroke activity across the state and within the SRP sites.

Site-specific stroke and thrombolysis data will not be available for analysis until Stage two of the evaluation where

the patient journey will be fully investigated. The descriptive statistics in this report are to be viewed as an

indicative overview of stroke care but do not specify thrombolysis treatment specifically. The statistics are derived

from the NSW Admitted Patient Data Collection using the following International Classification of Disease (ICD)-10

codes for stroke where the ICD code occurs as the primary diagnosis:

• I63 Cerebral infarction (I63.0, I63.1, I63.2, I63.3, I63.4, I63.5, I63.6, I63.8, I63.9)

• I64 Stroke, not specified as haemorrhage or infarction

• I61 Intracerebral haemorrhage (I61.0-I61.9)

• I62 Other non-traumatic intracerebral haemorrhage (I62.0, I62.1, I62.9)

• G45 TIA (all G45 codes).

These codes were agreed by the SRP Evaluation Advisory Committee. An acute flag and further filtering by acute

care type was used to ensure only acute episodes were captured.

Further analysis then occurred at diagnosis-related group (DRG) level using AR-DRG version 6. DRGs were selected

on the basis of volume, with stroke patients being grouped into four main DRGs comprising:

• B02 Cranial procedures

• B04 Extracranial vascular procedures

• B69 TIA and precerebral occlusion

• B70 Stroke and other cerebrovascular disorders.

The use of AR-DRG codes in extracting the patient data has enabled analysis of the NWAUs as a proxy of complexity

and cost. The slight difference between DRG and ICD numbers may be accounted for by type change in ICD codes,

whereas DRGs are based on primary diagnosis at separation along with the elimination of some DRGs for further

analysis given lack of volume or materiality. This results in a slightly higher number of episodes grouped within the

ICD codes, but this does not change the average NWAU as this calculation is based on the primary DRGs.

Site visits

The ACI Evaluation Manager visited the 18 participating sites between 14 May and 14 August 2014 as follows:

• Gosford Hospital

• Nepean Hospital

• Campbelltown Hospital

• Orange Hospital

• Bathurst Hospital

• St Vincent’s Hospital

• Royal Prince Alfred Hospital


• Prince of Wales Hospital

• Bankstown-Lidcombe Hospital

• Westmead Hospital

• Liverpool Hospital

• Royal North Shore Hospital

• Sydney Adventist Hospital

• St George Hospital

• Wagga Wagga Base Hospital

• Hornsby Ku-Ring-Gai Hospital

• Blacktown Hospital

• Concord Hospital.

A semi-structured group interview format was employed at each site, guided by the SRAT, to map the components

of the program and local translation. The interviews included discussion about the ACI implementation processes,

barriers and support factors of program delivery. Each interview took between 1 and 1.5 hours. A site visit pack was

developed and distributed to each site prior to the visits.

Six of the 18 sites plus ASNSW were invited to participate in a more in-depth semi-structured group interview

focusing on:

• assessment of the implemented program at each site and within ASNSW

• identification of factors that facilitate or impede implementation and, where relevant, an audit of

implementation processes, such as sighting of MD stroke team meeting minutes, local pathways, patient

assessment sheets and other relevant documents in place such as local guidelines and policies.

The intention of the interviews was to gather more detailed information than that provided by the SRAT. Site

selection for these interviews was based on 2012-13 quantum of separations for ischaemic stroke and included a mix

of metropolitan and rural sites. The interviews were conducted by the ACI Evaluation Manager and comprised the

following sites:

• Gosford Hospital

• Royal Prince Alfred Hospital

• Bankstown-Lidcombe Hospital

• St George Hospital

• Blacktown Hospital

• Wagga Wagga Hospital.

An interview guide was developed for sites and for ASNSW. A simple audit tool was developed to guide the

sighting of relevant documents and this was included in the site visit pack.

In total, 90 people attended the interviews comprising ED medical officers (n=6) and nursing (n=16), stroke and

neurology medical officers (n=23) and nursing (n=28), data managers (n=2), pharmacy (n=1) and administration and

executive directors (n=14) as depicted in Figure 2.

All interviews were recorded and transcribed. A data reduction matrix was developed and used to code themes and

sub-themes. This was based in part on the Success Factors for Strategic Change Initiatives (Kash et al, 2014). This

informed the development of a data display grid quantifying emerging themes. An emerging theme is classified as

any topic that has been raised by three or more sites. Other issues are raised in the key findings section where


considered important for discussion and improvement. To assist the reader in determining if it is emerging as a

theme, the number of sites relating to the points is noted in the narrative. Emerging themes are summarised in

the Key findings section from the site visits and interviews section in this report.

Figure 3 shows the code groupings for emerging themes.

Number of attendees

Posi

tio

ns

0

Pharmacy

Data Manager

Stroke Nurse

Administration / Medical Director

Neurology / Directors

ED Nurse

ED Medical Officers / Directors

2010 305 2515

Site visit meetings

Figure 2: SRP site visits by participants and position

Data, benchmarking, reports Access to information

Planning, implementation, sustainability Coherent planning

Training, engagement, public awareness People and engagement

Patient flows, governance, resources Business processes

Leadership, champions Leadership

Collaboration, patient-centred care Cultures and values

Code groupings Emerging themes

Figure 3: Code groupings and emerging themes

Further semi-structured interviews were undertaken with ACI staff to ascertain the implementation process

used to support the sites with SRP, barriers and enablers. This comprised face-to-face interviews with the ACI

Stroke Network Manager and the ACI Implementation Manager, and assessment of a written submission

provided by the ACI Implementation Officer involved with the SRP. The data has been coded into themes and

incorporated in the narrative in the Key findings from the site visits section and interviews section.


Section 5 Stroke in NSW

Compared with the treatment of all strokes, stroke units where SRP is provided (over 50% of

all strokes) had a higher complexity of patients, an only slightly longer length of stay than

the NSW average and had experienced increased volume over the period 2007-08 to 2012-

13.

As the growth in volume started to occur before the formal implementation of the SRP, care

needs to be taken in terms of attribution. A number of factors may have influenced this

including the establishment of stroke units prior to the SRP, differences in access to post-

acute care, consolidation of stroke patients in formalised stroke units and transfer patterns

at non-stroke unit hospitals. Detailed work around attribution will occur in the next

evaluation stages.

Across NSW in the 2012-13 year, there were a total of 14,991 acute episodes of stroke with almost 51% presenting to

SRP sites. It needs to be noted that SRP services are part of formal stroke units and the data in this section reflects

all strokes as defined by the ICD list in Section 5. As noted, it is not possible, at this stage, to determine how many

of these strokes received thrombolysis.

Using the average NWAU associated with the specified AR-DRGs as a proxy for complexity (with 1 being standard),

SRP sites combined are indicated to have patients with higher complexity than non-SRP sites at 1.9 and 1.2

respectively. The Royal Prince Alfred Hospital has the highest complexity of patients in this cohort as indicated by

the average NWAU at 2.5, followed by St George Hospital at 2.4 and Liverpool Hospital at 2.3.

Figure 4 shows the average NWAU per SRP site compared to the average NWAU for NSW in total, SRP sites in total

and non-SRP sites in total.

Figure 4: Average NWAU for SRP sites

Average NWAU for selected stroke DRGs by SRP sites 2012-13

SRP sites

0.0

0.5

1.0

1.5

2.0

2.5

Ave

rag

e N

WA

U

Concord

Hosp

ital

Blackt

own H

ospita

l

Wag

ga Wag

ga Bas

e Hosp

ital

Royal N

orth Sh

ore H

ospita

l

Wes

tmea

d Hosp

ital

Prin

ce o

f Wale

s Hosp

ital

St V

ince

nt’s H

ospita

l

Orange H

ealth

Serv

ice

Nepea

n Hosp

ital

John H

unter H

ospita

l

Hornsb

y Ku-R

ing-G

ai Hosp

ital

St G

eorg

e Hosp

ital

Liver

pool Hosp

ital

Banks

tow

n Hosp

ital

Royal P

rince

Alfr

ed H

ospita

l

Bathurst

Hosp

ital

Campbell

tow

n Hosp

ital

Gosford

Hosp

ital

Tam

worth B

ase H

ospita

l

Average NWAU by site NSW SRP Non-SRP


SRP sites had a slightly higher average length of stay compared to the NSW average and had a higher average

NWAU. This indicates that although the complexity of patients presenting at SRP sites was higher than the NSW

and non-SRP site averages, the length of stay was only minimally increased. This may be due to the timeliness of

stroke care provided at SRP sites indicating a more effective mode of service provision. This preliminary finding

is to be explored further in subsequent stages of the evaluation. The average length of stay varies across sites

with the NSW average at 6 days, SRP sites at 6.9 days and non-SRP sites at 5.2 days in 2012-13. The sites with the

highest average length of stay within SRP sites are generally those with higher complexity than the state and

combined SRP averages.

Royal North Shore Hospital had the highest volume of patients experiencing stroke in the 2012-13 year with 645

episodes (acute ICD codes) and accounting for 4.3% of all episodes for NSW and 8.4% of all episodes at SRP sites.

This is followed by St George Hospital, which had 626 acute episodes, accounting for 8.1% of all episodes

presenting to SRP sites, and Gosford Hospital, with 607 episodes and 7.9% of the SRP patient load for this cohort.

The intensity summary in Table 2 is shaded from white to dark crimson to emphasise the lowest to highest

scores in each column with white as the lowest score. Although all episodes of stroke presenting to NSW

hospitals have risen by 3%, from 14,229 in 2007-08 to 14,700 in 2012-13, stroke presentations to SRP sites have

risen by 14% in the same period, indicating that prior to the ‘‘go live’’ date (January 2013) of the SRP, diversion

to these sites was well underway.

Table 2: Summary activity by SRP site 2012-13

2012-13ACUTE

AR-DRGACUTE

ICD% NSW

ACUTE ICD% SRP

ACUTE ICDAVERAGE

NWAU ALOS

NSW combined 2012-13 14700 14991 100.0 1.5 7.5

Acute episodes SRP sites 2012-13 7516 7699 51.4 100.0 1.9 6.7

Acute episodes non-SRP sites 2012-13

7184 7292 48.6 0.0 1.2 5.2

Concord Hospital 354 359 2.4 4.7 2.0 8.3

Blacktown Hospital 403 405 2.7 5.3 1.6 6.4

Hornsby Ku-Ring-Gai Hospital 229 235 1.6 3.1 1.3 6.2

Wagga Wagga Base Hospital 255 263 1.8 3.4 1.4 5.0

St George Hospital 592 626 4.2 8.1 1.9 7.5

Royal North Shore Hospital 628 645 4.3 8.4 2.1 6.8

Liverpool Hospital 571 594 4.0 7.7 2.3 8.1

Westmead Hospital 552 564 3.8 7.3 2.0 6.3

Bankstown-Lidcombe Hospital 339 350 2.3 4.5 1.8 8.0

Prince of Wales Hospital 399 417 2.8 5.4 2.4 8.0

Royal Prince Alfred Hospital 433 443 3.0 5.8 2.5 7.8

St Vincent's Hospital 360 365 2.4 4.7 1.5 6.1

Bathurst Hospital 132 132 0.9 1.7 1.1 4.7

Orange Health Service 197 197 1.3 2.6 1.1 4.0

Campbelltown Hospital 297 298 2.0 3.9 1.4 6.8

Nepean Hospital 443 451 3.0 5.9 2.1 6.4

Gosford Hospital 594 607 4.0 7.9 1.3 5.7

John Hunter Hospital 549 554 3.7 7.2 2.1 7.3

Tamworth Base Hospital 189 194 1.3 2.5 1.5 6.5


From 2007-08 to 2012-13, the acute episodes for stroke by selected DRG had the highest volume in stroke and other

cerebrovascular disorders at 56,357 episodes for this period.

The ICD within these DRGs have remained relatively stable as shown in Figure 5 with cerebral infarction having the

highest volume as shown in the first graph. The second graph depicts the average length of stay for all acute

episodes within the selected codes showing a decline across NSW from 7.8 days in 2007-08 to 6 days in 2012-13.

It must be noted that although the first graph in Figure 5 shows the episodes by selected ICD-10 codes as all are

relevant to the presentation of stroke and subsequent assessment for thrombolysis, once condition is determined,

only cerebral infarction and stroke, not specified will be potentially amenable to thrombolysis.

The second graph in Figure 5 shows the length of stay for all selected ICD-10 codes to provide the broad context of

stroke care in NSW; however, subsequent analysis of length of stay by SRP site includes only those conditions

relevant to SRP – contained in Attachment II.

Figure 5: NSW ICD-10 stroke episodes and average length of stay 2007-08 to 2012-13

Figure 6: SRP ICD-10 stroke episodes and average length of stay 2007-08 to 2012-13

Similar to the NSW rates, cerebral infarction had the highest volume at SRP sites in total with 43,442 acute episodes

from 2007-08 to 2012-13. Consistent with the total NSW trend, in 2007-08, the average length of stay for these sites

was 8.8 days, which has declined steadily for all stroke types to 6.9 days in 2012-13. Figure 6 shows the episodes and

average length of stay for selected ICDs.

Deriving from these DRGs, the following tables shows the episodesand average length of stay by the specified ICD codes These have remained relatively stable from 2007/08 to 2012/13 with a total increase of 3.8 percent over this time period. The largest volume was for cerebral infarction with 5455 episodes in 2012/13.The average lengtyh of stay hase steadily decreased over this time period for all specified ICD with an overall average of 7.4 days in 2012/13.

07/08 to 2012/13 in NSW public hospitals.

me of episodes each year being for Stroke and other cerebral vascular disorders followed by TIA and cerebral occlusion.

0

1000

2000

3000

4000

5000

6000

2007/08 2008/09 2009/10 2010/11 2011/12 2012/13

Epis

od

es

Year

Stroke by ICD-10 NSW 2007/08 to 2012/13 Episodes and average length of stay

Other non-traumatic intracerebral haemorrhage

Stroke not specified

Intracerebral haemorrhage

Cerebral infarction.

Transient ischaemic attack

0

2

4

6

8

10

12

2007/08 2008/09 2009/10 2010/11 2011/12 2012/13

Days

Year

0

2000

4000

6000

8000

10000

12000

2007/08 2008/09 2009/10 2010/11 2011/12 2012/13

Episides

Year

Stroke by DRG NSW 2007/08 to 2012/13 Acute episodes

Cranial procedures

Extracranial vascular procedures

TIA and precerebral occlusion

Stroke and other cerebovascular disorders

0

500

1000

1500

2000

2500

3000

3500

4000

2007/08 2008/09 2009/10 2010/11 2011/12 2012/13

Epis

od

es

Year

Stroke by ICD-10 SRP sites 2007/08 to 2012/13 Acute episodes and average length of stay

Intracerebral haemorrhage Other non-traumatic intracerebral haemorrhage

Cerebral infarction Stroke not specified


0

2

4

6

8

10

12

2007/08 2008/09 2009/10 2010/11 2011/12 2012/13

Days

Year


Non-SRP sites had a total of 44,503 acute episodes in selected ICD codes from 2007-08 to 2012-13 as depicted in

Figure 7, the highest volume being for TIA at 2,668 episodes in 2012-13. The average length of stay has steadily

declined from 6.9 days in 2007-08 to 5.2 days in 2012-13, with the biggest decline being for cerebral infarction from

10.4 days to 7.7 days over the same time period.

Figure 7: Non-SRP sites ICD-10 stroke episodes and average length of stay 2007-08 to 2012-13 2012/13

Cranial procedures

Extracranial vascular procedures

TIA and precerebral occlusion

Stroke and other cerebovascular disorders 0

500

1000

1500

2000

2500

3000

2007/08 2008/09 2009/10 2010/11 2011/12 2012/13

Epis

od

es

Year

Stroke by ICD-10 non SRP sites 2007/08 to 2012/13 Acute episodes and average length of stay




Cerebral infarction


0

2

4

6

8

10

12

2007/08 2008/09 2009/10 2010/11 2011/12 2012/13

Day

s

Year

0

500

1000

1500

2000

2500

3000

3500

4000

2007/08 2008/09 2009/10 2010/11 2011/12 2012/13

Epis

od

es

Year

Stroke by ICD-10 SRP sites 2007/08 to 2012/13 Acute episodes and average length of stay




Cerebral infarction



Section 6 Key findings from site visits and interviews

Table 3 shows a summary of the emergent themes emanating from site visits, interviews with

selected sites and interviews with ASNSW. The proceeding narrative provides an outline of the

key findings from these data and includes interviews with ACI Implementation Officers. The

results reflect the perspectives of the interview participants and until completion of Stage two

evaluation comprising quantitative analysis, provide a descriptive case study only forming part of

the baseline.

Table 3: Emerging themes

Emerging themes Issues raised Number of responses

Access to information Statewide consistency neededAbility to benchmark and share knowledge transferData collection system mandatedProvision of ASNSW FAST+ dataData collection established prior to program commencement Lack of ability to identify thrombolysis patients in administrative datasets

18 5 4 4 3 4

Coherent planning Limited impact of implementationPre-notification improved timeliness of treatmentSupport for program delivery and sustainability required

8 4 4

People and engagement Need for a public awareness and training campaign about stroke systems and time-critical treatment

3

Business processes Models of care to comprise key performance indicators (KPIs) rather than processes to enable flexibility Difficulty in timely transfer to ward

3 4

Leadership Perceived leadership of an evidence-based program (HNE)Local champions and leadersDistrict-wide leadership and coordinationACI and ECI leadership in promoting thrombolysis as standard care for stroke

5 3 3 4

Culture and values Positive relationships with ASNSWAdopting a patient-centred approach to stroke care

3 3

6.1 Access to information

Data has emerged as the major theme discussed by 17 of the 18 sites visited and by ASNSW. All of these discussions

included the need for a consistent and statewide data collection approach at a minimum with other emerging

themes around data concerning:

• the need for projects to have data collection systems in place prior to launching, with participating sites

mandated to use this as part of the program

• the provision of FAST+ patient data by ASNSW by site

• transparency of consistent data enabling sites to benchmark and share knowledge.

6.1.1 Research

Several sites noted a preference for using either existing national or worldwide datasets. Sites also referred to the

large number of data collections occurring for stroke including:


• Australian Stroke Clinical Registry (AuSCR) hosted through a partnership between the National Stroke

Foundation, George Institute for Global Health, Stroke Society of Australasia and the National Stroke Research

Institute (NSF website). The collection is aimed at monitoring quality improvements for stroke.

• Safe Implementation of Treatments in Stroke (SITS). This database is used by an international network of stroke

centres as part of a prospective, international, multicentre controlled study to determine the benefits and

safety of thrombolectomy and intravenous thrombolysis for stroke (SITS website).

• INSPIRE, an international stroke perfusion imaging registry providing a web-based data collection of imaging and

clinical stroke data to validate the use of CTP to refine the selection of patients for thrombolysis (SSA website).

• Thrombolysis ImPlementation in Stroke (TIPS) is hosted by the National Stroke Foundation aimed at evaluating

the effectiveness of thrombolysis for the treatment of stroke (SSA website).

In addition to these databases, the Australian Stroke Coalition (ASC) data and quality working group is working on

the development of the Australian Stroke Data Tool (AuSDaT) that will combine the AuSCR, INSPIRE, SITS and TIPS

as well as various telemedicine projects. The AusDat tool was released and is being rolled out to participating

hospitals throughout 2015.

These datasets have been established for research purposes and have an important function in collecting

information to enable national and international monitoring and evaluation of stroke care. SRP sites will continue

to be involved in and contribute to selected collections at the discretion of the participating site.

6.1.2 NSW administrative data requirements

Most sites have local data collections in place and several provide data to the research-orientated collections noted

above. It was noted by four sites that ACI should not develop a new database and suggested that ACI mandate use

of one of the existing databases to monitor the program. Five sites noted the importance of having consistent data

collection and reporting systems and retrieval to provide sites with the ability to benchmark against other sites and

to facilitate knowledge transfer of lessons learned. Three sites strongly stated that the official launch of the program

should not have occurred until a data collection system was in place to monitor and evaluate progress, and one site

noted that consistent data collections are essential for moving towards an accredited system for stroke services.

Due to the considerable onus that the establishment of another data collection system will place on sites, it is more

feasible to collect the relevant data required to enable collection and extraction of patient activity within the

existing statewide administrative datasets. Collection of this data will support identification of the patient cohort.

6.1.3 Patient outcome data

Four sites noted that ASNSW data showing FAST+ patients arriving by ambulance is needed for sites to monitor the

pre-notification system, the quantum of bypasses, accuracy of FAST+ diagnosis, and subsequent thrombolysis rates

and patient outcomes. ASNSW noted the need for sites to provide data to enable identification of any issues, with

the aim of resolving these issues quickly.

Thrombolysis treatment for stroke is not assigned with a dedicated DRG. This was raised by four sites as a potential

disincentive to thrombolysis as a standard of care for stroke patients. In response, ACI is working with the ABF

Taskforce to identify the resource requirements for stroke thrombolysis and to potentially establish a way to

identify the patient cohort in administrative datasets to address this. This may be adequately addressed through

the refinement of coding systems rather than establishing a dedicated DRG. Several options are being canvassed

and it is anticipated that this work will continue throughout Stage two of the evaluation.

In March 2014, the Australian Commission on Safety

and Quality released a consultation draft: Clinical

Care Standard for Stroke. The paper comprises seven

quality standards incorporating stroke assessment,

thrombolysis, acute stroke care, initiation of

rehabilitation, stroke prevention, carer training and

EDs and people who are seeing acute

patients don’t like to collect data for data’s sake

unless it’s going to drive their processes.“ “


support and individualised care plans. At a minimum, these standards, once endorsed, should form the basis of

KPIs for SRP sites in NSW and guide data collection requirements. The consultation draft can be accessed at

http://www.safetyandquality.gov.au/wp-content/uploads/2014/03/Full-version-Consultation-Draft-Clinical-Care-

Standard-for-Stroke.pdf.

Other issues raised with regard to data included the limited ability of the FirstNet system to track stroke patients

adequately, as it does not include time of onset data, and the need for sites to collect the National Institute of

Health Stroke Scale (NIHSS) information for all patients to enable assessment of patient outcomes. One site noted

that it is overly prescriptive for ACI to request data from sites at this stage of the program.

