REPORT · Changes in adherence over time 23 Adherence to clinical process and mortality 25...

Collaboration. Innovation. Better Healthcare.Collaboration. Innovation. Better Healthcare.

REPORT

Stroke clinical audit process Initial report

Stroke Network

ACI Stroke Network – Stroke clinical audit process: Initial report Page i

AGENCY FOR CLINICAL INNOVATION

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Produced by: ACI Stroke Network

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Version: V1

Trim: ACI/D16/1573

Date Amended: 5/8/2016

© Agency for Clinical Innovation 2016

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

• 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 key priority for the ACI is identifying unwarranted variation in clinical practice. ACI teams work in

partnership with healthcare providers to develop mechanisms aimed at reducing unwarranted variation

and improving clinical practice and patient care.

www.aci.health.nsw.gov.au

ACI Stroke Network – Stroke clinical audit process: Initial report Page ii

Acknowledgments

Associate Professor John Worthington Clinical Lead ACI Stroke Clinical Audit Process (SCAP)

Mr Mark Longworth ACI Stroke Network Manager

Associate Professor Martin Jude Medical Co-chair Stroke Network

Ms Nadia Burkolter Nursing Co-chair Stroke Network

Associate Professor Dominique Cadilhac Head: Translational Public Health and Evaluation Division, Stroke and

Ageing Research, School of Clinical Sciences, Monash University and

Head Public Health, Stroke Division, Florey Institute of Neuroscience

and Mental Health (Florey)

Ms Tara Purvis Research Officer, Translational Public Health and Evaluation Division,

Stroke and Ageing Research, School of Clinical Sciences, Monash

University

Mr Daniel Comerford Director Acute Care, ACI

Contributions

Assoc. Professor Worthington has been responsible for the concept and development of the project, some of its

analyses, local face-to-face feedback and the broader presentation of the SCAP project, including a primary role in

authorship of this report.

Mark Longworth assisted in the development of the project and provided its day-to-day management, supervising

the site audits, facilitating local Quality Improvement and providing peer support. He has contributed to the

authorship of the report.

Assoc. Professor Dominique Cadilhac had a key role in the development and delivery of the SCAP leading the

relevant ethics applications, oversight of data management and analysis and writing of individual site reports and

making a substantive intellectual contribution to the SCAP project.

Tara Purvis was the project officer responsible for coordinating the ethics applications and site governance approval

processes for the audit process, liaised with hospitals in relation to their audit data, performed the data analyses and

drafted the individual hospital reports. She also provided summary data for ACI and other meetings, as requested.

Daniel Comerford was responsible for the State-wide Stroke Clinical Variation Strategy at an executive level, of

which the SCAP is a part. Daniel provided SCAP project management, a substantive intellectual contribution to the

project and provided considerable input to the drafting of this report.

Additional

We would also like to acknowledge members of the ACI and NSW clinicians who contributed to the audit tool

content; and the hospital staff who collected the audit data. We also acknowledge Li Chun Quang and Adele Gibbs

from the Florey who were involved with set-up of the Teleform questionnaires and database and Nancy Capitanio

for data processing. Megan Reyneke and Tharshanah Thayabaranathan from Monash University assisted with the

production of individual hospital reports that were fed back to hospitals as part of the SCAP project.

The individual audit reports were funded by the ACI, with involvement of the ACI Stroke Network and the

Unwarranted Clinical Variation Taskforce.

ACI Stroke Network – Stroke clinical audit process: Initial report Page iii

Abbreviations

Abbreviation Description

ACI NSW Agency for Clinical Innovation

AF Atrial fibrillation

ASNSW Ambulance Service of New South Wales

ASSIST Acute screening of swallow in stroke/TIA

ASU Acute stroke unit

ATC Acute thrombolysis centre

BHI Bureau of Health Information

CCU Coronary care unit

CPD Continuing professional development

CT Computed tomography

CXR Chest Xray

ECG Electrocardiograph

ED Emergency department

HDU High dependency unit

HEET Health economics and evaluation team

HIE Health Information Exchange

ICH Intracerebral haemorrhage

ICU Intensive care unit

IV Intravenous

LHD Local health district

MRA Magnetic resonance angiogram

MRI Magnetic resonance imaging

NBM Nil by mouth

NG Nasogastric

NOAC Novel oral anticoagulant

NSW New South Wales

OECD Organisation for Economic Co-operation and Development

OT Occupational therapy

PFO Patent foramen ovale

RSMR Risk standardised mortality ratio

RSP Rural Stroke Project

SCAP Stroke clinical audit process

SES Socioeconomic status

SSA Site specific assessment

SSCVS State-wide Stroke Clinical Variation Strategy

SU Stroke unit

TIA Transient ischaemic attack

TOE Transesophageal echocardiography

TTE Transthoracic echocardiogram

UCV Unwarranted clinical variation

UK United Kingdom

VTE Venous thromboembolism prophylaxis

ACI Stroke Network – Stroke clinical audit process: Initial report Page iv

Table of Contents

Acknowledgments ii

Abbreviations iii