6.2 Coherent planning

The SRP initiative commenced in the MoH in 2010 and was handed over to ACI in 2012. The then DDG was the

executive sponsor of the program and ECI was involved in the design of the model through engagement on the

SRP Steering Committee. It was initially based on a successful program operating in the then HNE Area Health

Service that was achieving thrombolysis rates and times comparative to international best practice standards.

The ACI process involved the exploration of what was working well (the HNE model) to apply to the rest of NSW to

improve stroke care and address clinical variation and to design elements that were considered more relevant to

NSW as a whole (e.g. using FAST+ rather than the identification model used by HNE). At the time, it was estimated

that only 7% of stroke patients were receiving thrombolysis (NSF, 2010).

The MoH provided funding to ASNSW for FAST+ training for paramedics and for ACI to document the NSW SRP model.

Development of the program involved:

• establishment of a bypass system so that smaller sites that do not provide thrombolysis can be bypassed and

patients transported directly to SRP sites

• training paramedics in advanced stroke recognition to identify these patients (FAST+)

• development of a pre-notification system to enable acute stroke teams to be mobilised at the receiving sites

and imaging ready to complete required scans to determine eligibility for treatment.

The ACI adopted a redesign process and designed a model of care for the SRP based on aspects of the HNE

model and using the NSF Clinical Guidelines for Stroke Management 2010. Chief Executives of each District were

asked to identify services in place that would satisfy the requirements set out in the model of care followed by a

validation process of those sites identified. This comprised audits, site visits, discussions with clinicians and a

‘walk-through’ of the patient journey to assess each component of the model. To facilitate this process, an

implementation toolkit and self-assessment checklist were developed and disseminated to sites to assist in

service review and quality improvement.

Once endorsed for inclusion as an official SRP site, each CE was requested to nominate an executive sponsor, a

clinical champion and a project officer to support the program. Sites were tasked with establishing local

governance committees to facilitate the implementation and delivery process.

To support the process, the ASNSW undertook workload modelling to project patient flows to SRP sites once

the bypass system was in place to enable planning by sites. At the time, it was reported that discussion occurred

around measuring for effectiveness and quality improvement; however, agreement was not reached on what

systems should be used, resulting in the program launched without clear data collection requirements.

A 12-month time-limited community of practice was established comprising SRP sites and hosted by ACI

(through a regularly scheduled teleconference) to provide a forum for discussion of lessons learned, knowledge

exchange, processes and issues arising. Attendees at this forum changed over time.

It was reported by ACI staff that major factors facilitating success of the implementation process included:


• support for the program by all levels of the LHDs from clinicians to executive members

• establishment of local governance arrangements

• the collaborative approach adopted by the ACI Implementation Team, Stroke Network Manager, ASNSW and

ACI Stroke Network in developing the specific SRP model of care and visiting sites to support local

implementation.

In relation to the ACI involvement in implementation, there were several key issues, as outlined below.

• A large number of sites considered the ‘‘go live’’ date in January 2013 to comprise the ASNSW pre-notification

system only. Accordingly, eight sites noted that the implementation processes employed by ACI had little or no

impact on their existing services although four sites said that the pre-notification system was instrumental in

improving patient transport times from onset to hospital.

• Two sites noted that the ACI implementation process assisted in gaining executive support for SRP at the local

level and in reviewing current service delivery.

• Four sites perceived the support provided by ACI to be relatively minimal and would have preferred an ongoing

structure to support delivery and sustainability of the program.

• One site noted that the ACI process assisted in overcoming the resistance to thrombolysis held by ED physicians

through the provision of leadership of thrombolysis as standard stroke care, while another site noted the

importance of ACI involvement in the adoption of a standardised tool (FAST+).

Separate from the implementation process, many sites mentioned the ongoing support provided by the ACI Stroke

Network Manager and the ASNSW Program Manager as a positive contribution to the program.

It must be noted that interview participants at sites consisted primarily of clinicians from stroke units, neurology

and emergency departments, and therefore may not be reflective of the perceptions held by administrators. In

addressing this potential bias, it is suggested that a small number of group interviews with LHD administrators

occurs at Stage two of the evaluation to expand the dataset surrounding the implementation process.

6.3 People and engagement

The need for ongoing public awareness campaigns was

raised by all of the rural services visited. It was perceived

that the information about stroke incorporates acute

symptoms only and the message about how time-critical

it is to seek treatment is not portrayed. As a result, rural

sites spoke of situations where patients did not

recognise symptoms and consequently, help was sought

too late for patients to be eligible for thrombolysis.

6.4 Business processes

Several themes specific to rural sites emerged throughout the site visit processes. These included the need for

flexible models of care that can be locally translated to each site and specifically to the needs of rural sites. This

would involve the establishment of shared principles around specific programs and development of a succinct set of

key performance indicators rather than prescriptive processes. As noted by all of the rural sites visited, flexibility for

LHDs to determine service structures will increase access to services for rural people and buy-in for local clinicians.

Vast distances in rural areas affect the time that patients arrive at designated SRP sites, as raised by two sites. Both

of these sites discussed concerns that there are other sites that provide thrombolysis treatment for stroke that may

be closer to the patient’s home but as they are not specifically identified as part of the SRP, predominantly due to

operating in business hours only, they are bypassed, resulting in longer transport times. This prompted further

discussion around the need for flexibility in models of care, as discussed above, and a review of the ambulance

bypass system.

The bigger hospitals, they have the

formal meetings. The smaller hospitals, they

have a cup of coffee and know what’s

happening in ward 5.

“ “


6.4.1 NSW Health Matrix

The principle relating to the Matrix system is that each ED will accept emergency patients from ambulance

consistent with clinical specialities offered on site and from within the respective hospital catchments.

There were no emerging themes relating to the Matrix system in relation to stroke, however it was raised by several

sites and ASNSW. The most prominent issue was raised by two sites concerning the lack of Matrix coverage in rural

areas. Discussion ensued around the need for the Matrix to include stroke on a statewide basis and concern was

raised with regards to limited awareness of the SRP in rural, non-SRP sites. It was perceived that this may delay

treatment for some patients as they may not be transferred to ATC and acute stroke unit (ASU) sites. It was also

noted that there are inherent difficulties in implementing a statewide protocol (pre-notification) because of the

diversity of sites with differing operational systems, pathways and awareness.

ASNSW discussed the benefits of establishing helicopter transport in rural sites for time-critical emergencies, such as

stroke. The use of helicopters for acute stroke patient transport has been used in the HNE District and is currently

under review.

One metropolitan site raised concerns about the apparent opaqueness of the Matrix and suggested that several

patients incorrectly classified as FAST+ are regularly transported to an ED outside of their district. However, without

access to FAST+ and local site data, this has not been quantified. This will be pursued further in Stage two when

data is provided. It was noted that the Matrix substantially increased the throughput of stroke patients to

participating sites, but limited data availability has resulted in the site not having the evidence to support an

increase in ASU beds.

Two metropolitan sites advocated for a review of the Matrix to enable an equitable work distribution among sites

in the catchment areas. The Matrix is reviewed every two years and required amendments are made at these times.

6.4.2 Repatriation

Repatriation of patients back to their local hospitals (where appropriate in relation to their respective care

requirements) is a component of the SRP model. Although issues of repatriation were not raised as emerging

themes, concerns are important for further discussion. Two sites, one metropolitan and one rural, discussed the

difficulties of transferring patients back to their local area, and in the case of the metropolitan site, back to the

patient’s LHD. This was noted to be due to bed shortages, minimum neurological support in smaller outlying areas

and the wishes of patients to remain in place and not start care at a new service.

An important issue was raised by one site in terms of repatriation and rehabilitation. There is substantial evidence

to support early rehabilitation for stroke patients (see, for example, AIHW, 2013). However, if a patient is to be

repatriated back to their local facility, it was noted that rehabilitation plans are not started at the first site, and

instead, are developed at the local facility. This delay in rehabilitative support is considered potentially detrimental

for the patient.

6.4.3 Treatment

There were three emergent themes regarding treatment for stroke patients. The first is the inequity of care

between BH and AH and the second the timely transfer of patients from ED to ward – both are discussed in the

section on Key findings from SRAT review in the next chapter. The third theme raised by three sites is a call for ACI

and ECI to provide leadership in promoting thrombolysis as standard care for eligible stroke patients. Other sites

identified some scepticism of the treatment, particularly amongst ED physicians, however did not feel that this

delayed or hindered the treatment as it was now accepted as standard care.

Two sites discussed the perceived accuracy of the FAST+ tool, noting that this was difficult to determine without

analysing the data. It was suggested that once accuracy is defined, this could be compared against that of the tool

used in the HNE LHD, with a view to adopting the most effective tool. However, sound evidence is required prior to

changing tools. In general, most sites were satisfied with the FAST+ assessments and several noted that accuracy has

improved as paramedic training has progressed.


Issues raised in terms of resourcing comprised the ability of sites to recruit and maintain staff with specific stroke

care skills and the subsequent, substantial workload of neurologists. This is particularly pertinent to rural sites that

do not have the throughput of patients to keep staff skills current.

6.5 Leadership

There were several emergent themes with regard to what sites considered enablers for the success of SRP. Due to

the lack of program data availability, these factors have not been analysed against progress indicators at this stage

of the evaluation.

The leadership provided by the HNE LHD in the development and delivery of the program was raised by five sites as

a success factor in the acceptance of thrombolysis as standard practice in treating stroke, alongside confidence

derived from the ongoing research and improvement. It was stated that ongoing research has ensured that the

program has been supported by a sound evidence base from its inception to its current iteration.

Local champions and leaders were seen to be pivotal in the success of the program in raising its profile and

acceptance. Three sites noted that District-wide leadership and service coordination has contributed substantially

towards the success of the program. This included the:

• support provided to the Sydney Adventist Hospital from Royal North Shore Hospital in installing the program

• shared protocols, pathways, coordination and medical staff across Liverpool, Bankstown-Lidcombe and

Campbelltown Hospitals

• delivery of a hub-and-spoke model of stroke care from Orange Hospital to the outlying facilities

• coordinated stroke care by Concord and Royal Prince Alfred Hospitals across the District including an outreach

stroke care team comprising allied health staff streamlining the patient journey across the continuum of care.

Two sites noted that there is a lack of coordination within their respective Districts resulting in difficulties for

consultants who work across the sites. Work was progressing in one site to develop a coordinated approach to SRP.

The three sites raising ACI and ECI leadership in this area stated that cultural changes will occur if thrombolysis is

promoted by lead agencies as a standard care for stroke. This is considered important for raising awareness about

stroke care outside of SRPs to ensure that contracted staff provide suitable care while working in SRP sites.

6.6 Culture and values

A positive relationship between sites and ASNSW was an emergent theme and considered a good indicator of

program success by several sites. At these same sites it was noted that ASNSW is involved in local site committees,

feedback is provided and sought by paramedics and regular contact with the ASNSW Program Manager is

maintained. Similarly, ASNSW discussed the importance of feedback loops and providing paramedics with patient

outcomes in a timely manner. Feedback loops informing paramedics of patient outcomes (for those arriving by

ambulance) are provided by the site within 48 hours in a formalised process in the HNE model. It is unclear why this

was not translated into the SRP model, and it has been suggested that its inclusion be reviewed and considered.

Taking a patient-centred approach to stroke care emerged as a strong theme throughout the site visits and is seen

as a success factor for SRP. However, although raised as a success factor, no site reported that patient-centred care

was an ongoing and formalised component of SRP delivery at their site. Patient-centred care was described as all

staff and units taking ownership and responsibility for patient stroke care from ambulance to ED staff, radiology,

stroke units and rehabilitation. Several sites noted that responsibility for stroke care is seen as a function of

neurology, rather than a shared responsibility, and suggested that clear mapping of the patient journey at each site

and identification of what each staff or unit contributes to that would be a good starting point for dialogue and

ensuing cultural shifts.

This is consistent with the ASNSW view that paramedics are part of the patient healthcare journey, not just the

transport. It was suggested by one site that ACI take a coordinating role in facilitating this process by bringing

people who contribute to the patient stroke care journey together to progress discussion. This was considered a


larger membership than that currently involved in the Stroke Network. However, if people don’t currently consider

their roles to be core to stroke care, they are unlikely to attend such a meeting. It may be a more viable option to

consider establishing a small, key team of people comprising representatives from ACI Stroke Network, ASNSW, ACI

and ECI, and Allied Health to map out the change management process for cultural shifts in patient care

responsibility prior to broadening the dialogue to sites.


Section 7 Key findings from SRAT review

7.1 Stroke Reperfusion Assessment Tool

The implementation of the SRP was based on a consistent service redesign approach indicating fidelity of

implementation processes as noted in the section above. However, as documented in the summary SRAT table (at

Appendix 1), there is a diversity of approaches adopted at sites and differences across metropolitan and rural areas

signifying infidelity in program delivery. This chapter provides an overview of each site that has participated in the

SRP evaluation Stage one.

Inpatient descriptive statistics (episodes of care and length of stay) are contained in Appendix II. Although most

sites stated that thrombolysis has been occurring prior to the formal implementation of SRP, improved rates of

thrombolysis (anecdotal) have been associated with improved pre-hospital identification and faster transfer of

patients to dedicated SRP sites. A full assessment of this requires consistent data. Further information, particularly

concerning site-specific patient data, will be assessed and reported in Stage two.

7.1.1 Gosford Hospital

Gosford Hospital has had an acute stroke team and has been thrombolysing people for several years prior to the

‘‘go live’’ date of the SRP. Pre-notification by ASNSW has been in place prior to the SRP and this comprises pre-

notification directly to the Acute Stroke Team rather than to ED. Gosford Hospital reported a close working

relationship with ASNSW, which was viewed as having positive benefits for the program.

Barriers identified in the SRP Pathway included blockages to radiology for imaging, for example, imaging is not

pre-notified of the imminent arrival of FAST+ and stroke patients.

There is no stroke reperfusion or general stroke governance committee in place at Gosford Hospital. It was

acknowledged that the establishment of such a body would provide value through the oversight of all components

of the patient journey, and ensure clear and consistent guidelines and criteria for each stage, monitoring and

addressing issues arising. This includes the ability to address potential blockages in imaging and the inclusion of EDs

as partners in the SRP to foster increased connection with the program. It was reported that the site is considering

the establishment of an SRP governance committee in the near future. The inclusion of a local governance structure

is a required component of formal SRP recognition. Patients are discussed at standard ED Mortality and Morbidity

(M&M) meetings, as required.

7.1.2 Nepean Hospital

Nepean Hospital reported that thrombolysis treatment had been occurring for several years prior to the official ‘‘go

live’’ of the SRP, and pathways and systems are consequently well established. Pre-notification of incoming FAST+

patients occurs from ambulance to ED and ED notifies the Stroke Team once diagnosis is verified by ED.

The patient pathways are the same after hours although processes differ by way of treatment lead. Within hours,

the Stroke Team leads the process once notified by ED. After hours, the process is led by ED. Stroke patients are

prioritised for scanning. However, access to scans is seen as the program component with the largest delay.

Regular in-services and training are provided to nurses and through the orientation of medical staff. At the

commencement of the SRP involving ASNSW, a stroke steering committee was established. However, this

committee has not met for almost 12 months.

Barriers reported included access to neurologists AH and difficulties encountered with limited and changing

staffing. On-call neurologists resided at a distance from the hospital, and consequently, delays were often

experienced in their arrival to assess patients. As a result, there has been an occasion when thrombolysis treatment

was administered by ED prior to neurology assessment. To address this issue, the hospital has now installed

telehealth facilities into the ED, and although a recent action, it is reported as a successful strategy in accessing

neurologists in a timely manner.


Nepean Hospital has had difficulty in attracting and maintaining neurologists over the past year. This transpired as

a major barrier in having no constant clinical champions or leadership for the SRP. The hospital is in the process of

engaging a team of neurologists and this is considered a major step to future program improvements through the

establishment of champions and leadership, reconvening the Stroke Committee (with the inclusion of ASNSW) to

provide governance, monitoring and facilitating broader awareness, education of best practice and importance of

time for thrombolysis treatment for stroke. The former Stroke Committee has been convened only once since the

‘‘go live’’ SRP date. Patients are discussed at regular ED and Neurology M&M meetings, as required.

7.1.3 Campbelltown Hospital

A 24/7 acute stroke service was in place at Campbelltown Hospital prior to SRP implementation in January 2013.

The official launch of the SRP assisted in providing validity to the program across all units involved in the patients’

journey. The current DTN time is reported at an average of 70 minutes.

A comprehensive training program occurs with the training of medical registrars in stroke and thrombolysis

treatment as part of the St Vincent’s – Wollongong Network orientation. A theory-based in-service accompanied

by an exam is held for nurses using a ‘train the trainer’ model, as well as training for ICU staff to enable

thrombolysis within the ICU.

Issues for ASNSW in the bypass system were reported stating that patients identified as FAST+ in the

Wingecarribee area bypass Bowral Hospital and go to Campbelltown or Liverpool. This potentially puts pressure

on the only two ambulances located in that area when transporting patients the considerable distance to the SRP

sites. Discussion ensued regarding possible assessment of patients at Bowral to confirm eligibility for thrombolysis

prior to transporting as a way to alleviate this problem. However, this would require access to a computed

tomography (CT) scanner. It was agreed that further discussion is needed to address this and similar issues at a

statewide level.

Another barrier identified concerned the lack of pathways and policies for patients in which thrombolysis doesn’t

work, i.e. for those requiring intra-arterial thrombolysis or thrombolectomy. This was suggested as the next phase

of the SRP development.

Campbelltown Hospital is part of a District-wide stroke service providing 24/7 thrombolysis, along with Liverpool

and Bankstown-Lidcombe Hospitals. This is reported as a SRP success due to District-wide knowledge sharing and

collaboration, localised flow charts reflecting different processes of care in each hospital underpinned by District-

wide policies, data collection, education packages and governance. The District is now aiming towards

standardised thrombolysis protocols across the District to complement the program. Medical teams are also shared

across the District enabling seamless patient transfers, where required, and shared agreement on tests, treatments

and approaches. This teamwork is reported as a major facilitator of the success of the SRP, with the ASNSW seen as

a major part of the team.

The Stroke Committee is District-wide and meets regularly as the governance body for the SRP. Patients are also

discussed at regular M&M meetings and the ED Neurology meetings, as required.

7.1.4 Orange Health Service

Orange Hospital has been operating a 24/7 stroke and thrombolysis service for several years. The internal pathways

for stroke care have remained relatively stable over that time. However, the official launch of the SRP enabled

Orange Hospital to develop external pathways for peripheral hospitals. This has established a hub-and-spoke model

resulting in more timely transfer and effective stroke care.

The Orange Hospital SRP is based in Cardiology. Neurologists working in the area are primarily room-based,

providing consultancy to the hospital and not available for on-call services. This has highlighted barriers to the AH

SRP that relies on on-call medical staff and Cardiology without leadership from Neurology. It was reported that this

limitation in staffing has resulted in several physicians being involved in thrombolysis, and due to the small

throughput, it is difficult to maintain practical skills, and therefore to sustain the program effectively.


Internal education is provided to medical registrars and Cardiology on a regular basis. In-services for nurses occur

regularly and through the orientation program.

Education of the peripheral hospitals has been identified as a success factor in the SRP at Orange Hospital. Sites

and general practitioners (GPs) are becoming increasingly aware of the time-critical nature of thrombolysis

treatment and transfer times are reported to be decreasing. A local evaluation of this is in progress and will be

used to guide service improvements across the sites.

Regular feedback to peripheral hospitals and GPs is suggested as a successful strategy to increase engagement and

education through the benchmarking of diagnosis, transfer times and outcomes across the spokes.

Stroke Committee and Patient Safety Meetings occur on a monthly basis and act as the local governance structure

for SRP. Patients are also discussed at regular M&M meetings, as required.

7.1.5 Bathurst Base Hospital

Similar to the Orange Health Service, Bathurst Base Hospital works on a hub-and-spoke model with peripheral

sites. The peripheral feeder hospitals include Rylstone, Blayney and Oberon. Although Lithgow is out of the LHD,

an increase in presentations from there has occurred due to the SRP FAST+ protocol being implemented.

Bathurst Base Hospital does not have a neurology service and relies significantly on locum, fly in/fly out staff,

particularly in ED. The need for stroke care and thrombolysis treatment to be standardised is therefore paramount

to ensure all attending staff are aware of practices and time-critical processes. Standardised care is seen as

essential in ensuring that staff at any hospital follow best practice in stroke care, inclusive of thrombolysis

treatment, not just those at designated sites.

Access to scans was reported as the program component where delays are most likely to occur. However, it was

noted that delays are shorter AH.

Internal education is provided to ED nurses and registrars at regular sessions. However, the nature of the rural

workforce and locum staff means that not all staff are adequately trained and aware of stroke care or thrombolysis.

Ongoing education was considered the biggest barrier to the effective delivery of SRP, particularly education

provided to peripheral sites and GPs. It was noted that the importance of timely transfer and GP referral requires

ongoing dialogue.

Similar to Orange Hospital, the Bathurst Base Hospital has monthly Stroke Committee and Patient Safely

Committee meetings that act as the governance structure for SRP. Patients are also discussed at regular M&M

meetings, where required.

7.1.6 St Vincent’s Hospital

St Vincent’s Hospital was the site of the official launch of SRP and commenced thrombolysis in 2003. It has a

well-established system for stroke care consistent with the requirements outlined in the SRP.

A comprehensive training program is in place at St Vincent’s Hospital comprising regular in-services for ED nurses

and registrars and orientation at triage. The Hospital has a simulation centre and provides six-monthly training for

ED consultants, registrars and nurses, and provides a six-monthly didactic lecture.

Collecting patient history was reported as a barrier to timeliness of the SRP. It was stated that this may take

considerable time once a patient arrives at ED, potentially resulting in treatment delays. It was considered more

successful when patient history is collected in transit and provided to ED along with the patient. However, it is

acknowledged that this is not always possible.

The SRP governance structure at St Vincent’s Hospital comprises a monthly governance, quality and variation

meeting where all aspects of the program are discussed. Patients are also discussed at regular M&M meetings,

where required.


7.1.7 Royal Prince Alfred Hospital

Royal Prince Alfred Hospital has been thrombolysing for stroke since 2000 and has well-established stroke care services, policies and pathways in place.

Training occurs every two months for all ED staff, on grand rounds for RMOs and during orientation for all hospital staff.

Stroke patients have priority for scanning. However, delays in scans have been identified as a potential barrier. It was reported that the journey for the patient works well from ambulance to ED and although radiology is pre-notified of potential stroke patients, ordering of scans is digital and cannot occur until registration, as registration and medical record numbers are required to generate the order. Discussions to find a viable solution are ongoing.

Previous delays in scans were identified resulting from neurology requests for labour-intensive diffusion/perfusion contrast studies. Consequent discussions resulted in agreement that non-contrast brain scans would be the standard and any decision about the need for more esoteric scanning would be made on a case-by-case basis. This reportedly decreased times significantly.

The success of the program was reported to include use of data for continuous improvement. Any DTN time beyond 60 minutes is interrogated to identify delays and remedied accordingly (average DTN currently 55 minutes).

The collaborative relationships across ambulance, ED, radiology and neurology was stated as a major facilitator of success and this is considered to be strengthened by other work involving partnerships between ED and neurology for several clinical trials.

The Royal Prince Alfred Hospital holds quarterly meetings as the governance structure for the SRP and provides reports about the program to the Executive and the Clinical Council. Attendants at quarterly meetings include ASNSW, ED Nursing, ED Medical Staff, Radiology, ICU Staff, Stroke Ward NUM, Rehabilitation Staff, Neurologists and Allied Health.

Patients are also discussed at regular M&M meetings.

7.1.8 Prince of Wales Hospital

The Prince of Wales Hospital commenced stroke thrombolysis in 2006. The ED is pre-notified of incoming FAST+ stroke patients, however the stroke team is not pre-notified. ED assesses patients to confirm diagnosis prior to notifying the stroke team. This notification includes medical imaging.

The SRP has clear policies and procedures in place and undertakes regular monitoring of KPIs through quality, morbidity and mortality meetings. Training and orientation is provided in ED to new nursing graduates and in-services.

Brain scans that contribute to the determination of a patient’s eligibility for thrombolysis vary in type requested across staff and a need for consistency was raised to facilitate accurate, but timely treatment.

Some feedback is provided to ASNSW, primarily concerning missed FAST+ patients and those incorrectly diagnosed. However, this is not a formalised process. Similarly, there is no formal feedback mechanism from the stroke unit to ED concerning patient outcomes.

After-hours access to scanning was reported as a barrier to timely administration of treatment and it was noted that staff education and cultural change is required to provide a seamless service across all aspects of the patient journey. The ACI has worked with Prince of Wales Hospital to review the SRP in depth resulting in a series of recommendations to improve the program.

The governance structure for SRP at Prince of Wales Hospital comprises regular meetings for stroke with membership from Neurology, ED and Imaging.

7.1.9 Bankstown-Lidcombe Hospital

Bankstown/Lidcombe Hospital has been offering stroke thrombolysis in BH since 2008. This expanded into a 24/7 service in 2011 and is part of the District-wide stroke care. The SRP at Bankstown/Lidcombe Hospital now has revised processes enabling neurologists to provide remote consent for thrombolysis treatment rather than having to attend the hospital. This has reportedly streamlined the SRP considerably.


Education is embedded into ED orientation and junior medical officer teaching and nurse orientation training.

Thrombolysis training is undertaken by nurses to enable administering of thrombolysis. The current mean door-to-

needle time is reported as approximately 50 minutes.

Success factors of the SRP at Bankstown-Lidcombe are reported as the collaborative working relationships across

the different components of the program. Radiology is considered an asset in prioritising stroke patients and clear

policies that are in place facilitate the smooth operation from arrival to discharge.

The SRP governance committee for Bankstown-Lidcombe Hospital meets bi-monthly and includes membership from ED,

Neurology, the Stroke Team, and the District Stroke Liaison Officer. Patients are also discussed at regular M&M meetings.

7.1.10 Westmead Hospital

Westmead has been thrombolysing people for stroke for several years and in the 2013/14 year, had a median DTN

time (in BH) of 52 minutes for the 39 patients thrombolysed, with the fastest at 17 minutes. The median door-to-

imaging time for the same period was 12 minutes. The Hospital is increasing the number of FAST+ patients taken

directly from ambulance to radiology for scans, although this has not yet been formalised.

Westmead Hospital provides ongoing ED training in stroke care and thrombolysis and an annual formal induction

for registrars on the stroke roster. In BH, stroke is led by the stroke registrar; AH, there is an age split, with patients

aged 70 years and over having treatment led by the on-call geriatrician, and those under 70 years, by the on-call

neurologist.

A barrier identified was the differential in consultants’ diagnostic preferences for scans, and another is access to the

drug for thrombolysis treatment. Being expensive, it is located in a locked cupboard and there are protocols that

must be followed for access, which may reportedly delay treatment. Westmead Hospital also identified difficulties

in patient transfer from ED to the stroke unit due to bed blockages.

Westmead Hospital does not have a specific governance structure for SRP in place. Patients are discussed at regular

M&M meetings.

7.1.11 Liverpool Hospital

Liverpool Hospital started thrombolysing in 2004 as a 9-to-5 service, gradually expanding to a 24/7 program.

Average DTN time is reportedly 40–50 minutes within BH, and similar to many other SRP sites, longer AH with an

estimated average of 100 minutes. The reasons noted for this inequity between in and out of hours include travel

time for stroke consultants and registrars to arrive at the hospital and the ED decision to not pre-notify AH until a

patient is assessed and diagnosis confirmed. The stroke consultant can read a scan remotely, but still undertakes an

on-site stroke medical assessment.

Access to radiology was reported as good, although can be tightened to improve time. The need for radiographers

to respond to AH pages and faster pathology were discussed as requirements for streamlining the service.

Training and orientation occurs regularly for ED nursing, junior medical officers and registrars. Nursing uses a

train-the-trainer model enabling the ongoing orientation of staff. Additionally, ED nurses have been trained in

administering thrombolysis treatment, which has resulted in improved DTN time. It was reported that further

internal education would raise awareness about the SRP, and consequently, involvement of the Acute Stroke Team

in internal strokes.

Cohesion across the District was raised as the success of the program effectively facilitated a “learn and share”

model, an avenue for solving any issues and development of shared protocols.

The committee established as the governance structure for SRP at Liverpool Hospital has convened only twice since

the ‘‘go live’’ date in January 2013. However, quarterly District-wide stroke meetings do occur and act as an

overarching governance structure for the program. Meetings are attended by ASNSW, Administration, Neurology,

Medical and Nursing, ED and Allied Health. Patients are also discussed at M&M meetings as required.

7.1.12 Royal North Shore Hospital


Royal North Shore Hospital commenced thrombolysing patients for stroke approximately 10 years ago. In the 2013 calendar year, the service reportedly thrombolysed 51 patients, or 20% of patients presenting with ischaemic stroke.

Royal North Shore Hospital provides orientation and education through in-services to ED nursing, registrars, ED medical and stroke unit staff. All training occurred on a six-weekly rotating roster. However, it now occurs as needed as staff are aware of the processes. Registrars receive three-monthly training to ensure coverage with staff changes.

The site undertakes advanced imaging which adds an estimated 20 minutes to treatment time. To address this, treatment for eligible patients starts in radiology or ED. Once treatment starts, patients are not moved until completion to minimise treatment error potentially caused by perfusion pump vial sizes. The pumps take only 50mg syringes. Whilst most patients require 60mg of medication, so a further syringe is required, and if the patient is transferred, there is potential for receiving staff to assume that the completion of the first syringe is all that is required.

The cost of the thrombolysis medication was identified as a barrier to its use, because the medication is required to be stored in a locked cabinet requiring dual identification for access. In addressing this, medication is now placed in a thrombolysis bag that accompanies the patient to radiology, effectively streamlining the process.

The Stroke Team meets regularly, forming the governance structure for SRP at Royal North Shore Hospital. As staff share the same physical office location, they also meet informally, as required, and patients are discussed at regular M&M meetings. The Stroke Team meetings comprise the Director of Stroke Network, Clinical Nurse Consultants (CNCs), Stroke Fellow, Data Manager and the Area Coordinator.

7.1.13 Sydney Adventist Hospital

The Sydney Adventist Hospital commenced acute stroke services in 2005 and established protocols and pathways to

guide service provision. A major review of stroke services was completed in 2012 resulting in changes to AH imaging

to streamline the process. This comprised formal agreement for scanners to operate 24/7 without requiring the

on-call radiologist to be contacted. Neurologists review scans AH, which are then formally reported by the

radiologist during BH. It was reported that an estimated 12% of FAST+ patients are thrombolysed.

The Sydney Adventist Hospital does not have an AH Acute Stroke Team registrar. After-hours services for acute

stroke are led by the senior doctor in ED with direct consultation from an on-call neurologist. The hospital does

treat public patients for stroke. Once stabilised, these patients are transferred to a suitable facility, such as Hornsby

Ku-Ring-Gai Hospital.

Orientation to stroke care and thrombolysis occurs for new staff through stroke workshops, and refreshers are held

as needed.

Sydney Adventist Hospital is working towards installation of a full location tracking system of patients and chores.

This consists of radio monitoring systems located throughout the hospital and has the potential to accurately track

the journey and treatment of stroke patients.

The committee that forms the governance structure for the SRP at Sydney Adventist Hospital convenes six-monthly

and includes Emergency Staff, Medical Officers, Neurology, Neuroscience Nurse Unit Manager (NUM) and other

invitees, as required. Patients are also discussed on a regular basis at Neurology Section meetings.

Sydney Adventist Hospital is a private hospital. Therefore, ACI does not have direct access to admitted inpatient

data for the site, but the hospital is providing data to the ACI from 1 October 2014 and this will be used for Stage

two of the evaluation.

7.1.14 St George Hospital

St George Hospital has had a stroke unit for many years and commenced thrombolysing for stroke in 2007. It is the

southernmost thrombolysis service in the metropolitan area and receives patients from Wollongong, Canterbury

and Sutherland.

St George Hospital reportedly thrombolyses an estimated 10–15% of patients arriving with stroke calls with the best

DTN time in the past year recorded at 18 minutes.


Training is provided on stroke care and thrombolysis through regular in-services to ED staff and at orientation

as new registrars commence at the hospital.

A major barrier for the service has been identified as the limitations to repatriating patients back to their local

area due to bed capacity issues. There are also issues regarding limited rehabilitation services in the patients’

local area, further impacting on repatriation.

The St George Hospital SRP is a busy service and the strict rules enforced on admission to the stroke unit have

been identified as a success factor. All admissions must be reviewed and approved by the neurologists.

The bi-monthly St George Hospital Stroke meetings acts as the governance structure for the SRP. Additionally,

each department has separate meetings and interdepartmental meetings occur, as required. Patients are

discussed at regular M&M meetings.

7.1.15 Wagga Wagga Base Hospital

The Wagga Wagga Base Hospital commenced thrombolysing for stroke in 2008. The service was regarded as

well-established by the time the SRP was officially launched in 2013.

The hospital shares registrars with Campbelltown and St Vincent’s Hospital and each year the stroke consultant

travels to Sydney to meet with those that will be going to Wagga Wagga. The meeting comprises a full day of

stroke and thrombolysis management orientation.

Additional training occurs regularly with ED junior medical staff, as well as orientation and training for nursing

staff in administering thrombolysis. Emergency department nurses have completed NET SMART online training

– a series of modules for stroke management associated with the TIPS trial.

Thrombolysis treatment occurs in ED prior to the patient being transferred to the high-dependency unit (HDU)

or acute stroke ward. The DTN time was reported to be on average 60 minutes with the door-to-scan time an

average of 24 minutes. Thrombolysis rates were noted as increasing from 3.7% of patients presenting with

ischaemic stroke in 2012 to 8.9% in 2013.

Radiology prioritises stroke patients, enabling streamlining of the service. This was enhanced in early 2014 with

the commencement of an advanced stroke trainee, effectively enabling this position to assess the patient on

site, while the neurologist can read scans remotely.

Similar to other sites, Wagga Wagga Base Hospital reported that there was an initial barrier to the SRP in ED

with the acronym FAST. In ED, FAST refers to a Focussed Abdominal Sonographic Trauma Exam and it has taken

some time to differentiate between this and stroke FAST+.

Delays in transfers from outlying hospitals were noted as a barrier to timely treatment. It was reported that

several patients were transported to the closest hospital rather than bypassed to the ASU. Wagga Wagga Base

Hospital has a large catchment area covering Griffith, Leeton, West Wyalong, Young, Lockhart, Nanandera and

Loxton. Thus, timely transfer to the appropriate service is crucial for treatment.

Community awareness of stroke FAST was raised as a major concern with an internal evaluation indicating that

of 132 patients experiencing ischaemic stroke, only 8% were aware of the FAST symptoms.

The governance structure for SRP at Wagga Wagga Base Hospital is the Executive Stroke meeting that occurs

bi-monthly. This comprises participation by the Stroke Consultant, Stroke Unit NUM, an Executive

representative, Allied Health and a Consumer representative. Patients are discussed at regular M&M meetings,

as necessary.


7.1.16 Hornsby and Ku-Ring-Gai Hospital

The Hornsby and Ku-Ring-Gai Hospital has been operating an acute stroke and thrombolysis service for several

years. The site reportedly thrombolyses approximately 10 to 12 patients per annum for stroke. The current

average DTN time was reported to be approximately 60 minutes.

Regular orientation and education occurs via in-services for ED staff and any changes to the pathways are

discussed with all staff. There is a stroke website that is consistently updated with information.

A recent LHD initiative has embedded e-copies of useful thrombolysis tools in the local Firstnet (in ‘ad-hoc

charting’) i.e. NIHSS, a version of inclusion and exclusion criteria and a decision-assist tool for treatment of

ischaemic stroke, including management of blood pressure etc.

Door-to-needle time can be improved.

• A CPI project is underway to facilitate improved rates of neurology-alert from the triage desk i.e. to include

FAST+ as an emergency-call alert (via the ‘33’ call to ‘Switch’).

• Order of initial CT: to address a particular delay in CT image availability, staff are now required to order CTs

and CT angiograms separately. If ordered together, the images can take up to 30 minutes longer to process.

• Strategies to prioritise and expedite pathology (‘bloods’) for stroke patients are being reviewed.

A small, local stroke meeting is used as the governance structure for the SRP. This meets quarterly. The meetings

include Stroke Unit NUM and ED staff. The neurologist at Hornsby and Ku-Ring-Gai Hospital is a Visiting Medical

Officer (VMO) and attends and chairs the meetings.

Eligible and thrombolysed patients are mini-case-studied monthly, and as necessary. Patients are discussed, as

needed, at M&M meetings and informal discussions occur about patient care, as required.

7.1.17 Blacktown Hospital

Blacktown Hospital has had an ASU offering thrombolysis in place for several years. Similar to Westmead, this

operates on a split service with the neurology unit treating patients up to 69 years old, while the geriatric

service treats those aged 70 years and older. The average DTN time is reported at 69 minutes.

Orientation and education is provided through in-services to ED nursing and medical staff. However, this is on

an “as needed” basis rather than scheduled for regular sessions.

After hours is serviced by an on-call neurologist who has remote access to scans, pathology and ED presentation

data. This system is considered ideal by the neurology staff because patients’ access to treatment may be more

timely, if seen by specialists in the field in the first instance. A barrier reported is the reluctance of ED staff to

call AH to access this process.

Inserting a bolus as soon as practical to streamline treatment was noted as a success in improving treatment

time. Attempts have been made to divert patients directly to imaging from the ambulance. However, unless a

patient is formally registered, scans cannot be generated.

A collaborative working relationship between the SRP units and support for the program from the executive

was reported as facilitating the success of the program.

The SRP governance structure for Blacktown Hospital meets regularly and comprises neurologists, Stroke CNC,

ED CNC, ED managers, Stroke Unit staff, geriatricians and ED senior physicians. Patients are discussed at M&M

meetings as required.


7.1.18 Concord Hospital

The Concord Hospital had the first stroke unit in NSW, commencing in 1994. The hospital has been thrombolysing

people for stroke for approximately 5 years. The DTN time was reported to be on average between 45 and 50

minutes. However, a recent extension of time has been attributed to new ED medical staff who are unaware of the

protocols. This is in the process of being addressed.

The Concord Hospital provides training and orientation to staff on an “as needed” basis and schedules formal

meetings to discuss stroke care and thrombolysis treatment when a new group of registrars commence.

Concord Hospital works on a District level regarding stroke care. Regular meetings occur with Royal Prince Alfred

Hospital to discuss shared knowledge, learnings, protocols and issues arising. A stroke outreach team (allied health)

is shared across the District. The governance committee for the SRP meets quarterly and includes representatives

from ASNSW, ED, Radiology and the Stroke Team. Additionally, patients are discussed at regular M&M meetings.

Ambulances pre-notify Concord Hospital ED of incoming FAST+ patients. However, ED does not notify the Stroke

Team or Radiology until the patient is assessed in ED to verify the diagnosis.

It was reported that the system works effectively within BH, however, AH can pose potential issues when new and/

or locum positions are rostered in ED and unaware of the protocol. When this occurs, a formal meeting is arranged

to discuss protocols with staff.

Radiology was identified as the program component with the most delays AH as the scanner must be started using

specific protocols and reviewed prior to commencing scans.

The presence of strong advocates in ED for thrombolysis treatment for stroke was considered a success factor of the

program and in raising awareness about the importance of time in treatment.


Section 8 Discussion

The context of Stage one of the evaluation is based on the perceptions of the program by

key stakeholders. Although this requires quantitative data analysis to fully consider the

implications, an analysis of the data gathered thus far indicates several areas for

consideration and further improvement.

8.1 Program fidelity

In terms of implementation fidelity, delivery as well as the implementation approach need to be considered. This is

consistent with the themes of ongoing support for delivery and sustainability of programs. ACI needs to consider

strategies to address this while being mindful of the role of ACI; to develop, implement and evaluate models of care,

but not necessarily provide ongoing program support. A balance between the requirements of LHDs and the role of

ACI is needed to enable adequate support and program sustainability.

Discussions with the ACI Implementation Team involved in this project and sighting of relevant documentation

confirmed fidelity of the implementation approach. However, SRP delivery has limited fidelity for all components of

the program. There is considerable variation across sites with the biggest differences, and potential for slowing the

treatment process, located within the scanning components of the program. A total of seven sites reported that

Imaging was not pre-notified for FAST+ patients.

Practices around pre-notification of FAST+ patients vary across sites, with all sites receiving pre-notification from

ambulance to ED, although Nepean, Prince of Wales and Concord Hospitals do not pre-notify the Acute Stroke Team

until ED assesses and verifies a patient’s diagnosis. Some sites reported that the Stroke Team can be contacted and

mobilised quickly once a diagnosis is confirmed; however, this has potential to slow times to treatment.

The redesign methods adopted by ACI and the benchmarking with a tested and successful program (the HNE model)

resulted in an evidence-based program design that is considered effective in delivering the SRP. Although sites

reported the usefulness of the design and implementation tools, many noted that some ongoing support to sites

would assist in program sustainability.

8.2 Barriers to program implementation and delivery

The issues raised pertaining to data are substantial and require an agreed approach not only in establishing systems to

collect data about the program now, but also in the establishment of methods of data collection prior to the

implementing programs in general, to enable adequate monitoring, benchmarking and evaluation.

Recognition of the SRP as a whole-of-system program incorporating all key components as part of the patients’ care is

required to foster a shared understanding and responsibility for patient needs and consequently, a patient-centred

model of care. This includes everything from ASNSW being recognised as part of the patient journey through to

adequate rehabilitation support. To achieve this, clearly articulated and detailed mapping of the program and

transparent systems (including the provision of data and timely feedback) is required at each stage of the SRP.

Within the program, medical imaging has shown the greatest diversity across sites and is potentially a major barrier to

timely thrombolysis intervention. Further investigation is required to ascertain the most effective processes for timely

imaging and establishment of guidelines for types of scans required, acceptable modes of neurology input (remote

monitoring, telehealth, face-to-face consultation) and SRP pathways to imaging (direct from ED or from ASNSW), and

subsequent processes to facilitate these processes. These decisions fall within the remit of the stroke discipline and

dialogue should commence in the near future to ensure any potential elements of clinical variation are addressed.


Local governance structures for the oversight of the SRP are a major component of the program and were an

element required for ACI to officially recognise sites as SRP sites. Although identification of existing structures or

establishment of specific structures were part of the SRP implementation, 6 out of the 18 sites interviewed stated

that there was not a formal governance structure in place that met at least quarterly. One of the sites noted a

structure that met six monthly, another was a local structure that met as required and another did not meet locally,

but had the benefit of District-wide governance meetings. Of the three remaining sites without governance

structures in place, all noted consideration to reconvene these structures, but no formal commitment was stated.

This is a concern worthy of further discussion with the sites. Formal governance of SRP is considered good practice

for the consistency and sustainability of the program.

8.3 Factors facilitating success of the program

The factors that promoted success of the program in implementation, delivery and sustainability comprised local

leadership, particularly in terms of executive sponsors and clinical champions. These roles were reported to be

instrumental in ensuring that the SRP remained a priority and worked with clinicians at each unit in the patient

journey to raise awareness of the SRP and stroke care and provided regular review reports and feedback to relevant

staff and governance bodies.

A District-wide collaborative approach across SRP sites within a District was reported as a positive influence on the

program. Shared knowledge, protocols, pathways and sometimes, medical teams, provided a cohesive service and

learning environment.

It was noted that positive relationships with ASNSW facilitated program success. This aligned with the point raised

in discussions from some sites and from ASNSW that ambulance officers are a key part of the patient journey and

consequently, should be regarded as an important part of the Acute Stroke Team. Similarly, adopting a patient-

centred approach to stroke care was seen as essential to program success and this comprised each unit delivering

care along the patient journey to take responsibility and accountability for that care.

To further expand on this concept, community awareness in stroke prevention, symptoms and time-critical

treatment will contribute to increasing patient and community literacy about stroke care. A comprehensive patient-

centred approach would include training and information to families and carers, individualised care plans for

patients and timely access to rehabilitation services.


Section 9 Conclusion and preliminary recommendations

The following recommendations are included in this document as a starting point to address

areas for improvement in the SRP. It is acknowledged that further analysis will occur in the next

stages of the evaluation as is required to make more fully considered changes. The following

provide areas for consideration in terms of formative assessment.

9.1 Recommendations

Access to information

1. Consistent data collection methods to be determined for the SRP, development of a data dictionary and

guidelines for collection, access and reporting.

2. Data provided across all components of the program to SRP stakeholders (sites, ASNSW and ACI) at a minimum

of ASNSW FAST+ patients by site, door-to-scan time, scan-to-needle time, transfer times and destinations, and

patient outcomes. This will be used for monitoring, evaluation and benchmarking.

3. ACI to continue work with the ABF taskforce to undertake a costing and counting study of stroke thrombolysis

treatment with the view of standardising identification of activity and costs associated with the provision of

stroke thrombolysis services within administrative and ABF data.

4. Consider the inclusion of formalised feedback loops that will provide patient outcomes to ASNSW within an

agreed time frame from patient delivery to the site to keep ASNSW staff informed.

5. ASNSW to provide weekly data of FAST+ patients taken to each site.

Coherent planning

6. Within the mandate of ACI, consideration to be given in how to ACI can best support delivery and

sustainability of programs beyond implementation. Formalised discussions with key LHD stakeholders

concerning needs is suggested.

7. All models of care are to include baseline data and data collection systems prior to implementation.

8. Further discussion to occur with relevant sites about the need to establish adequate governance structures to

oversee the SRP.

People and engagement

9. A public awareness campaign is suggested comprising stroke and time-critical aspects of treatment with a

specific focus on rural areas and cohorts with highest stroke prevalence – Aboriginal and Torres Strait Islander

people and people from low socio-economic backgrounds. Although noted as an SRP, public awareness

campaigns are outside the remit of ACI suggesting that the Stroke Network discuss options for these

recommendations and forward to the relevant bodies for consideration.

Business processes

10. Stroke Network to convene an expert group to discuss and determine guidelines for SRP sites concerning

relevant scan types required for ascertaining eligibility for stroke thrombolysis treatment and subsequent

decision making (remote, telehealth) and access to imaging (via ED or directly from ambulance).

11. Matrix to be reviewed in terms of providing statewide coverage and allocation of workload within catchment areas.

12. Stroke Network to convene a forum of SRP and other relevant sites to discuss issues of repatriation with the

purpose of resolution. To include commencement of rehabilitation services and capacity at outlying sites and

assessment of options for patients.


Leadership

13. ACI and ECI to continue the discussion of options for affirming thrombolysis treatment for stroke as standard

practice in stroke care.

Culture and values

14. Promote the SRP as an integrated program across ASNSW and LHDs.

15. Define and promote a person/patient-centred focus for stroke care in NSW.

16. Further explore the areas of interest as contained in the attached Patient Experience Trackers Report at

Appendix III.


Section 10 Next steps

The next stage of the evaluation will comprise analysis of data from ASNSW and sites to assess

KPIs for the SRP and provide more in-depth context for Stage one.

Stage two will also incorporate the work discussed with the ABF Taskforce to investigate potential coding solutions

for stroke thrombolysis treatment. The time frame for Stage two will be reliant on access to site data (may be

subject to various ethics approvals) and will be confirmed once Stage one is complete.


Section 11 References

1. ABS Causes of death (cat no 3303.0), Canberra, Australia; 2009.

2. ACI Stroke Program: Early Access to Stroke Thrombolysis - Implementation Toolkit.

3. ACI What is the NSW Stroke Reperfusion Service and why do we need it?; 2013.

4. AIHW Stroke and its management in Australia: an update. Canberra; 2013.

5. Asimos, A., Ward, S., Brice, J., Enright, D., Rosamond, W., Goldstein, L., Studnek, J. A geographical information system analysis of the impact of a statewide acute stroke emergency medical services routing protocol on community hospital bypass, Journal of Stroke and Cerebralvascular Disease, Nov-Dec 2014, vol 23, issue 10; 2014.

6. Australian Commission on Safety and Quality in Health Care. Consultation draft: Clinical care standards for stroke 2014. [Online] Available at: http://www.safetyandquality.gov.au/wp-content/uploads/2014/03/Full-version-Consultation-Draft-Clinical-Care-Standard-for-Stroke.pdf

7. BHI The Insight Series: 30 day mortality following hospitalisation, five clinical conditions, NSW, July 2009 - June 2012. Chatswood: BHI; 2013.

8. Department of Health Model of Stroke Care. Perth: Health Networks Branch, Department of Health, Western Australia; 2010.

9. Department of Health Framework for Regional Acute Stroke Services in Victoria, State Government; October 2013.

10. Golstein, L. Statewide Hospital-Based Stroke Services in North Carolina: Changes Over 10 Years. Stroke: Journal of the American Heart Association, vol 41; February 2010.

11. Hoffman T, L. R. Stroke care in Australia: why is it still the poor cousin of health care? Medical Journal Australia, 5; 2013.

12. Jaunch, S., Adams, H., del Zoppo, G., Alberts, M., Bhatt, D., Brass, L., Furlan, A., Grubb, R., Higashida, R., Kidwell, C., Lyden, P., Morgenstern, L., Oureshi, A., Rosenwasser, R., Scott, P., Wijdicks, E. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke: Journal of the American Heart Association, published on PubMed; March 2013.

13. Kash, B., Spaulding, A., Johnson, C., Gamm, L. Success factors for strategic change initiatives: a qualitative study of healthcare administrators perspectives, Journal of Healthcare Management, 59:1; January-February 2014.

Lindsberg, P., Happola, O., Kallela, M., Valanne, L.,

Kuisma, M., Kaste, M. Door to thrombolysis: ER

reorganization and reduced delays to stroke treatment,

Neurology, vol 67 no 2; July 2006.

14. Lovett, J., Sandercock, P., Bamford, J., Warlow, C.,

Rothwell, P. Very early risk of stroke after a fgirst transient

ischaemic attack, Stroke v34; 2003.

15. Mansour, O. Thrombolysis for ishaemic stroke: Where we

are (time is brain). The Internet Journal of Interventional

Medicine, vol 2 #1; 2013.

Meretoja, A., Weir, L., Ugalde, M., Yassi, N., Yan, B., Hand,

P., Truesdale, M., Davis, S., Campbell, B. Helsinki model cut

stroke thrombolysis delays to 25 minutes in Melbourne in

only 4 months, Neurology, vol 81 no 12; Sept 17 2013.

16. Merino, J., Silver, B., Wong, E., Foell, B., Demaerschalk, B.,

Tamayo, A., Poncha, F., Hachinski, V. Extending Tissue

Plasminogen Activator Use to Community and Rural

Stroke Patients. Stroke: Journal of the American Heart

Association, vol 33; 2002.

17. Morris, S. Impact of centralising acute stroke services in

English metropolitan areas on mortality and length of

hospital stay: difference-in-differences analysis, British

Medical Journal; August 2014.

18. National Stroke Foundation website. [Online] Available at:

http://strokefoundation.com.au/health-professionals/

auscr-partnership

19. National Stroke Foundation. Clinical guidelines for

stroke management. Canberra: National Stroke

Foundation; 2010.

20. Stroke Society of Australia website. [Online] Available at:

http://www.strokesociety.com.au/index.php?option=com_

content&view=article&id=367:inspire-international-

stroke-perfusion-imaging-registry&catid=40:astn&Item

id=162

Wardlaw JM, M. V., Berge E, del Zoppo GJ. Thrombolysis

for acute ischaemic stroke (Review). Cochrane

Collaboration(4); 2009.

21. Wyatt Knowlton. L., Phillips. C. The logic model

guidebook: better strategies for great results, 2nd Ed.

Sage Publications Inc., Thousand Oaks, California; 2013.

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 4

7

App

endi

x I

Go

sfo

rd

Ho

spit

alN

epea

n

Ho

spit

alC

amp

bel

ltow

n

Ho

spit

alO

ran

ge

Ho

spit

alB

ath

urs

t H

osp

ital

St

Vin

cen

t’s

Ho

spit

al

Roy

al

Prin

ce

Alf

red

H

osp

ital

Prin

ce o

f W

ales

H

osp

ital

Co

nco

rd

Ho

spit

al

Do

yo

u r

ecei

ve s

tro

ke F

AST

+ p

atie

nts

?Ye

sYe

sYe

sYe

sYe

sYe

sYe

sYe

sYe

s

Are

th

ere

syst

ems

in p

lace

fo

r ac

tiva

tin

g a

st

roke

pag

e al

ert?

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Is E

D p

re-n

oti

fied

of

FAST

+ p

atie

nts

?N

o (

Acu

te

Stro

ke T

eam

n

oti

fied

)

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Is M

edic

al Im

agin

g p

re-n

oti

fied

of

stro

ke

FAST

+ p

atie

nts

?N

oN

oYe

sYe

sYe

sYe

sYe

sN

oN

o

Is A

cute

Str

oke

Tea

m p

re-n

oti

fied

of

stro

ke

FAST

+ p

atie

nts

?Ye

sN

oYe

sYe

sYe

s Ye

sYe

sN

oN

o

Are

pat

ien

ts t

riag

ed a

s C

ateg

ory

2?

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Are

AH

Neu

rolo

gy,

Rad

iolo

gy,

Str

oke

Un

it

and

Pat

ien

t Fl

ow s

taff

aw

are

of

pro

cess

es

AH

fo

r FA

ST+

pat

ien

ts?

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Is t

he

pro

cess

fo

r FA

ST+

the

sam

e 24

/7?

If

no

t w

hat

are

th

e d

iffe

ren

ces?

Yes

No

, ED

-led

A

H, S

tro

ke

Team

- led

in

BH

No

ED

-led

AH

, St

roke

Tea

m-l

ed

in B

H

No

, AH

ra

dio

log

y re

adin

g

serv

ice,

m

edic

al

on

-cal

l AH

No

, AH

ra

dio

log

y re

adin

g

serv

ice

No

, ED

-led

A

H, S

tro

ke

Team

-led

in

BH

Yes

Yes

No

, ED

-led

A

H, S

tro

ke

Team

led

in

BH

Are

str

oke

pat

ien

ts t

hat

arr

ive

by

amb

ula

nce

, bu

t n

ot

iden

tifi

ed a

s FA

ST+

ap

pro

pri

atel

y as

sess

ed a

nd

tri

aged

? W

hat

m

easu

res

are

use

d t

o a

sses

s th

is?

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

FAST

+R

oss

ier

FAST

+FA

ST+

14.1

Str

oke

Rep

erfu

sio

n A

sses

smen

t To

ol

Tab

le 4

: Str

oke

Rep

erfu

sio

n A

sses

smen

t To

ol s

um

mar

y

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 4

8

Go

sfo

rd

Ho

spit

alN

epea

n

Ho

spit

alC

amp

bel

ltow

n

Ho

spit

alO

ran

ge

Ho

spit

alB

ath

urs

t H

osp

ital

St

Vin

cen

t’s

Ho

spit

al

Roy

al

Prin

ce

Alf

red

H

osp

ital

Prin

ce o

f W

ales

H

osp

ital

Co

nco

rd

Ho

spit

al

Are

FA

ST+

pat

ien

ts w

ho

arr

ive

by n

on

-am

bu

lan

ce m

ean

s ap

pro

pri

atel

y id

enti

fied

an

d a

sses

sed?

Wh

at m

easu

res

are

use

d t

o

asse

ss t

his

?

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

FAST

+R

oss

ier

FAST

+FA

ST+

Pati

ents

rec

eive

tre

atm

ent

wit

h

intr

aven

ou

s th

rom

bo

lysi

s as

per

pro

toco

l <

60 m

ins

No

t al

lYe

sN

oYe

sN

oN

oYe

sU

sual

lyN

o

Pati

ents

are

tra

nsf

erre

d t

o A

SU/I

CU

/HD

U

do

or

to a

dm

issi

on

<3

ho

urs

No

No

t al

way

s Ye

sYe

sN

oN

oN

oN

o –

bed

av

aila

bili

ty

an is

sue

Yes

Hav

e p

athw

ays

chan

ged

sin

ce ‘‘

go

live

’’ d

ate

in J

anu

ary

2013

? H

ow?

No

, pat

hw

ay

imp

lem

ente

d

pri

or

to t

he

SRP

No

, alr

ead

y in

pla

ceYe

s, u

pd

ated

to

re

flec

t p

re-

no

tifi

cati

on

Yes,

ad

ded

es

cala

tio

n

pro

cess

fr

om

su

rro

un

din

g

site

s

Yes,

ad

ded

es

cala

tio

n

pro

cess

fr

om

su

rro

un

din

g

site

s

No

, pat

hw

ay

imp

lem

ente

d

pri

or

to t

he

SRP

No

, pat

hw

ay

imp

lem

ente

d

pri

or

to t

he

SRP

No

, alr

ead

y in

pla

ceN

o, a

lrea

dy

in p

lace

Has

pro

po

sed

loca

l pat

hway

bee

n

succ

essf

ully

imp

lem

ente

d? I

f n

ot

wh

at a

re

the

bar

rier

s?

See

abo

veSe

e ab

ove

Yes

Yes

Yes

See

abo

veSe

e ab

ove

Yes

See

abo

ve

All

staf

f ar

e aw

are

of

the

chan

ges

to

g

uid

elin

es a

nd

po

licie

sN

o –

no

ch

ang

e in

p

ract

ice

No

– s

ee

abo

veYe

sYe

sYe

sYe

sYe

sYe

sYe

s

Ori

enta

tio

n a

nd

tra

inin

g o

n t

he

SRP

is

sch

edu

led

on

a r

egu

lar

bas

is f

or

all s

taff

in

volv

ed a

cro

ss t

he

ho

spit

al

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Are

th

rom

bo

lyse

d p

atie

nts

/th

ose

ass

esse

d

for

thro

mb

oly

sis

reco

rded

in a

dat

abas

e o

r cl

inic

al lo

g?

Yes

– lo

cal

dat

abas

e,

INSP

IRE

Yes

– lo

cal

dat

abas

e,

INSP

IRE

Yes

– D

istr

ict

dat

abas

e, T

IPS

Yes,

TIP

S,

INSP

IRE

Yes

– lo

cal

dat

abas

eYe

s –

SITS

Yes

– lo

cal

dat

abas

e,

Au

SCR

Yes,

loca

l d

atab

ase

Yes,

loca

l d

atab

ase

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 4

9

Go

sfo

rd

Ho

spit

alN

epea

n

Ho

spit

alC

amp

bel

ltow

n

Ho

spit

alO

ran

ge

Ho

spit

alB

ath

urs

t H

osp

ital

St

Vin

cen

t’s

Ho

spit

al

Roy

al

Prin

ce

Alf

red

H

osp

ital

Prin

ce o

f W

ales

H

osp

ital

Co

nco

rd

Ho

spit

al

The

SRP

com

mit

tee

mee

ts a

t le

ast

qu

arte

rly

No

No

Yes

– D

istr

ict

mee

tin

g, n

ot

SRP-

spec

ific

Yes

– M

on

thly

St

roke

C

om

mit

tee

and

Pat

ien

t Sa

fety

m

eeti

ng

s

Yes

– M

on

thly

St

roke

C

om

mit

tee

and

Pat

ien

t Sa

fety

m

eeti

ng

s

Yes

–

Mo

nth

ly

go

vern

ance

qu

alit

y an

d

vari

atio

n

man

agem

ent

mee

tin

gs

Yes

– Q

uar

terl

y m

eeti

ng

s an

d f

eed

b

ack

to

Exec

uti

ve

and

Clin

ical

C

ou

nci

l

Yes

– st

roke

u

nit

tea

m,

no

t-SR

P sp

ecifi

c

Yes

– Q

uar

terl

y

Wh

o r

egu

larl

y at

ten

ds

the

SRP

mee

tin

gs?

n/a

n/a

Stro

ke D

irec

tor,

st

roke

tea

ms

and

oth

ers

as

invi

ted

GM

, DO

N,

DM

S, D

DO

N,

Qu

alit

y

Man

ager

,

Infe

ctio

n

Co

ntr

ol,

Car

dio

log

y

CN

Cs

, Str

oke

Car

e

Co

ord

inat

or,

Hea

lth

Co

un

cil r

ep,

GP

rep

,

NU

MS

See

Ora

ng

e H

osp

ital

fo

r d

etai

ls

ED C

NC

, D

irec

tor

Med

Tr

ain

ing

, D

irec

tor

Stro

ke U

nit

, C

NC

Str

oke

U

nit

ASN

SW, E

D

nu

rse

and

med

ical

sta

ff,

rad

iolo

gy,

ICU

,

NU

M s

tro

ke

war

d,

Reh

abili

atio

n,

Neu

rolo

gy,

Alli

ed h

ealt

h

Neu

rolo

gy,

ED

, Im

agin

gA

SNSW

, ED

, R

adio

log

y,

Stro

ke T

eam

Wh

at d

ata

is r

ou

tin

ely

colle

cted

to

mo

nit

or

the

clin

ical

an

d o

per

atio

nal

asp

ects

of

this

se

rvic

e an

d w

ho

has

acc

ess

to t

his

in

form

atio

n? D

escr

ibe

the

feed

bac

k p

roce

sses

fo

r p

arti

cip

atin

g s

ervi

ces

DTN

, tim

es,

trea

tmen

t,

len

gth

of

stay

(LO

S)

– re

gu

larl

y re

view

ed

rele

van

t st

aff

No

ne

at

pre

sen

tTr

iag

e, a

rriv

al,

CT,

DTN

, NH

ISS,

is

sues

# FA

ST+

/

thro

mb

oly

sed

/

reas

on

no

t/

on

set

to

nee

dle

, DTN

,

bar

rier

s

See

Ora

ng

e H

osp

ital

fo

r d

etai

ls

All

SITS

dat

a (o

nse

t to

n

eed

le,

DTN

, o

utc

om

es)

On

set,

as

sess

men

t,

trea

tmen

t,

DTN

Yes

– re

po

rted

to

st

roke

un

it

mee

tin

gs,

q

ual

ity

and

M

&M

m

eeti

ng

s

DTN

, d

oo

r-to

-CT,

o

nse

t to

st

roke

te

am,

ou

tco

mes

(m

od

ified

R

anki

n)

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 5

0

Go

sfo

rd

Ho

spit

alN

epea

n

Ho

spit

alC

amp

bel

ltow

n

Ho

spit

alO

ran

ge

Ho

spit

alB

ath

urs

t H

osp

ital

St

Vin

cen

t’s

Ho

spit

al

Roy

al

Prin

ce

Alf

red

H

osp

ital

Prin

ce o

f W

ales

H

osp

ital

Co

nco

rd

Ho

spit

al

How

are

issu

es r

epo

rted

an

d r

eso

lved

?M

on

ito

red

th

rou

gh

d

atab

ase,

o

n s

tro

ke

war

d

IMS

Neu

rolo

gy

M&

MD

iscu

ssed

at

mo

nth

ly

mee

tin

gs

Iden

tifi

ed

and

d

iscu

ssed

at

mo

nth

ly

mee

tin

gs,

cl

inic

ian

in

terv

iew

s

Stro

ke U

nit

Thro

mb

oly

sis

and

Go

vern

ance

M&

M

Thro

ug

h

mee

tin

gs

as

no

ted

ab

ove

Thro

ug

h

abo

ve

pro

cess

es

– IM

S

Info

rmal

ly,

un

less

IMS

req

uir

ed

The

team

has

cle

ar r

ole

s an

d

resp

on

sib

iliti

esYe

sYe

sYe

sYe

sYe

sYe

sYe

sYe

sYe

s

Pati

ents

are

dis

cuss

ed a

t M

&M

mee

tin

gs

Stan

dar

d E

D

M&

MED

M&

M,

Neu

rolo

gy

M&

M

Yes

– ED

, N

euro

log

yYe

s Ye

sYe

s –

see

abo

veYe

sYe

sYe

s

Wh

at is

th

e p

roce

ss t

o a

sses

s an

d im

pro

ve

the

SRP

pat

hway

an

d s

ervi

ces

in p

lace

to

m

on

ito

r an

d r

esp

on

d t

o a

dve

rse

even

ts in

cl

inic

al o

utc

om

es?

No

–

gen

eral

sy

stem

m

on

ito

rin

g

on

ly

Mo

nit

or

exis

tin

g

syst

ems

– IM

S

Mo

nit

ori

ng

of

issu

es a

risi

ng

, IM

S

IMS

IMS

Dis

cuss

ion

th

rou

gh

va

rio

us

com

mit

tees

, m

on

ito

rin

g

Ever

y

trea

tmen

t

ove

r 60

min

ute

s

inte

rro

gat

ed

to id

enti

fy

po

ten

tial

del

ays

and

reso

lve

Stro

ke

mee

tin

gs

Info

rmal

m

eeti

ng

s,

Dis

tric

t St

roke

m

eeti

ng

s,

Stro

ke

mee

tin

gs

Wh

at is

th

e p

roce

ss t

o m

axim

ise

use

of

clin

ical

bes

t p

ract

ice

and

use

th

e SR

P to

im

pro

ve p

atie

nt

safe

ty a

nd

ou

tco

mes

?

Reg

ula

r re

view

ag

ain

st

gu

idel

ines

Reg

ula

r m

on

ito

rin

gM

on

ito

rin

gN

etw

ork

ing

st

atew

ide

Net

wo

rkin

g

stat

ewid

eR

egu

lar

revi

ew

Rev

iew

com

plic

atio

ns,

feed

bac

k,

ben

chm

arki

ng

/

KPI

s, r

egu

lar

revi

ew

Rev

iew

an

d

mo

nit

or

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 5

1

Ban

ksto

wn

H

osp

ital

Wes

tmea

d

Ho

spit

alLi

verp

oo

l H

osp

ital

Roy

al

No

rth

Sh

ore

H

osp

ital

Syd

ney

A

dve

nti

st

Ho

spit

alSt

Geo

rge

Ho

spit

al

Wag

ga

Wag

ga

Ho

spit

al

Ho

rnsb

y K

uri

ng

-Gai

H

osp

ital

Bla

ckto

wn

H

osp

ital

Do

yo

u r

ecei

ve s

tro

ke F

AST

+ p

atie

nts

?Ye

sYe

sYe

sYe

sYe

sYe

sYe

sYe

sYe

s

Are

th

ere

syst

ems

in p

lace

fo

r ac

tiva

tin

g a

st

roke

pag

e al

ert?

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Is E

D p

re-n

oti

fied

of

FAST

+ p

atie

nts

?Ye

sYe

sYe

sYe

sYe

sYe

sYe

sYe

sYe

s

Is M

edic

al Im

agin

g p

re-n

oti

fied

of

stro

ke

FAST

+ p

atie

nts

?N

oYe

sYe

sYe

sYe

sYe

sN

oN

oYe

s

Is A

cute

Str

oke

Tea

m p

re-n

oti

fied

of

stro

ke

FAST

+ p

atie

nts

?Ye

sYe

sYe

sYe

sYe

sYe

sYe

sYe

sYe

s

Are

pat

ien

ts t

riag

ed a

s C

ateg

ory

2?

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Are

AH

Neu

rolo

gy,

Rad

iolo

gy,

Str

oke

Un

it

and

Pat

ien

t Fl

ow s

taff

aw

are

of

pro

cess

es

AH

fo

r FA

ST+

pat

ien

ts?

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Is t

he

pro

cess

fo

r FA

ST+

the

sam

e 24

/7?

If

no

t w

hat

are

th

e d

iffe

ren

ces?

No

, ED

-led

A

H, S

tro

ke

Team

in B

H

Yes

No

, ED

cal

ls

on

-cal

l n

euro

log

ist

on

ce p

atie

nt

asse

ssed

No

, led

by

stro

ke

fello

w in

B

H, o

n-c

all

reg

istr

ar A

H

Yes,

n

euro

log

y re

gis

trar

in

BH

, on

-cal

l n

euro

log

ist

AH

Yes

Yes

No

, on

-cal

l n

euro

AH

Yes

Are

str

oke

pat

ien

ts t

hat

arr

ive

by a

mb

ula

nce

, b

ut

no

t id

enti

fied

as

FAST

+ ap

pro

pri

atel

y as

sess

ed a

nd

tri

aged

? W

hat

mea

sure

s ar

e u

sed

to

ass

ess

this

?

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes,

Ro

ssie

rN

IHSS

Ro

ssie

r an

d

NIH

SSN

IHSS

Cat

ego

ry

3/4

as p

er

nat

ion

al

gu

idel

ines

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 5

2

Ban

ksto

wn

H

osp

ital

Wes

tmea

d

Ho

spit

alLi

verp

oo

l H

osp

ital

Roy

al

No

rth

Sh

ore

H

osp

ital

Syd

ney

A

dve

nti

st

Ho

spit

alSt

Geo

rge

Ho

spit

al

Wag

ga

Wag

ga

Ho

spit

al

Ho

rnsb

y K

uri

ng

-Gai

H

osp

ital

Bla

ckto

wn

H

osp

ital

Are

FA

ST+

pat

ien

ts w

ho

arr

ive

by n

on

-am

bu

lan

ce m

ean

s ap

pro

pri

atel

y id

enti

fied

an

d a

sses

sed?

Wh

at m

easu

res

are

use

d t

o

asse

ss t

his

?

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Ro

ssie

rN

IHSS

Ro

ssie

r an

d

NIH

SSN

IHSS

Pati

ents

rec

eive

tre

atm

ent

wit

h in

trav

eno

us

thro

mb

oly

sis

as p

er p

roto

col <

60 m

ins

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

Pati

ents

are

tra

nsf

erre

d t

o A

SU/I

CU

/HD

U

do

or–

to-a

dm

issi

on

<3

ho

urs

Yes

No

Yes

Yes

No

No

No

Yes

No

Hav

e p

athw

ays

chan

ged

sin

ce ‘g

o li

ve’ d

ate

in J

an 2

013?

How

?Ye

s, w

ent

24/7

Yes,

in

crea

sed

am

bu

lan

ce

dir

ect

to C

T

Yes,

re

view

ed

exis

tin

g

pat

hw

ays

No

, exi

stin

g

serv

ice

No

, exi

stin

g

serv

ice

No

, exi

stin

g

serv

ice

No

, exi

stin

g

serv

ice

No

, exi

stin

g

serv

ice

Yes

,

com

mu

nic

atio

n

chan

ged

,

imp

rove

d E

D

tim

ing

Has

pro

po

sed

loca

l pat

hway

bee

n

succ

essf

ully

imp

lem

ente

d?If

no

t, w

hat

are

th

e b

arri

ers?

Yes

Yes

Yes

See

abo

veSe

e ab

ove

See

abo

veSe

e ab

ove

See

abo

veYe

s

All

staf

f ar

e aw

are

of

the

chan

ges

to

g

uid

elin

es a

nd

po

licie

sYe

sYe

sYe

sYe

sYe

sYe

sYe

sYe

sYe

s

Ori

enta

tio

n a

nd

tra

inin

g o

n t

he

SRP

is

sch

edu

led

on

a r

egu

lar

bas

is f

or

all s

taff

in

volv

ed a

cro

ss t

he

ho

spit

al

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

Are

th

rom

bo

lyse

d p

atie

nts

/th

ose

ass

esse

d

for

thro

mb

oly

sis

reco

rded

in a

dat

abas

e o

r cl

inic

al lo

g?

Yes

– lo

cal

dat

abas

e,

SITS

Yes

– lo

cal

dat

abas

eYe

s –

loca

l d

atab

ase

Yes

– lo

cal

dat

abas

e,

TIPS

Yes

– lo

cal

dat

abas

e,

TIPS

Yes

– lo

cal

dat

abas

eYe

s –

loca

l d

atab

ase,

TI

PS, S

ITS

Yes

– lo

cal

dat

abas

eYe

s ––

loca

l d

atab

ase,

TI

PS

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 5

3

Ban

ksto

wn

H

osp

ital

Wes

tmea

d

Ho

spit

alLi

verp

oo

l H

osp

ital

Roy

al

No

rth

Sh

ore

H

osp

ital

Syd

ney

A

dve

nti

st

Ho

spit

alSt

Geo

rge

Ho

spit

al

Wag

ga

Wag

ga

Ho

spit

al

Ho

rnsb

y K

uri

ng

-Gai

H

osp

ital

Bla

ckto

wn

H

osp

ital

The

SRP

com

mit

tee

mee

ts a

t le

ast

qu

arte

rly

Yes

– b

i-m

on

thly

No

No

– m

et

twic

e si

nce

Ja

nu

ary

2013

. Q

uar

terl

y D

istr

ict

stro

ke

mee

tin

gs

occ

ur

Yes

– St

roke

te

am,

info

rmal

No

–

6-m

on

thly

Yes

– St

roke

m

eeti

ng

b

i-m

on

thly

Yes

– St

roke

Ex

ecu

tive

, b

i-m

on

thly

No

– S

mal

l lo

cal

mee

tin

g

Yes

Wh

o r

egu

larl

y at

ten

ds

the

SRP

mee

tin

gs?

ED,

Neu

rolo

gy,

St

roke

Te

am,

Stro

ke

Liai

son

O

ffice

r

n/a

Ad

min

, M

edic

al,

Nu

rsin

g, E

D,

Alli

ed

hea

lth

, A

SNSW

Dir

ecto

r o

f St

roke

N

etw

ork

, C

NC

s, S

tro

ke

fello

w, D

ata

man

ager

, A

rea

coo

rdin

ato

r

EC, A

MO

s,

Neu

rolo

gy

reg

istr

ar,

Neu

rosc

ien

ces

NU

M

– in

vite

es a

s

nee

ded

Each

d

epar

tmen

t h

as s

epar

ate

mee

tin

gs.

In

form

al

dis

cuss

ion

s in

tra-

dep

artm

ent

Stro

ke

con

sult

ant,

Stro

ke IU

it

NU

M, E

xecu

tive

rep

rese

nta

tive

,

Alli

ed h

ealt

h,

con

sum

er

NU

M, s

tro

ke

un

it, E

D

– n

o

neu

rolo

gy

as V

MO

Neu

rolo

gy,

Stro

ke C

NC

,

ED C

NC

, ED

man

ager

s,

Stro

ke U

nit

,

ger

iatr

icia

ns,

ED s

enio

r

ph

ysic

ian

s

Wh

at d

ata

is r

ou

tin

ely

colle

cted

to

mo

nit

or

the

clin

ical

an

d o

per

atio

nal

asp

ects

of

this

se

rvic

e an

d w

ho

has

acc

ess

to t

his

in

form

atio

n? -

des

crib

e th

e fe

edb

ack

pro

cess

es f

or

par

tici

pat

ing

ser

vice

s

SITS

req

uir

emen

t,

i.e. o

nse

t to

nee

dle

, DTN

,

ou

tco

mes

Stro

ke c

alls

,

ou

tco

mes

dat

a, D

TN,

ble

edin

g

com

plic

atio

ns

Stro

ke

cod

es, D

TN,

do

or-

to-

scan

, re

spo

nse

ti

me,

o

utc

om

es

DTN

, d

oo

r-to

-sc

an,

trea

tmen

t,

ou

tco

mes

FAST

dat

a,

thro

mb

oly

sis

All

pat

ien

t

dat

a fr

om

adm

issi

on

to

dis

char

ge

has

bee

n k

ept

for

all

thro

mb

oly

sed

pat

ien

ts s

ince

2007

DTN

, d

oo

r-to

-sc

an,

trea

tmen

t,

ou

tco

mes

DTN

, d

oo

r-to

-sc

an,

trea

tmen

t,

ou

tco

mes

Tim

ing

, im

ages

, N

IHSS

, ad

vers

e re

acti

on

s,

del

ays,

o

utc

om

es

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 5

4

Ban

ksto

wn

H

osp

ital

Wes

tmea

d

Ho

spit

alLi

verp

oo

l H

osp

ital

Roy

al

No

rth

Sh

ore

H

osp

ital

Syd

ney

A

dve

nti

st

Ho

spit

alSt

Geo

rge

Ho

spit

al

Wag

ga

Wag

ga

Ho

spit

al

Ho

rnsb

y K

uri

ng

-Gai

H

osp

ital

Bla

ckto

wn

H

osp

ital

How

are

issu

es r

epo

rted

an

d r

eso

lved

?IM

S, lo

cal

rep

ort

ing

to

ol

To C

linic

al

Lead

or

rele

van

t H

OD

/NU

M

Dis

cuss

ion

, fo

rmal

is

sues

re

gis

ter,

w

eekl

y st

roke

m

eeti

ng

s,

IMS

M&

M

mee

tin

gs,

IM

S, R

CA

Dat

a re

view

ed b

y St

roke

C

om

mit

tee

M&

Ms,

re

gu

lar

mee

tin

gs,

as

aris

e

Ro

uti

ne

serv

ice

revi

ew

IMS,

reg

ula

r re

view

IMS,

M&

M

mee

tin

gs

The

team

has

cle

ar r

ole

s an

d r

esp

on

sib

iliti

esYe

sYe

sYe

sYe

sYe

sYe

sYe

sYe

sYe

s

Pati

ents

are

dis

cuss

ed a

t M

&M

mee

tin

gs

Yes

Yes

Yes

Yes

Neu

rolo

gy

sect

ion

m

eeti

ng

s

Yes

Dis

cuss

ed,

as n

eed

edYe

sYe

s

Wh

at is

th

e p

roce

ss t

o a

sses

s an

d im

pro

ve

the

SRP

pat

hway

an

d s

ervi

ces

in p

lace

to

m

on

ito

r an

d r

esp

on

d t

o a

dve

rse

even

ts in

cl

inic

al o

utc

om

es?

Dis

cuss

ion

at

reg

ula

r m

eeti

ng

s,

revi

ew o

f d

ata

Dis

sem

inat

ion

of

dat

a,

dis

cuss

ion

reg

ard

ing

dat

a w

ith

ED

Rev

iew

of

dat

aD

iscu

ssio

n

at r

egu

lar

mee

tin

gs,

d

ata

revi

ew

Feed

bac

k,

M&

Ms,

St

roke

C

om

mit

tee

Dis

cuss

ion

at

reg

ula

r m

eeti

ng

s,

revi

ew o

f d

ata

Reg

ula

r re

view

s o

ccu

r,

inte

rnal

an

d

exte

rnal

au

dit

s

Inte

rro

gat

ion

of

dat

a,

reg

ula

r

dis

cuss

ion

Reg

ula

r re

view

of

po

licy

and

p

roce

du

res

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 5

5

App

endi

x II

15.1

SR

P si

tes

– in

pat

ient

uti

lisat

ion

dat

a

15.1

.1 G

osf

ord

Ho

spit

al

Go

sfo

rd H

osp

ital

rec

eive

d 7

.9%

of

the

tota

l pat

ien

t lo

ad t

hat

pre

sen

ted

at

SRP

site

s in

201

2-13

. Fro

m 2

007-

08 t

o 2

012-

13, 3

552

acu

te s

tro

ke e

pis

od

es b

y se

lect

ed D

RGs

are

sho

wn

in T

able

5. T

he

hig

hes

t vo

lum

e D

RG w

as s

tro

ke a

nd

oth

er c

ereb

rova

scu

lar

dis

ord

ers.

Tab

le 5

: Go

sfo

rd H

osp

ital

sel

ecte

d s

tro

ke D

RG

s 20

07-0

8 to

201

2-13 A

cute

ep

iso

des

AR

-DR

G G

osf

ord

Ho

spit

al

C

ran

ial p

roce

du

res

Extr

acra

nia

l vas

cula

r p

roce

du

res

TIA

an

d p

rece

reb

ral o

cclu

sio

nSt

roke

an

d o

ther

cer

ebro

vasc

ula

r d

iso

rder

s

2007

-08

08

138

398

2008

-09

05

119

470

2009

-10

07

145

491

2010

-11

07

176

393

2011

-12

18

181

411

2012

-13

08

176

410

Wit

hin

th

ese

DRG

s, t

her

e w

ere

a to

tal o

f 36

30 a

cute

ep

iso

des

fro

m 2

007-

08 t

o 2

012-

13 b

y se

lect

ed IC

D a

s sh

ow

n in

Fig

ure

8. T

he

hig

hes

t vo

lum

e w

as f

or

cere

bra

l

infa

rcti

on

wit

h 2

80 e

pis

od

es in

201

2-13

.

The

aver

age

len

gth

of

stay

ste

adily

dec

lined

fro

m 9

day

s in

200

7-08

to

5.8

day

s 20

12-1

3. In

201

2-13

, th

e av

erag

e N

WA

U w

as 1

.3 in

dic

atin

g a

slig

htl

y hi

gh

er c

om

ple

xity

leve

l

than

no

n-S

RP

site

s, a

lth

ou

gh

thi

s w

as lo

wer

th

an N

SW in

to

tal.

The

firs

t g

rap

h in

Fig

ure

8 s

ho

ws

the

epis

od

es o

f ca

re b

y se

lect

ed IC

D-1

0 co

des

. Th

ese

are

con

sist

ent

wit

h t

he

con

dit

ion

s th

at a

re a

sses

sed

fo

r el

igib

ility

fo

r th

rom

bo

lysi

s at

pat

ien

t p

rese

nta

tio

n a

nd

are

sh

ow

n h

ere

to p

rovi

de

an in

dic

atio

n o

f th

e vo

lum

e o

f ep

iso

des

. Th

e se

con

d g

rap

h s

ho

ws

the

len

gth

of

stay

, in

day

s, f

or

on

ly t

he

ICD

-10

epis

od

es t

hat

wer

e am

enab

le t

o t

hro

mb

oly

sis

to p

rovi

de

an in

dic

ativ

e p

ictu

re o

f an

y tr

end

s th

at m

ay b

e em

erg

ing

in in

pat

ien

t ca

re f

or

this

co

ho

rt.

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 5

6

Fig

ure

8: G

osf

ord

Ho

spit

al IC

D-1

0 st

roke

ep

iso

des

an

d a

vera

ge

len

gth

of

stay

200

7-08

to

201

2-13

0 50

100

150

200

250

300

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Episodes

Year

Go

sfo

rd H

osp

ital

St

roke

by

sele

cted

ICD

-10

2007

/08

to 2

012/

13 e

pis

od

es a

nd

ALO

S

Oth

er n

on

-tra

um

atic

intr

acer

ebra

l hae

mo

rrh

age

Stro

ke n

ot

spec

ified

Intr

acer

ebra

l hae

mo

rrh

age

Cer

ebra

l in

farc

tio

n

Tran

sien

t is

chae

mic

att

ack

0 2 4 6 8 10

12

14

16

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Days

Year

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 5

7

15.1

.2 N

epea

n H

osp

ital

Nep

ean

Ho

spit

al h

ad a

to

tal o

f 24

84 a

cute

ep

iso

des

fo

r se

lect

ed D

RGs

fro

m 2

007-

08 t

o 2

012-

13 a

s sh

ow

n in

Tab

le 6

. Th

e hi

gh

est

volu

me

was

fo

r st

roke

an

d o

ther

cere

bro

vasc

ula

r d

iso

rder

s at

286

ep

iso

des

in 2

012-

13.

Tab

le 6

: Nep

ean

Ho

spit

al s

elec

ted

str

oke

DR

Gs

2007

-08

to 2

012-

13 Acu

te e

pis

od

es A

R-D

RG

Nep

ean

Ho

spit

al

C

ran

ial p

roce

du

res

Extr

acra

nia

l vas

cula

r p

roce

du

res

TIA

an

d p

rece

reb

ral o

cclu

sio

nSt

roke

an

d o

ther

cer

ebro

vasc

ula

r d

iso

rder

s

2007

-08

313

125

228

2008

-09

254

131

257

2009

-10

131

130

251

2010

-11

285

123

240

2011

-12

416

132

267

2012

-13

323

122

286

Wit

hin

th

ese

DRG

s, t

her

e w

ere

2549

ep

iso

des

in s

elec

ted

ICD

s fo

r th

e p

erio

d 2

007-

08 t

o 2

012-

13, a

s d

epic

ted

in F

igu

re 9

. Th

e hi

gh

est

volu

me

was

fo

r ce

reb

ral i

nfar

ctio

n a

t

174

epis

od

es in

201

2-13

.

The

aver

age

len

gth

of

stay

fo

r in

trac

ereb

ral h

aem

orr

hag

e in

crea

sed

fro

m 9

.6 d

ays

in 2

007-

08 t

o 1

2.3

day

s in

201

2-13

. TIA

has

rem

ain

ed s

tab

le a

t th

is t

ime

wit

h 3

.2 d

ays

whi

le o

ther

str

oke

ep

iso

des

hav

e st

ead

ily d

ecre

ased

. Th

e sp

ike

sho

wn

in t

he

aver

age

len

gth

of

stay

fo

r o

ther

no

n-t

rau

mat

ic in

trac

ereb

ral h

aem

orr

hag

e m

ay in

dic

ate

a

cod

ing

issu

e o

r in

clu

sio

n o

f o

utl

ier

bed

day

s. O

vera

ll, t

he

aver

age

len

gth

of

stay

dec

reas

ed f

rom

7.7

day

s in

200

7-08

to

6.4

day

s in

201

2-13

.

The

aver

age

NW

AU

fo

r N

epea

n H

osp

ital

in 2

012-

13 w

as 2

.1 in

dic

atin

g a

hig

her

co

mp

lexi

ty t

han

SR

P si

tes

in t

ota

l.

The

firs

t g

rap

h in

Fig

ure

9 s

ho

ws

the

epis

od

es o

f ca

re b

y se

lect

ed IC

D-1

0 co

des

. Th

ese

are

con

sist

ent

wit

h t

he

con

dit

ion

s th

at a

re a

sses

sed

fo

r el

igib

ility

fo

r th

rom

bo

lysi

s at

pat

ien

t p

rese

nta

tio

n a

nd

are

sh

ow

n h

ere

to p

rovi

de

an in

dic

atio

n o

f th

e vo

lum

e o

f ep

iso

des

.

The

seco

nd

gra

ph

sh

ow

s th

e le

ng

th o

f st

ay in

day

s fo

r o

nly

th

e IC

D-1

0 ep

iso

des

th

at a

re a

men

able

to

th

rom

bo

lysi

s to

pro

vid

e an

ind

icat

ive

pic

ture

of

any

tren

ds

that

may

be

emer

gin

g in

inp

atie

nt

care

fo

r th

is c

oh

ort

.

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 5

8

Fig

ure

9: N

epea

n H

osp

ital

ICD

-10

stro

ke e

pis

od

es a

nd

ave

rag

e le

ng

th o

f st

ay 2

007-

08 t

o 2

012-

13

0 20

40

60

80

100

120

140

160

180

200

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Episodes

Year

Nep

ean

Ho

spit

al

Stro

ke b

y se

lect

ed IC

D-1

0 20

07/0

8 to

201

2/13

. Acu

te e

pis

od

es a

nd

ALO

S

Oth

er n

on

-tra

um

atic

intr

acer

ebra

l hae

mo

rrh

age

Stro

ke n

ot

spec

ified

Intr

acer

ebra

l hae

mo

rrh

age

Cer

ebra

l in

farc

tio

n

Tran

sien

t is

chae

mic

att

ack

0 2 4 6 8 10

12

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Days

Year

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 5

9

15.1

.3 C

amp

bel

ltow

n H

osp

ital

Cam

pb

ellt

ow

n H

osp

ital

had

a t

ota

l of

1726

acu

te e

pis

od

es f

or

sele

cted

DRG

s fr

om

200

7-08

to

201

2-13

as

sho

wn

in T

able

7. T

he

hig

hes

t vo

lum

e w

as f

or

stro

ke a

nd

oth

er

cere

bro

vasc

ula

r d

iso

rder

s at

179

ep

iso

des

in 2

012-

13.

Tab

le 7

: Cam

pb

ellt

own

Ho

spit

al s

elec

ted

str

oke

DR

Gs

2007

-08

to 2

012-

13

Acu

te e

pis

od

es A

R-D

RG

Cam

pb

ellt

own

Ho

spit

al

C

ran

ial p

roce

du

res

Extr

acra

nia

l vas

cula

r p

roce

du

res

TIA

an

d p

rece

reb

ral o

cclu

sio

nSt

roke

an

d o

ther

cer

ebro

vasc

ula

r d

iso

rder

s

2007

-08

00

100

177

2008

-09

00

102

178

2009

-10

00

118

183

2010

-11

00

106

187

2011

-12

00

100

178

2012

-13

00

118

179

Acu

te e

pis

od

es b

y se

lect

ed IC

D c

od

es t

ota

lled

173

7 fo

r th

e 20

07-0

8 to

201

2-13

per

iod

. Th

e hi

gh

est

volu

me

was

fo

r ce

reb

ral i

nfar

ctio

n w

ith

131

ep

iso

des

in 2

012-

13. T

he

aver

age

len

gth

of

stay

dec

lined

fro

m 7

.1 d

ays

in 2

007-

08 t

o 6

.8 d

ays

in 2

012-

13. H

ow

ever

, as

sho

wn

in F

igu

re 1

0, t

her

e w

as a

n in

crea

se in

oth

er n

on

-tra

um

atic

intr

acer

ebra

l

hae

mo

rrh

age

fro

m 1

.5 d

ays

in 2

007-

08 t

o 4

.5 d

ays

in 2

012-

13 a

nd

str

oke

no

t sp

ecifi

ed f

rom

5.8

day

s to

17.

2 fo

r th

e sa

me

per

iod

. Th

ere

wer

e re

lati

vely

sm

all n

um

ber

s o

f

pat

ien

ts in

th

ese

coh

ort

s so

incr

ease

s m

ay r

epre

sen

t o

utl

iers

in b

ed d

ays.

The

aver

age

NW

AU

fo

r C

amp

bel

lto

wn

Ho

spit

al in

201

2-13

was

1.4

. Thi

s in

dic

ates

a lo

wer

co

mp

lexi

ty c

om

par

ed t

o S

RP

site

s in

to

tal a

nd

th

e N

SW a

vera

ge,

alt

ho

ug

h a

hig

her

co

mp

lexi

ty t

han

th

at f

or

no

n-S

RP

site

s.

The

firs

t g

rap

h in

Fig

ure

10

sho

ws

the

epis

od

es o

f ca

re b

y se

lect

ed IC

D-1

0 co

des

. Th

ese

are

con

sist

ent

wit

h t

he

con

dit

ion

s th

at a

re a

sses

sed

fo

r el

igib

ility

fo

r th

rom

bo

lysi

s

at p

atie

nt

pre

sen

tati

on

an

d a

re s

ho

wn

her

e to

pro

vid

e an

ind

icat

ion

of

the

volu

me

of

epis

od

es. T

he

seco

nd

gra

ph

sh

ow

s th

e le

ng

th o

f st

ay in

day

s fo

r o

nly

th

e IC

D-1

0

epis

od

es t

hat

are

am

enab

le t

o t

hro

mb

oly

sis

to p

rovi

de

an in

dic

ativ

e p

ictu

re o

f an

y tr

end

s th

at m

ay b

e em

erg

ing

in in

pat

ien

t ca

re f

or

this

co

ho

rt.

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 6

0

Fig

ure

10:

Cam

pb

ellt

own

Ho

spit

al IC

D-1

0 st

roke

ep

iso

des

an

d a

vera

ge

len

gth

of

stay

200

7-08

to

201

2-13

0 20

40

60

80

100

120

140

160

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Episodes

Year

Cam

pb

ellt

ow

n H

osp

ital

St

roke

by

sele

cted

ICD

-10

2007

/08

to 2

012/

13. A

cute

ep

iso

des

an

d A

LOS

Oth

er n

on

-tra

um

atic

intr

acer

ebra

l hae

mo

rrh

age

Stro

ke n

ot

spec

ified

Intr

acer

ebra

l hae

mo

rrh

age

Cer

ebra

l in

farc

tio

n

Tran

sien

t is

chae

mic

att

ack

0 5 10

15

20

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Days

Year

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 6

1

15.1

.4 O

ran

ge

Hea

lth

Ser

vice

Ove

r th

e p

erio

d 2

007-

08 t

o 2

012-

13, t

he

Ora

ng

e H

ealt

h S

ervi

ce h

ad a

to

tal o

f 10

16 a

cute

ep

iso

des

fo

r se

lect

ed D

RGs.

Th

e se

rvic

e d

id n

ot

hav

e an

y ep

iso

des

fo

r cr

ania

l or

extr

acra

nial

vas

cula

r p

roce

du

res

and

th

e hi

gh

est

volu

me

for

stro

ke a

nd

oth

er c

ereb

rova

scu

lar

dis

ord

ers.

Tab

le 8

: Ora

ng

e H

ealt

h S

ervi

ce s

elec

ted

str

oke

DR

Gs

2007

-08

to 2

012-

13

Acu

te e

pis

od

es A

R-D

RG

Ora

ng

e H

ealt

h S

ervi

ce

C

ran

ial p

roce

du

res

Extr

acra

nia

l vas

cula

r p

roce

du

res

TIA

an

d p

rece

reb

ral o

cclu

sio

nSt

roke

an

d o

ther

cer

ebro

vasc

ula

r d

iso

rder

s

2007

-08

00

3511

0

2008

-09

00

6411

4

2009

-10

00

6096

2010

-11

00

4710

0

2011

-12

00

5014

3

2012

-13

00

5813

9

Ther

e w

ere

1032

acu

te e

pis

od

es f

or

sele

cted

ICD

co

des

acc

ou

nti

ng

fo

r 2.

6% o

f th

e SR

P p

atie

nt

load

. Lik

e m

ost

sit

es, c

ereb

ral i

nfar

ctio

n h

as t

he

hig

hes

t q

uan

tum

of

pre

sen

tati

on

s co

nsi

sten

tly

over

thi

s ti

me

wit

h 7

6 ep

iso

des

in 2

012-

13 d

eclin

ing

fro

m 9

0 ep

iso

des

th

e p

revi

ou

s ye

ar.

The

aver

age

len

gth

of

stay

is s

tead

ily d

eclin

ing

fro

m 5

.5 d

ays

in 2

007-

08 f

or

all e

pis

od

es t

o 4

day

s in

201

2-13

.

The

aver

age

NW

AU

is 1

.1 in

dic

atin

g a

low

er c

om

ple

xity

th

an m

ost

oth

er s

ites

.

The

firs

t g

rap

h in

Fig

ure

11

sho

ws

the

epis

od

es o

f ca

re b

y se

lect

ed IC

D-1

0 co

des

. Th

ese

are

con

sist

ent

wit

h t

he

con

dit

ion

s th

at a

re a

sses

sed

fo

r el

igib

ility

fo

r th

rom

bo

lysi

s

at p

atie

nt

pre

sen

tati

on

an

d a

re s

ho

wn

her

e to

pro

vid

e an

ind

icat

ion

of

the

volu

me

of

epis

od

es. T

he

seco

nd

gra

ph

sh

ow

s th

e le

ng

th o

f st

ay, i

n d

ays

for

on

ly t

he

ICD

-10

epis

od

es t

hat

are

am

enab

le t

o t

hro

mb

oly

sis

to p

rovi

de

an in

dic

ativ

e p

ictu

re o

f an

y tr

end

s th

at m

ay b

e em

erg

ing

in in

pat

ien

t ca

re f

or

this

co

ho

rt.

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 6

2

Fig

ure

11:

Ora

ng

e H

ealt

h S

ervi

ce IC

D-1

0 st

roke

ep

iso

des

an

d a

vera

ge

len

gth

of

stay

200

7-08

to

201

2-13

0 10

20

30

40

50

60

70

80

90

100

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Episodes

Year

Ora

ng

e H

ealt

h S

ervi

ce

Stro

ke b

y se

lect

ed IC

D-1

0 20

07/0

8 t

o 2

012/

13. A

cute

ep

iso

des

an

d A

LOS

Oth

er n

on-t

rau

mat

ic in

trac

ereb

ral h

aem

orr

hag

e

Stro

ke n

ot

spec

ified

Intr

acer

ebra

l hae

mo

rrh

age

Cer

ebra

l in

farc

tio

n

Tran

sien

t is

chae

mic

att

ack

0 1 2 3 4 5 6 7 8 9 10

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Days

Year

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 6

3

15.1

.5 B

athu

rst

Bas

e H

osp

ital

Fro

m 2

007-

08 t

o 2

012-

13, t

he

Bat

hu

rst

Bas

e H

osp

ital

had

707

to

tal a

cute

ep

iso

des

fo

r se

lect

ed D

RGs.

Sim

ilar

to t

he

Ora

ng

e H

ealt

h S

ervi

ce, t

her

e w

ere

no

cra

nial

or

extr

acra

nial

vas

cula

r p

roce

du

res

wit

h t

he

hig

hes

t q

uan

tum

of

epis

od

es b

ein

g f

or

stro

ke a

nd

oth

er c

ereb

rova

scu

lar

dis

ord

ers

as s

ho

wn

in T

able

9.

Tab

le 9

: Bat

hu

rst

Bas

e H

osp

ital

sel

ecte

d s

tro

ke D

RG

s 20

07-0

8 to

201

2-13

Acu

te e

pis

od

es A

R-D

RG

Bat

hu

rst

Bas

e H

osp

ital

C

ran

ial p

roce

du

res

Extr

acra

nia

l vas

cula

r p

roce

du

res

TIA

an

d p

rece

reb

ral o

cclu

sio

nSt

roke

an

d o

ther

cer

ebro

vasc

ula

r d

iso

rder

s

2007

-08

00

3851

2008

-09

00

5482

2009

-10

00

4365

2010

-11

00

5263

2011

-12

00

5869

2012

-13

00

4389

Wit

hin

th

ese

DRG

s, t

her

e w

ere

715

acu

te e

pis

od

es in

sel

ecte

d IC

D c

od

es w

ith

th

e hi

gh

est

volu

me

for

cere

bra

l inf

arct

ion

at

46 e

pis

od

es in

201

2-13

clo

sely

fo

llow

ed b

y TI

A

wit

h 4

3 ep

iso

des

fo

r th

e sa

me

per

iod

.

Ther

e h

as b

een

a s

har

p d

eclin

e in

th

e av

erag

e le

ng

th o

f st

ay f

rom

11

day

s in

200

7-08

to

4.7

day

s in

201

2-13

ind

icat

ive

of

the

hig

h le

vel o

f TI

A e

pis

od

es.

The

Bat

hu

rst

Bas

e H

osp

ital

had

an

ave

rag

e N

WA

U f

or

the

sele

cted

DRG

s co

mb

ined

in 2

012-

13 o

f 1.

1. T

his

ind

icat

es a

low

er c

om

ple

xity

fo

r st

roke

th

an m

ost

oth

er s

ites

.

The

firs

t g

rap

h in

Fig

ure

12

sho

ws

the

epis

od

es o

f ca

re b

y se

lect

ed IC

D-1

0 co

des

. Th

ese

are

con

sist

ent

wit

h t

he

con

dit

ion

s th

at a

re a

sses

sed

fo

r el

igib

ility

fo

r th

rom

bo

lysi

s

at p

atie

nt

pre

sen

tati

on

an

d a

re s

ho

wn

her

e to

pro

vid

e an

ind

icat

ion

of

the

volu

me

of

epis

od

es. T

he

seco

nd

gra

ph

sh

ow

s th

e le

ng

th o

f st

ay in

day

s fo

r o

nly

th

e IC

D-1

0

epis

od

es t

hat

are

am

enab

le t

o t

hro

mb

oly

sis

to p

rovi

de

an in

dic

ativ

e p

ictu

re o

f an

y tr

end

s th

at m

ay b

e em

erg

ing

in in

pat

ien

t ca

re f

or

this

co

ho

rt.

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 6

4

Fig

ure

12:

Bat

hu

rst

Bas

e H

osp

ital

ICD

-10

stro

ke e

pis

od

es a

nd

ave

rag

e le

ng

th o

f st

ay 2

007-

08 t

o 2

012-

13

0 10

20

30

40

50

60

70

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Episodes

Year

Bat

hu

rst

Bas

e H

osp

ital

St

roke

by

sele

cted

ICD

-10

2007

/08

to 2

012/

13. A

cute

ep

iso

des

an

d A

LOS

Oth

er n

on-t

rau

mat

ic in

trac

ereb

ral h

aem

orr

hag

e

Stro

ke n

ot

spec

ified

Intr

acer

ebra

l hae

mo

rrh

age

Cer

ebra

l in

farc

tio

n

Tran

sien

t is

chae

mic

att

ack

0 5 10

15

20

25

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Days

Year

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 6

5

15.1

.6 S

t V

ince

nt’s

Ho

spit

al

St V

ince

nt’

s H

osp

ital

has

had

a t

ota

l of

2119

acu

te e

pis

od

es f

or

sele

cted

DRG

s fo

r th

e p

erio

d 2

007-

08 t

o 2

012-

13.

The

hig

hes

t vo

lum

e o

f ep

iso

des

, as

sho

wn

in T

able

10,

was

fo

r st

roke

an

d o

ther

cer

ebro

vasc

ula

r d

iso

rder

s w

ith

222

acu

te e

pis

od

es in

201

2-13

.

Tab

le 1

0: S

t V

ince

nt’

s H

osp

ital

sel

ecte

d s

tro

ke D

RG

s 20

07-0

8 to

201

2-13

Acu

te e

pis

od

es A

R-D

RG

St

Vin

cen

t’s

Ho

spit

al

C

ran

ial p

roce

du

res

Extr

acra

nia

l vas

cula

r p

roce

du

res

TIA

an

d p

rece

reb

ral o

cclu

sio

nSt

roke

an

d o

ther

cer

ebro

vasc

ula

r d

iso

rder

s

2007

-08

155

138

227

2008

-09

184

120

228

2009

-10

126

105

211

2010

-11

232

109

188

2011

-12

179

124

198

2012

-13

156

117

222

Ther

e w

ere

2146

acu

te e

pis

od

es f

or

sele

cted

ICD

co

des

wit

h t

he

hig

hes

t vo

lum

e b

ein

g f

or

cere

bra

l inf

arct

ion

wit

h 1

36 e

pis

od

es in

201

2-13

an

d 1

20 e

pis

od

es f

or

TIA

fo

r th

e

sam

e p

erio

d.

The

aver

age

len

gth

of

stay

is s

tead

ily d

eclin

ing

fo

r al

l ep

iso

des

wit

h t

he

tota

l dec

reas

ing

fro

m 8

.1 d

ays

in 2

007-

08 t

o 6

.1 d

ays

in 2

012-

13.

The

aver

age

NW

AU

is c

on

sist

ent

wit

h t

he

NSW

ave

rag

e at

1.5

. Thi

s is

low

er t

han

th

e to

tal a

vera

ge

for

SRP

site

s an

d h

igh

er t

han

th

at f

or

no

n-S

RP

site

s.

The

firs

t g

rap

h in

Fig

ure

13

sho

ws

the

epis

od

es o

f ca

re b

y se

lect

ed IC

D-1

0 co

des

. Th

ese

are

con

sist

ent

wit

h t

he

con

dit

ion

s th

at a

re a

sses

sed

fo

r el

igib

ility

fo

r th

rom

bo

lysi

s

at p

atie

nt

pre

sen

tati

on

an

d a

re s

ho

wn

her

e to

pro

vid

e an

ind

icat

ion

of

the

volu

me

of

epis

od

es. T

he

seco

nd

gra

ph

sh

ow

s th

e le

ng

th o

f st

ay in

day

s fo

r o

nly

th

e IC

D-1

0

epis

od

es t

hat

are

am

enab

le t

o t

hro

mb

oly

sis

to p

rovi

de

an in

dic

ativ

e p

ictu

re o

f an

y tr

end

s th

at m

ay b

e em

erg

ing

in in

pat

ien

t ca

re f

or

this

co

ho

rt.

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 6

6

Fig

ure

13:

St

Vin

cen

t’s

Ho

spit

al IC

D-1

0 st

roke

ep

iso

des

an

d a

vera

ge

len

gth

of

stay

200

7-08

to

201

2-13

0 20

40

60

80

100

120

140

160

180

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Episodes

Year

St V

ince

nt'

s H

osp

ital

St

roke

by

sele

cted

ICD

-10

2007

/08

to 2

012/

13. A

cute

ep

iso

des

an

d A

LOS

Oth

er n

on-t

rau

mat

ic in

trac

ereb

ral h

aem

orr

hag

e

Stro

ke n

ot

spec

ified

Intr

acer

ebra

l hae

mo

rrh

age

Cer

ebra

l in

farc

tio

n

Tran

sien

t is

chae

mic

att

ack

0 2 4 6 8 10

12

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Days

Year

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 6

7

15.1

.7 R

oyal

Pri

nce

Alf

red

Ho

spit

al

Fro

m 2

007-

08 t

o 2

012-

13, R

oyal

Pri

nce

Alf

red

Ho

spit

al h

ad a

to

tal o

f 22

83 a

cute

ep

iso

des

fo

r se

lect

ed D

RGs

wit

h t

he

hig

hes

t vo

lum

e b

ein

g f

or

stro

ke a

nd

oth

er

cere

bro

vasc

ula

r d

iso

rder

s w

ith

288

ep

iso

des

in 2

012-

13. T

able

11

sho

ws

the

epis

od

es b

y D

RG.

Tab

le 1

1: R

oyal

Pri

nce

Alf

red

Ho

spit

al s

elec

ted

str

oke

DR

Gs

2007

-08

to 2

012-

13

Acu

te e

pis

od

es A

R-D

RG

Roy

al P

rin

ce A

lfre

d H

osp

ital

C

ran

ial p

roce

du

res

Extr

acra

nia

l vas

cula

r p

roce

du

res

TIA

an

d p

rece

reb

ral o

cclu

sio

nSt

roke

an

d o

ther

cer

ebro

vasc

ula

r d

iso

rder

s

2007

-08

4321

6923

6

2008

-09

3817

6623

9

2009

-10

4016

9022

2

2010

-11

4416

7122

6

2011

-12

4820

7325

5

2012

-13

4821

7628

8

The

Roya

l Pri

nce

Alf

red

Ho

spit

al r

ecei

ved

5.8

% o

f th

e to

tal p

atie

nt

load

pre

sen

tin

g a

t SR

P si

tes

in 2

012-

13. D

uri

ng

th

e p

erio

d 2

007-

08 t

o 2

012-

13, i

t h

ad 2

328

acu

te

epis

od

es b

y se

lect

ed IC

D c

od

es w

ith

th

e hi

gh

est

volu

me

for

cere

bra

l inf

arct

ion

wit

h 1

99 e

pis

od

es in

201

2-13

.

The

aver

age

len

gth

of

stay

has

dec

lined

ste

adily

in t

ota

l fro

m 8

.1 d

ays

in 2

007-

08 t

o 7

.8 d

ays

in 2

012-

13.

The

aver

age

NW

AU

fo

r th

e se

lect

ed D

RGs

for

Roya

l Pri

nce

Alf

red

Ho

spit

al w

as 2

.5 in

201

2-13

. Thi

s is

th

e hi

gh

est

wei

gh

tin

g f

or

all S

RP

site

s an

d in

dic

ates

th

at t

he

site

has

the

hig

hes

t p

atie

nt

com

ple

xity

load

.

The

firs

t g

rap

h in

Fig

ure

14

sho

ws

the

epis

od

es o

f ca

re b

y se

lect

ed IC

D-1

0 co

des

. Th

ese

are

con

sist

ent

wit

h t

he

con

dit

ion

s th

at a

re a

sses

sed

fo

r el

igib

ility

fo

r th

rom

bo

lysi

s

at p

atie

nt

pre

sen

tati

on

an

d a

re s

ho

wn

her

e to

pro

vid

e an

ind

icat

ion

of

the

volu

me

of

epis

od

es. T

he

seco

nd

gra

ph

sh

ow

s th

e le

ng

th o

f st

ay in

day

s fo

r o

nly

th

e IC

D-1

0

epis

od

es t

hat

are

am

enab

le t

o t

hro

mb

oly

sis

to p

rovi

de

an in

dic

ativ

e p

ictu

re o

f an

y tr

end

s th

at m

ay b

e em

erg

ing

in in

pat

ien

t ca

re f

or

this

co

ho

rt.

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 6

8

Fig

ure

14:

Roy

al P

rin

ce A

lfre

d H

osp

ital

ICD

-10

stro

ke e

pis

od

es a

nd

ave

rag

e le

ng

th o

f st

ay 2

007-

08 t

o 2

012-

13

0 50

100

150

200

250

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Episodes

Year

Ro

yal P

rin

ce A

lfre

d H

osp

ital

St

roke

by

sele

cted

ICD

-10

2007

/08

to 2

012/

13. A

cute

ep

iso

des

an

d A

LOS

Intr

acer

ebra

l hae

mo

rrh

age

Cer

ebra

l in

farc

tio

n

Tran

sien

t is

chae

mic

att

ack

0 2 4 6 8 10

12

Days

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Year

Oth

er n

on-t

rau

mat

ic in

trac

ereb

ral h

aem

orr

hag

e

Stro

ke n

ot

spec

ified

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 6

9

15.1

.8 P

rin

ce o

f W

ales

Ho

spit

al

The

Prin

ce o

f W

ales

Ho

spit

al h

ad a

to

tal o

f 22

88 a

cute

ep

iso

des

by

sele

cted

DRG

fo

r th

e p

erio

d 2

007-

08 t

o 2

012-

13, a

s sh

ow

n in

Tab

le 1

2. T

he

hig

hes

t vo

lum

e w

as f

or

stro

ke a

nd

oth

er v

ascu

lar

dis

ord

ers

at 2

57 e

pis

od

es in

201

2-13

fo

llow

ed b

y TI

A a

nd

cer

ebra

l occ

lusi

on

at

90 e

pis

od

es f

or

the

sam

e ti

me.

Tab

le 1

2: P

rin

ce o

f W

ales

Ho

spit

al s

elec

ted

str

oke

DR

Gs

2007

-08

to 2

012-

13

Acu

te e

pis

od

es A

R-D

RG

Pri

nce

of

Wal

es H

osp

ital

C

ran

ial p

roce

du

res

Extr

acra

nia

l vas

cula

r p

roce

du

res

TIA

an

d p

rece

reb

ral o

cclu

sio

nSt

roke

an

d o

ther

cer

ebro

vasc

ula

r d

iso

rder

s

2007

-08

3611

127

252

2008

-09

226

9526

6

2009

-10

364

103

238

2010

-11

267

7223

2

2011

-12

286

7724

5

2012

-13

3913

9025

7

The

Prin

ce o

f W

ales

Ho

spit

al h

ad a

to

tal o

f 23

58 a

cute

ep

iso

des

fo

r th

e se

lect

ed IC

D c

od

es a

s sh

ow

n in

Fig

ure

15.

Thi

s re

pre

sen

ts 5

.4%

of

the

tota

l SR

P p

atie

nt

load

an

d

sim

ilar

to m

ost

oth

er s

ites

, th

e hi

gh

est

volu

me

was

fo

r ce

reb

ral i

nfar

ctio

n w

ith

a t

ota

l of

200

epis

od

es in

201

2-13

.

The

aver

age

len

gth

of

stay

is d

eclin

ing

fo

r al

l ep

iso

des

wit

h a

to

tal d

ecre

ase

fro

m 9

.7 d

ays

in 2

007-

08 t

o 8

day

s in

201

2-13

.

The

aver

age

NW

AU

fo

r th

e se

lect

ed s

tro

ke D

RGs

was

2.4

in 2

012-

13 in

dic

atin

g a

hig

h le

vel o

f p

atie

nt

com

ple

xity

an

d t

he

seco

nd

hig

hes

t am

on

gst

SR

P si

tes.

The

firs

t g

rap

h in

Fig

ure

15

sho

ws

the

epis

od

es o

f ca

re b

y se

lect

ed IC

D-1

0 co

des

. Th

ese

are

con

sist

ent

wit

h t

he

con

dit

ion

s th

at a

re a

sses

sed

fo

r el

igib

ility

fo

r th

rom

bo

lysi

s

at p

atie

nt

pre

sen

tati

on

an

d a

re s

ho

wn

her

e to

pro

vid

e an

ind

icat

ion

of

the

volu

me

of

epis

od

es. T

he

seco

nd

gra

ph

sh

ow

s th

e le

ng

th o

f st

ay in

day

s fo

r o

nly

th

e IC

D-1

0

epis

od

es t

hat

are

am

enab

le t

o t

hro

mb

oly

sis

to p

rovi

de

an in

dic

ativ

e p

ictu

re o

f an

y tr

end

s th

at m

ay b

e em

erg

ing

in in

pat

ien

t ca

re f

or

this

co

ho

rt.

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 7

0

Fig

ure

15:

Pri

nce

of

Wal

es H

osp

ital

ICD

-10

stro

ke e

pis

od

es a

nd

ave

rag

e le

ng

th o

f st

ay 2

007-

08 t

o 2

012-

13

0 50

100

150

200

250

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Episodes

Year

Prin

ce o

f W

ales

Ho

spit

al

Stro

ke b

y se

lect

ed IC

D-1

0 20

07/0

8 to

201

2/13

. Acu

te e

pis

od

es a

nd

ALO

S

Oth

er n

on

-tra

um

atic

intr

acer

ebra

l

hae

mo

rrh

age

Stro

ke n

ot

spec

ified

Intr

acer

ebra

l hae

mo

rrh

age

Cer

ebra

l in

farc

tio

n

Tran

sien

t is

chae

mic

att

ack

0 2 4 6 8 10

12

14

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Days

Year

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 7

1

15.1

.9 B

anks

tow

n-L

idco

mb

e H

osp

ital

The

Ban

ksto

wn

-Lid

com

be

Ho

spit

al h

ad a

to

tal o

f 21

63 a

cute

ep

iso

des

fo

r se

lect

ed D

RGs

fro

m 2

007-

08 t

o 2

012-

13, a

s sh

ow

n in

Tab

le 1

3. T

he

hig

hes

t vo

lum

es a

re f

or

stro

ke

and

oth

er c

ereb

rova

scu

lar

dis

ord

ers

and

TIA

an

d p

rece

reb

ral o

cclu

sio

n.

Tab

le 1

3: B

anks

tow

n-L

idco

mb

e H

osp

ital

sel

ecte

d s

tro

ke D

RG

s 20

07-0

8 to

201

2-13

Acu

te e

pis

od

es A

R-D

RG

Ban

ksto

wn

-Lid

com

be

Ho

spit

al

C

ran

ial p

roce

du

res

Extr

acra

nia

l vas

cula

r p

roce

du

res

TIA

an

d p

rece

reb

ral o

cclu

sio

nSt

roke

an

d o

ther

cer

ebro

vasc

ula

r d

iso

rder

s

2007

-08

07

104

282

2008

-09

05

106

257

2009

-10

03

101

243

2010

-11

04

103

260

2011

-12

04

8925

6

2012

-13

14

105

229

By

sele

cted

ICD

co

des

, Ban

ksto

wn

-Lid

com

be

Ho

spit

al h

ad a

to

tal o

f 22

24 e

pis

od

es f

or

the

per

iod

200

7-08

to

201

2-13

. Thi

s h

as r

emai

ned

rel

ativ

ely

stab

le o

ver

the

tim

e

per

iod

. In

201

2-13

, thi

s re

pre

sen

ted

4.5

% o

f th

e to

tal p

atie

nt

load

pre

sen

tin

g a

t SR

P si

tes.

The

aver

age

len

gth

of

stay

is d

eclin

ing

in t

ota

l fro

m 1

2.4

day

s in

200

7-08

to

8 d

ays

in 2

012-

13. F

igu

re 1

6 sh

ow

s th

e av

erag

e le

ng

th o

f st

ay f

or

sele

cted

ICD

co

des

.

In 2

012-

13, B

anks

tow

n-L

idco

mb

e H

osp

ital

had

an

ave

rag

e N

WA

U f

or

sele

cted

DRG

s o

f 1.

8. T

his

is h

igh

er t

han

th

e N

SW a

nd

no

n-S

RP

site

to

tal a

vera

ges

an

d o

nly

slig

htl

y

low

er t

han

th

e to

tal S

RP

site

ave

rag

e o

f 1.

9.

The

firs

t g

rap

h in

Fig

ure

16

sho

ws

the

epis

od

es o

f ca

re b

y se

lect

ed IC

D-1

0 co

des

. Th

ese

are

con

sist

ent

wit

h t

he

con

dit

ion

s th

at a

re a

sses

sed

fo

r el

igib

ility

fo

r th

rom

bo

lysi

s

at p

atie

nt

pre

sen

tati

on

an

d a

re s

ho

wn

her

e to

pro

vid

e an

ind

icat

ion

of

the

volu

me

of

epis

od

es. T

he

seco

nd

gra

ph

sh

ow

s th

e le

ng

th o

f st

ay in

day

s fo

r o

nly

th

e IC

D-1

0

epis

od

es t

hat

are

am

enab

le t

o t

hro

mb

oly

sis

to p

rovi

de

an in

dic

ativ

e p

ictu

re o

f an

y tr

end

s th

at m

ay b

e em

erg

ing

in in

pat

ien

t ca

re f

or

this

co

ho

rt.

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 7

2

Fig

ure

16:

Ban

ksto

wn

-Lid

com

be

Ho

spit

al IC

D-1

0 st

roke

ep

iso

des

an

d a

vera

ge

len

gth

of

stay

200

7-08

to

201

2-13

0 20

40

60

80

100

120

140

160

180

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Episodes

Year

Ban

ksto

wn-L

idcomb

e H

osp

ital

St

roke

by

sele

cted

ICD

-10

2007

/08

to 2

012/

13. A

cute

ep

iso

des

an

d A

LOS

Oth

er n

on-t

rau

mat

ic in

trac

ereb

ral

hae

mo

rrh

age

Stro

ke n

ot

spec

ified

Intr

acer

ebra

l hae

mo

rrh

age

Cer

ebra

l in

farc

tio

n

Tran

sien

t is

chae

mic

att

ack

0 2 4 6 8 10

12

14

16

18

20

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Days

Year

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 7

3

15.1

.10

Wes

tmea

d H

osp

ital

Fro

m 2

007-

08 t

o 2

012-

13, W

estm

ead

Ho

spit

al h

ad a

to

tal o

f 30

95 a

cute

str

oke

ep

iso

des

by

sele

cted

DRG

wit

h t

he

hig

hes

t vo

lum

e fo

r st

roke

an

d o

ther

cer

ebro

vasc

ula

r

dis

ord

ers

at 3

29 in

201

2-13

.

Tab

le 1

4 sh

ow

s al

l ep

iso

des

by

sele

cted

DRG

fo

r fr

om

200

7-08

to

201

2-13

.

Tab

le 1

4: W

estm

ead

Ho

spit

al s

elec

ted

str

oke

DR

Gs

2007

-08

to 2

012-

13

Acu

te e

pis

od

es A

R-D

RG

Wes

tmea

d H

osp

ital

C

ran

ial p

roce

du

res

Extr

acra

nia

l vas

cula

r p

roce

du

res

TIA

an

d p

rece

reb

ral o

cclu

sio

nSt

roke

an

d o

ther

cer

ebro

vasc

ula

r d

iso

rder

s

2007

-08

4211

111

302

2008

-09

495

137

363

2009

-10

5810

116

307

2010

-11

466

126

329

2011

-12

459

121

350

2012

-13

3915

127

371

Ther

e w

ere

3148

acu

te e

pis

od

es b

y se

lect

ed IC

D c

od

es f

or

the

2007

-08

to 2

012-

13 t

ime

per

iod

wit

h t

he

hig

hes

t vo

lum

e fo

r ce

reb

ral i

nfar

ctio

n w

ith

228

ep

iso

des

in 2

012-

13.

This

has

rem

ain

ed r

elat

ivel

y st

able

ove

r th

e ti

me

per

iod

.

The

aver

age

len

gth

of

stay

has

dec

lined

by

all s

elec

ted

ICD

co

des

wit

h a

to

tal d

ecre

ase

fro

m 9

.1 d

ays

in 2

007-

08 t

o 6

.3 d

ays

in 2

012-

13.

The

aver

age

NW

AU

fo

r se

lect

ed D

RGs

for

2012

-13

was

2. T

his

is h

igh

er t

han

th

e SR

P si

te a

vera

ge

of

1.9

and

rep

rese

nts

a h

igh

pat

ien

t co

mp

lexi

ty.

The

firs

t g

rap

h in

Fig

ure

17

sho

ws

the

epis

od

es o

f ca

re b

y se

lect

ed IC

D-1

0 co

des

. Th

ese

are

con

sist

ent

wit

h t

he

con

dit

ion

s th

at a

re a

sses

sed

fo

r el

igib

ility

fo

r th

rom

bo

lysi

s

at p

atie

nt

pre

sen

tati

on

an

d a

re s

ho

wn

her

e to

pro

vid

e an

ind

icat

ion

of

the

volu

me

of

epis

od

es. T

he

seco

nd

gra

ph

sh

ow

s th

e le

ng

th o

f st

ay in

day

s fo

r o

nly

th

e IC

D-1

0

epis

od

es t

hat

are

am

enab

le t

o t

hro

mb

oly

sis

to p

rovi

de

an in

dic

ativ

e p

ictu

re o

f an

y tr

end

s th

at m

ay b

e em

erg

ing

in in

pat

ien

t ca

re f

or

this

co

ho

rt.

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 7

4

Fig

ure

17:

Wes

tmea

d H

osp

ital

ICD

-10

stro

ke e

pis

od

es a

nd

ave

rag

e le

ng

th o

f st

ay 2

007-

08 t

o 2

012-

13

0 50

100

150

200

250

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Episodes

Year

Wes

tmea

d H

osp

ital

St

roke

by

sele

cted

ICD

-10.

Acu

te e

pis

od

es a

nd

ALO

S

Oth

er n

on-t

rau

mat

ic in

trac

ereb

ral

hae

mo

rrh

age

Stro

ke n

ot

spec

ified

Intr

acer

ebra

l hae

mo

rrh

age

Cer

ebra

l in

farc

tio

n

Tran

sien

t is

chae

mic

att

ack

0 2 4 6 8 10

12

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Days

Year

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 7

5

15.1

.11

Live

rpo

ol H

osp

ital

Ove

r th

e p

erio

d 2

007-

08 t

o 2

012-

13, L

iver

po

ol H

osp

ital

had

a t

ota

l of

3420

acu

te e

pis

od

es o

f st

roke

by

sele

cted

DRG

. In

201

2-13

, th

e hi

gh

est

volu

me

was

fo

r st

roke

an

d

oth

er c

ereb

rova

scu

lar

dis

ord

ers

wit

h 3

46 e

pis

od

es, a

s sh

ow

n in

Tab

le 1

5.

Tab

le 1

5: L

iver

po

ol H

osp

ital

sel

ecte

d s

tro

ke D

RG

s 20

07-0

8 to

201

2-13

Acu

te e

pis

od

es A

R-D

RG

Liv

erp

oo

l Ho

spit

al

C

ran

ial p

roce

du

res

Extr

acra

nia

l vas

cula

r p

roce

du

res

TIA

an

d p

rece

reb

ral o

cclu

sio

nSt

roke

an

d o

ther

cer

ebro

vasc

ula

r d

iso

rder

s

2007

-08

6415

145

294

2008

-09

5515

148

352

2009

-10

6613

152

343

2010

-11

6520

152

351

2011

-12

4919

189

342

2012

-13

5314

158

346

Live

rpo

ol H

osp

ital

had

a t

ota

l of

3508

acu

te e

pis

od

es b

y se

lect

ed IC

D c

od

es f

or

the

per

iod

200

7-08

to

201

2-13

rep

rese

nti

ng

7.7

% o

f th

e to

tal p

atie

nt

load

pre

sen

tin

g t

o

SRP

site

s in

201

2-13

. Ep

iso

de

volu

mes

rem

ain

ed s

tab

le f

rom

200

7-08

to

201

2-13

wit

h t

he

hig

hes

t vo

lum

e b

ein

g f

or

cere

bra

l inf

arct

ion

wit

h 2

50 e

pis

od

es in

201

2-13

.

Ther

e w

as a

dec

line

in t

he

aver

age

len

gth

of

stay

fo

r al

l sel

ecte

d IC

D c

od

es w

ith

th

e ex

cep

tio

n o

f st

roke

, no

t sp

ecifi

ed w

hich

rem

ain

ed s

tead

y at

12.

8 d

ays

in 2

007-

08 a

nd

12.7

day

s in

201

2-13

. In

to

tal,

the

aver

age

len

gth

of

stay

dec

reas

ed f

rom

12.

4 d

ays

in 2

007-

08 t

o 8

day

s in

201

2-13

.

The

aver

age

NW

AU

fo

r se

lect

ed D

RGs

for

Live

rpo

ol H

osp

ital

in 2

012-

13 w

as 2

.3. T

his

is t

he

thir

d h

igh

est

for

SRP

site

s in

dic

atin

g a

hig

h p

atie

nt

com

ple

xity

.

The

firs

t g

rap

h in

Fig

ure

18

sho

ws

the

epis

od

es o

f ca

re b

y se

lect

ed IC

D-1

0 co

des

. Th

ese

are

con

sist

ent

wit

h t

he

con

dit

ion

s th

at a

re a

sses

sed

fo

r el

igib

ility

fo

r th

rom

bo

lysi

s

at p

atie

nt

pre

sen

tati

on

an

d a

re s

ho

wn

her

e to

pro

vid

e an

ind

icat

ion

of

the

volu

me

of

epis

od

es. T

he

seco

nd

gra

ph

sh

ow

s th

e le

ng

th o

f st

ay in

day

s fo

r o

nly

th

e IC

D-1

0

epis

od

es t

hat

are

am

enab

le t

o t

hro

mb

oly

sis

to p

rovi

de

an in

dic

ativ

e p

ictu

re o

f an

y tr

end

s th

at m

ay b

e em

erg

ing

in in

-pat

ien

t ca

re f

or

this

co

ho

rt.

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 7

6

Fig

ure

18:

Liv

erp

oo

l Ho

spit

al IC

D-1

0 st

roke

ep

iso

des

an

d a

vera

ge

len

gth

of

stay

200

7-08

to

201

2-13

0 50

100

150

200

250

300

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Episodes

Live

rpo

ol H

osp

ital

St

roke

by

sele

cted

ICD

-10.

Acu

te e

pis

od

es a

nd

ALO

S

Oth

er n

on-t

rau

mat

ic in

trac

ereb

ral

hae

mo

rrh

age

Stro

ke n

ot

spec

ified

Year

Intr

acer

ebra

l hae

mo

rrh

age

Cer

ebra

l in

farc

tio

n

Tran

sien

t is

chae

mic

att

ack

0 2 4 6 8 10

12

14

16

18

20

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Days

Year

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 7

7

15.1

.12

Roya

l Nor

th S

hore

Ho

spit

al

The

Roya

l No

rth

Sh

ore

Ho

spit

al h

ad a

to

tal o

f 34

20 a

cute

str

oke

ep

iso

des

by

sele

cted

DRG

s in

th

e p

erio

d 2

007-

08 t

o 2

012-

13. T

he

hig

hes

t vo

lum

e, a

s sh

ow

n in

Tab

le 1

6,

was

fo

r st

roke

an

d o

ther

cer

ebro

vasc

ula

r d

iso

rder

s w

ith

415

ep

iso

des

in 2

012-

13.

Tab

le 1

6: R

oyal

No

rth

Sh

ore

Ho

spit

al s

elec

ted

str

oke

DR

Gs

2007

-08

to 2

012-

13

Acu

te e

pis

od

es A

R-D

RG

Roy

al N

ort

h S

ho

re H

osp

ital

C

ran

ial p

roce

du

res

Extr

acra

nia

l vas

cula

r p

roce

du

res

TIA

an

d p

rece

reb

ral o

cclu

sio

nSt

roke

an

d o

ther

cer

ebro

vasc

ula

r d

iso

rder

s

2007

-08

4910

9932

6

2008

-09

5711

116

353

2009

-10

7225

143

353

2010

-11

6528

121

353

2011

-12

7218

116

405

2012

-13

659

139

415

Ther

e w

ere

3506

acu

te s

tro

ke e

pis

od

es f

or

sele

cted

ICD

co

des

fo

r th

e p

erio

d 2

007-

08 t

o 2

012-

13 r

epre

sen

tin

g t

he

hig

hes

t p

atie

nt

load

pre

sen

tin

g t

o S

RP

site

s at

8.4

% o

f

the

tota

l qu

anti

ty.

Cer

ebra

l inf

arct

ion

is t

he

hig

hes

t vo

lum

e an

d a

cco

un

ted

fo

r 25

6 ac

ute

ep

iso

des

in 2

012-

13. T

he

aver

age

len

gth

of

stay

has

dec

reas

ed f

or

all s

elec

ted

ICD

s fo

r th

e p

erio

d

2007

-08

to 2

012-

13 w

ith

th

e ex

cep

tio

n o

f o

ther

no

n-t

rau

mat

ic in

trac

ereb

ral h

aem

orr

hag

e, w

hich

sta

yed

sta

ble

at

7.7

day

s in

200

7-08

an

d 7

.6 d

ays

in 2

012-

13. I

n t

ota

l, th

e

aver

age

len

gth

of

stay

dec

reas

ed f

rom

9 d

ays

to 6

.8 d

ays

resp

ecti

vely

fo

r th

e sa

me

tim

e p

erio

d.

The

aver

age

NW

AU

fo

r se

lect

ed D

RGs

was

2.1

in 2

012-

13 s

igni

fyin

g h

igh

er c

om

ple

xity

th

an t

he

aver

age

for

NSW

in t

ota

l an

d S

RP

site

s co

mb

ined

.

The

firs

t g

rap

h in

Fig

ure

19

sho

ws

the

epis

od

es o

f ca

re b

y se

lect

ed IC

D-1

0 co

des

. Th

ese

are

con

sist

ent

wit

h t

he

con

dit

ion

s th

at a

re a

sses

sed

fo

r el

igib

ility

fo

r th

rom

bo

lysi

s

at p

atie

nt

pre

sen

tati

on

an

d a

re s

ho

wn

her

e to

pro

vid

e an

ind

icat

ion

of

the

volu

me

of

epis

od

es. T

he

seco

nd

gra

ph

sh

ow

s th

e le

ng

th o

f st

ay in

day

s fo

r o

nly

th

e IC

D-1

0

epis

od

es t

hat

are

am

enab

le t

o t

hro

mb

oly

sis

to p

rovi

de

an in

dic

ativ

e p

ictu

re o

f an

y tr

end

s th

at m

ay b

e em

erg

ing

in in

pat

ien

t ca

re f

or

this

co

ho

rt.

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 7

8

Fig

ure

19:

Roy

al N

ort

h S

ho

re H

osp

ital

ICD

-10

stro

ke e

pis

od

es a

nd

ave

rag

e le

ng

th o

f st

ay 2

007-

08 t

o 2

012-

13

0 50

100

150

200

250

300

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Episodes

Year

Ro

yal N

ort

h S

ho

re H

osp

ital

St

roke

by

sele

cted

ICD

-10

2007

/08

to 2

012/

13. A

cute

ep

iso

des

an

d A

LOS

Oth

er n

on-t

rau

mat

ic in

trac

ereb

ral

hae

mo

rrh

age

Stro

ke n

ot

spec

ified

Intr

acer

ebra

l hae

mo

rrh

age

Cer

ebra

l in

farc

tio

n

Tran

sien

t is

chae

mic

att

ack

0 2 4 6 8 10

12

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Days

Year

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 7

9

15.1

.13

Sydn

ey A

dven

tist

Ho

spit

al

Syd

ney

Ad

ven

tist

Ho

spit

al is

a p

riva

te h

osp

ital

; th

eref

ore

AC

I do

es n

ot

hav

e ac

cess

to

ad

mit

ted

inp

atie

nt

dat

a fo

r th

e si

te. I

t is

an

tici

pat

ed t

hat

SR

P-sp

ecifi

c d

ata

will

be

colle

cted

fo

r St

age

two

of

this

eva

luat

ion

.

15.1

.14

St G

eorg

e H

osp

ital

St G

eorg

e H

osp

ital

had

a t

ota

l of

3407

acu

te s

tro

ke e

pis

od

es b

y se

lect

ed D

RG o

ver

the

per

iod

200

7-08

to

201

2-13

. As

sho

wn

in T

able

17,

th

e hi

gh

est

volu

me

was

fo

r st

roke

and

oth

er c

ereb

rova

scu

lar

dis

ord

ers

wit

h 4

19 e

pis

od

es f

or

2012

-13.

Tab

le 1

7: S

t G

eorg

e H

osp

ital

sel

ecte

d s

tro

ke D

RG

s 20

07-0

8 to

201

2-13

Acu

te e

pis

od

es A

R-D

RG

St

Geo

rge

Ho

spit

al

C

ran

ial p

roce

du

res

Extr

acra

nia

l vas

cula

r p

roce

du

res

TIA

an

d p

rece

reb

ral o

cclu

sio

nSt

roke

an

d o

ther

cer

ebro

vasc

ula

r d

iso

rder

s

2007

-08

274

131

359

2008

-09

411

151

371

2009

-10

313

156

377

2010

-11

296

137

387

2011

-12

404

145

415

2012

-13

264

143

419

Wit

hin

th

ese

DRG

s, t

her

e w

ere

a to

tal o

f 35

62 a

cute

ep

iso

des

by

sele

cted

ICD

co

des

fro

m 2

007-

08 t

o 2

012-

13 a

cco

un

tin

g f

or

8.1%

of

the

tota

l pat

ien

t lo

ad p

rese

nti

ng

at

SRP

site

s in

201

2-13

. Thi

s is

th

e se

con

d h

igh

est

pat

ien

t lo

ad a

fter

Roy

al N

ort

h S

ho

re H

osp

ital

. As

sho

wn

in F

igu

re 2

1, t

he

hig

hes

t vo

lum

e w

as f

or

cere

bra

l inf

arct

ion

whi

ch

had

a 2

0% in

crea

se f

rom

238

ep

iso

des

in 2

007-

08 t

o 2

86 e

pis

od

es in

201

2-13

.

The

aver

age

len

gth

of

stay

dec

reas

ed f

or

all s

elec

ted

ICD

exc

ept

for

cere

bra

l inf

arct

ion

an

d s

tro

ke, n

ot

spec

ified

, whi

ch b

oth

rem

ain

ed s

tead

y at

aro

un

d 1

0 d

ays

and

5.5

day

s re

spec

tive

ly. I

n t

ota

l, th

e av

erag

e le

ng

th o

f st

ay d

ecre

ased

fro

m 8

.4 d

ays

in 2

007-

08 t

o 7

.6 d

ays

in 2

012-

13.

The

aver

age

NW

AU

fo

r 20

12-1

3 fo

r se

lect

ed D

RGs

was

1.9

. Thi

s is

co

nsi

sten

t w

ith

th

e SR

P av

erag

e.

The

firs

t g

rap

h in

Fig

ure

20

sho

ws

the

epis

od

es o

f ca

re b

y se

lect

ed IC

D-1

0 co

des

. Th

ese

are

con

sist

ent

wit

h t

he

con

dit

ion

s th

at a

re a

sses

sed

fo

r el

igib

ility

fo

r th

rom

bo

lysi

s

at p

atie

nt

pre

sen

tati

on

an

d a

re s

ho

wn

her

e to

pro

vid

e an

ind

icat

ion

of

the

volu

me

of

epis

od

es. T

he

seco

nd

gra

ph

sh

ow

s th

e le

ng

th o

f st

ay in

day

s fo

r o

nly

th

e IC

D-1

0

epis

od

es t

hat

are

am

enab

le t

o t

hro

mb

oly

sis

to p

rovi

de

an in

dic

ativ

e p

ictu

re o

f an

y tr

end

s th

at m

ay b

e em

erg

ing

in in

pat

ien

t ca

re f

or

this

co

ho

rt.

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 8

0

Fig

ure

20:

St

Geo

rge

Ho

spit

al IC

D-1

0 st

roke

ep

iso

des

an

d a

vera

ge

len

gth

of

stay

200

7-08

to

201

2-13

0 50

100

150

200

250

300

350

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Episodes

Year

St G

eorg

e H

osp

ital

St

roke

by

sele

cted

ICD

-10

2007

/08

to 2

012/

13. A

cute

ep

iso

des

an

d A

LOS

Oth

er n

on-t

rau

mat

ic in

trac

ereb

ral

hae

mo

rrh

age

Stro

ke n

ot

spec

ified

Intr

acer

ebra

l hae

mo

rrh

age

Cer

ebra

l in

farc

tio

n

Tran

sien

t is

chae

mic

att

ack

0 2 4 6 8 10

12

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Days

Year

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 8

1

15.1

.15

Wag

ga W

agga

Bas

e H

osp

ital

For

the

per

iod

200

7-08

to

201

2-13

, Wag

ga

Wag

ga

Bas

e H

osp

ital

had

a t

ota

l of

1380

acu

te s

tro

ke e

pis

od

es b

y se

lect

ed D

RGs.

Th

ere

wer

e n

o e

pis

od

es f

or

cran

ial p

roce

du

res

and

th

e hi

gh

est

nu

mb

er o

f ep

iso

des

bei

ng

fo

r st

roke

an

d o

ther

cer

ebro

vasc

ula

r d

iso

rder

s w

ith

179

ep

iso

des

in 2

012-

13.

Tab

le 1

8: W

agg

a W

agg

a B

ase

Ho

spit

al s

elec

ted

str

oke

DR

Gs

2007

-08

to 2

012-

13

Acu

te e

pis

od

es A

R-D

RG

Wag

ga

Wag

ga

Bas

e H

osp

ital

C

ran

ial p

roce

du

res

Extr

acra

nia

l vas

cula

r p

roce

du

res

TIA

an

d p

rece

reb

ral o

cclu

sio

nSt

roke

an

d o

ther

cer

ebro

vasc

ula

r d

iso

rder

s

2007

-08

03

5710

8

2008

-09

03

7118

3

2009

-10

01

7516

8

2010

-11

02

6813

8

2011

-12

01

6917

8

2012

-13

08

6817

9

Ther

e w

ere

1411

acu

te s

tro

ke e

pis

od

es b

y se

lect

ed IC

D c

od

es w

ith

a 9

4% in

crea

se in

th

e n

um

ber

of

cere

bra

l inf

arct

ion

ep

iso

des

fro

m 7

3 in

200

7-08

to

142

in 2

012-

13.

The

aver

age

len

gth

of

stay

is d

ecre

asin

g f

or

all I

CD

s w

ith

a t

ota

l co

mb

ined

dec

reas

e fr

om

6.2

day

s in

200

7-08

to

5 d

ays

in 2

012-

13.

Wag

ga

Wag

ga

Bas

e H

osp

ital

had

an

ave

rag

e N

WA

U f

or

sele

cted

DRG

s o

f 1.

4 w

hich

is s

ligh

tly

low

er t

han

th

e N

SW a

vera

ge

and

hig

her

th

an t

he

aver

age

for

SRP

site

s

com

bin

ed.

The

firs

t g

rap

h in

Fig

ure

21

sho

ws

the

epis

od

es o

f ca

re b

y se

lect

ed IC

D-1

0 co

des

. Th

ese

are

con

sist

ent

wit

h t

he

con

dit

ion

s th

at a

re a

sses

sed

fo

r el

igib

ility

fo

r th

rom

bo

lysi

s

at p

atie

nt

pre

sen

tati

on

an

d a

re s

ho

wn

her

e to

pro

vid

e an

ind

icat

ion

of

the

volu

me

of

epis

od

es. T

he

seco

nd

gra

ph

sh

ow

s th

e le

ng

th o

f st

ay in

day

s fo

r o

nly

th

e IC

D-1

0

epis

od

es t

hat

are

am

enab

le t

o t

hro

mb

oly

sis

to p

rovi

de

an in

dic

ativ

e p

ictu

re o

f an

y tr

end

s th

at m

ay b

e em

erg

ing

in in

pat

ien

t ca

re f

or

this

co

ho

rt.

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 8

2

Fig

ure

21:

Wag

ga

Wag

ga

Bas

e H

osp

ital

ICD

-10

stro

ke e

pis

od

es a

nd

ave

rag

e le

ng

th o

f st

ay 2

007-

08 t

o 2

012-

13

0 20

40

60

80

100

120

140

160

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Episodes

Year

Wag

ga

Wag

ga

Bas

e H

osp

ital

St

roke

by

sele

cted

ICD

-10

2007

/08

to 2

012/

13. A

cute

ep

iso

des

an

d A

LOS

Oth

er n

on

-tra

um

atic

intr

acer

ebra

l

hae

mo

rrh

age

Stro

ke n

ot

spec

ified

Intr

acer

ebra

l hae

mo

rrh

age

Cer

ebra

l in

farc

tio

n

Tran

sien

t is

chae

mic

att

ack

0 1 2 3 4 5 6 7 8 9

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Days

Year

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 8

3

15.1

.16

Hor

nsb

y an

d K

u-R

ing

-Gai

Ho

spit

al

The

Ho

rnsb

y an

d K

u-R

ing

-Gai

Ho

spit

al h

ad a

to

tal o

f 11

7 ac

ute

str

oke

DRG

s fr

om

200

7-08

to

201

2-13

. Th

ere

wer

e n

o e

pis

od

es f

or

cran

ial p

roce

du

res

in t

his

tim

e an

d t

he

hig

hes

t vo

lum

e w

as f

or

stro

ke a

nd

oth

er c

ereb

rova

scu

lar

dis

ord

ers

wit

h 1

55 e

pis

od

es in

201

2-13

, as

sho

wn

in T

able

19.

Tab

le 1

9: H

orn

sby

and

Ku

-Rin

g-G

ai H

osp

ital

sel

ecte

d s

tro

ke D

RG

s 20

07-0

8 to

201

2-13

Acu

te e

pis

od

es A

R-D

RG

Ho

rnsb

y an

d K

u-R

ing

-Gai

Ho

spit

al

C

ran

ial p

roce

du

res

Extr

acra

nia

l vas

cula

r p

roce

du

res

TIA

an

d p

rece

reb

ral o

cclu

sio

nSt

roke

an

d o

ther

cer

ebro

vasc

ula

r d

iso

rder

s

2007

-08

00

5112

1

2008

-09

02

4614

5

2009

-10

00

3916

3

2010

-11

02

5612

1

2011

-12

01

4814

9

2012

-13

01

7315

5

Wit

hin

th

ese

DRG

s, t

her

e w

ere

a to

tal o

f 12

04 a

cute

ep

iso

des

in t

he

sele

cted

ICD

co

des

, wit

h s

tead

y in

crea

ses

for

cere

bra

l inf

arct

ion

an

d T

IA, w

hile

th

e o

ther

s re

mai

ned

stab

le, a

s d

epic

ted

in F

igu

re 2

2 b

elo

w.

The

aver

age

len

gth

of

stay

dec

reas

ed s

tead

ily f

rom

7.1

day

s in

200

7-08

to

6.2

day

s in

201

2-13

.

The

aver

age

NW

AU

fo

r th

e se

lect

ed D

RGs

in 2

012-

13 w

as 1

.3. T

his

rep

rese

nts

a h

igh

er c

om

ple

xity

th

an t

hat

exp

erie

nce

d b

y n

on

-SR

P si

tes,

alt

ho

ug

h lo

wer

th

an t

he

NSW

aver

age

in t

ota

l.

The

firs

t g

rap

h in

Fig

ure

22

sho

ws

the

epis

od

es o

f ca

re b

y se

lect

ed IC

D-1

0 co

des

. Th

ese

are

con

sist

ent

wit

h t

he

con

dit

ion

s th

at a

re a

sses

sed

fo

r el

igib

ility

fo

r th

rom

bo

lysi

s

at p

atie

nt

pre

sen

tati

on

an

d a

re s

ho

wn

her

e to

pro

vid

e an

ind

icat

ion

of

the

volu

me

of

epis

od

es. T

he

seco

nd

gra

ph

sh

ow

s th

e le

ng

th o

f st

ay in

day

s fo

r o

nly

th

e IC

D-1

0

epis

od

es t

hat

are

am

enab

le t

o t

hro

mb

oly

sis

to p

rovi

de

an in

dic

ativ

e p

ictu

re o

f an

y tr

end

s th

at m

ay b

e em

erg

ing

in in

pat

ien

t ca

re f

or

this

co

ho

rt.

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 8

4

Fig

ure

22:

Ho

rnsb

y an

d K

u-R

ing

-Gai

Ho

spit

al IC

D-1

0 st

roke

ep

iso

des

an

d a

vera

ge

len

gth

of

stay

200

7-08

to

201

2-13

0 20

40

60

80

100

120

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Episodes

Year

Ho

rnsb

y an

d K

u-R

ing

-Gai

Ho

spit

al

Stro

ke b

y se

lect

ed IC

D-1

0 20

07/0

8 to

201

2/13

. Acu

te e

pis

od

es a

nd

ALO

S

Oth

er n

on-t

rau

mat

ic in

trac

ereb

ral h

aem

orr

hag

e

Stro

ke n

ot

spec

ified

Intr

acer

ebra

l hae

mo

rrh

age

Cer

ebra

l in

farc

tio

n

Tran

sien

t is

chae

mic

att

ack

0 2 4 6 8 10

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Days

Year

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 8

5

15.1

.17

Bla

ckto

wn

Ho

spit

al

Fro

m 2

007-

08 t

o 2

012-

13, t

ota

l of

stro

ke e

pis

od

es b

y se

lect

ed D

RGs

for

Blac

kto

wn

Ho

spit

al a

re s

ho

wn

in T

able

20.

Th

e hi

gh

est

volu

me

was

fo

r st

roke

an

d o

ther

cere

bro

vasc

ula

r d

iso

rder

s at

268

ep

iso

des

in 2

012-

13. T

her

e w

ere

no

cra

nial

pro

ced

ure

s d

uri

ng

thi

s ti

me.

Tab

le 2

0: B

lack

tow

n H

osp

ital

sel

ecte

d s

tro

ke D

RG

s 20

07-0

8 to

201

2-13

Acu

te e

pis

od

es A

R-D

RG

Bla

ckto

wn

Ho

spit

al

C

ran

ial p

roce

du

res

Extr

acra

nia

l vas

cula

r p

roce

du

res

TIA

an

d p

rece

reb

ral o

cclu

sio

nSt

roke

an

d o

ther

cer

ebro

vasc

ula

r d

iso

rder

s

2007

-08

00

5623

0

2008

-09

00

9022

5

2009

-10

00

108

228

2010

-11

00

7923

6

2011

-12

04

111

242

2012

-13

00

135

268

Fro

m 2

007-

08 t

o 2

012-

13, t

her

e w

ere

a to

tal o

f 20

27 e

pis

od

es f

or

sele

cted

ICD

co

des

rep

rese

nti

ng

5.3

% o

f th

e to

tal p

atie

nt

load

pre

sen

tin

g t

o S

RP

site

s in

201

2-13

. Th

ere

wer

e in

crea

ses

in c

ereb

ral i

nfar

ctio

n f

rom

159

ep

iso

des

in 2

007-

08 t

o 1

97 in

201

2-13

an

d s

tro

ke, n

ot

spec

ified

fro

m 2

0 to

45

epis

od

es f

or

the

sam

e ti

me

per

iod

s.

The

aver

age

len

gth

of

stay

dec

reas

ed in

to

tal f

rom

7.2

day

s in

200

7-08

to

6.4

day

s in

201

2-13

. As

can

be

seen

in F

igu

re 2

3, t

her

e w

ere

incr

ease

s in

th

e av

erag

e le

ng

th o

f

stay

fo

r al

l IC

Ds

fro

m 2

009-

10 t

o 2

011-

12, b

efo

re t

his

aver

age

dec

reas

ed a

gai

n.

The

aver

age

NW

AU

fo

r th

e se

lect

ed D

RGs

is 1

.6 in

dic

atin

g h

igh

er p

atie

nt

com

ple

xity

th

an t

hat

fo

r N

SW in

to

tal a

nd

low

er t

han

th

e SR

P co

mb

ined

ave

rag

e o

f 1.

9.

The

firs

t g

rap

h in

Fig

ure

23

sho

ws

the

epis

od

es o

f ca

re b

y se

lect

ed IC

D-1

0 co

des

. Th

ese

are

con

sist

ent

wit

h t

he

con

dit

ion

s th

at a

re a

sses

sed

fo

r el

igib

ility

fo

r th

rom

bo

lysi

s

at p

atie

nt

pre

sen

tati

on

an

d a

re s

ho

wn

her

e to

pro

vid

e an

ind

icat

ion

of

the

volu

me

of

epis

od

es. T

he

seco

nd

gra

ph

sh

ow

s th

e le

ng

th o

f st

ay in

day

s fo

r o

nly

th

e IC

D-1

0

epis

od

es t

hat

are

am

enab

le t

o t

hro

mb

oly

sis

to p

rovi

de

an in

dic

ativ

e p

ictu

re o

f an

y tr

end

s th

at m

ay b

e em

erg

ing

in in

pat

ien

t ca

re f

or

this

co

ho

rt.

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 8

6

Fig

ure

23:

Bla

ckto

wn

Ho

spit

al IC

D-1

0 st

roke

ep

iso

des

an

d a

vera

ge

len

gth

of

stay

200

7-08

to

201

2-13

0 50

100

150

200

250

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Episodes

Year

Bla

ckto

wn

Ho

spit

al

Stro

ke b

y se

lect

ed IC

D-1

0 20

07/0

8 to

201

2/13

. Acu

te e

pis

od

es a

nd

ALO

S

Oth

er n

on

-tra

um

atic

intr

acer

ebra

l hae

mo

rrh

age

Stro

ke n

ot

spec

ified

Intr

acer

ebra

l hae

mo

rrh

age

Cer

ebra

l in

farc

tio

n

Tran

sien

t is

chae

mic

att

ack

0 2 4 6 8 10

12

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Days

Year

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 8

7

15.1

.18

Co

nco

rd H

osp

ital

Co

nco

rd H

osp

ital

had

a t

ota

l of

1919

acu

te s

tro

ke e

pis

od

es f

or

sele

cted

DRG

s fr

om

200

7-08

to

201

2-13

. Th

e hi

gh

est

volu

me,

as

sho

wn

in T

able

21,

was

fo

r st

roke

an

d o

ther

cere

bro

vasc

ula

r d

iso

rder

s w

ith

256

ep

iso

des

in 2

012-

13.

Tab

le 2

1: C

on

cord

Ho

spit

al s

elec

ted

str

oke

DR

Gs

2007

-08

to 2

012-

13

Acu

te e

pis

od

es A

R-D

RG

Co

nco

rd H

osp

ital

C

ran

ial p

roce

du

res

Extr

acra

nia

l vas

cula

r p

roce

du

res

TIA

an

d p

rece

reb

ral o

cclu

sio

nSt

roke

an

d o

ther

cer

ebro

vasc

ula

r d

iso

rder

s

2007

-08

155

6422

4

2008

-09

213

5919

3

2009

-10

137

7121

3

2010

-11

184

8024

6

2011

-12

333

6023

3

2012

-13

96

8325

6

Wit

hin

th

ese

DRG

s th

ere

wer

e a

tota

l of

1947

ep

iso

des

fo

r se

lect

ed IC

D c

od

es f

or

the

per

iod

200

7-08

to

201

2-13

. Th

e hi

gh

est

volu

me

of

epis

od

es w

as f

or

cere

bra

l

infa

rcti

on

wit

h 1

71 e

pis

od

es in

201

2-13

rep

rese

nti

ng

a 2

5% in

crea

se f

rom

136

ep

iso

des

in 2

007-

08.

The

aver

age

len

gth

of

stay

dec

reas

ed in

to

tal f

rom

9.8

day

s in

200

7-08

to

8.3

day

s in

201

2-13

.

The

aver

age

NW

AU

fo

r th

e se

lect

ed D

RGs

was

2 in

201

2-13

sig

nify

ing

a s

ligh

tly

hig

her

pat

ien

t co

mp

lexi

ty t

han

SR

P si

tes

com

bin

ed a

vera

ge.

The

firs

t g

rap

h in

Fig

ure

24

sho

ws

the

epis

od

es o

f ca

re b

y se

lect

ed IC

D-1

0 co

des

. Th

ese

are

con

sist

ent

wit

h t

he

con

dit

ion

s th

at a

re a

sses

sed

fo

r el

igib

ility

fo

r th

rom

bo

lysi

s

at p

atie

nt

pre

sen

tati

on

an

d a

re s

ho

wn

her

e to

pro

vid

e an

ind

icat

ion

of

the

volu

me

of

epis

od

es. T

he

seco

nd

gra

ph

sh

ow

s th

e le

ng

th o

f st

ay in

day

s fo

r o

nly

th

e IC

D-1

0

epis

od

es t

hat

are

am

enab

le t

o t

hro

mb

oly

sis

to p

rovi

de

an in

dic

ativ

e p

ictu

re o

f an

y tr

end

s th

at m

ay b

e em

erg

ing

in in

pat

ien

t ca

re f

or

this

co

ho

rt.

Hea

lth

Econ

omic

s an

d Ev

alua

tion

Tea

m –

NSW

Str

oke

Rep

erfu

sion

Pro

gram

Eva

luat

ion

repo

rtPa

ge 8

8

Fig

ure

24:

Co

nco

rd H

osp

ital

ICD

-10

stro

ke e

pis

od

es a

nd

ave

rag

e le

ng

th o

f st

ay 2

007-

08 t

o 2

012-

13

0 20

40

60

80

100

120

140

160

180

200

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Episodes

Year

Co

nco

rd H

osp

ital

St

roke

by

sele

cted

ICD

-10

2007

/08

to 2

012/

13. A

cute

ep

iso

des

an

d A

LOS

Oth

er n

on

-tra

um

atic

intr

acer

ebra

l hae

mo

rrh

age

Stro

ke n

ot

spec

ified

Intr

acer

ebra

l hae

mo

rrh

age

Cer

ebra

l in

farc

tio

n

Tran

sien

t is

chae

mic

att

ack

0 2 4 6 8 10

12

14

2007

/08

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

Days

Year


Appendix III

NSW Stroke Reperfusion Program Evaluation Report€¦ · Health Economics and Evaluation Team –...

Documents

Transcript of NSW Stroke Reperfusion Program Evaluation Report€¦ · Health Economics and Evaluation Team –...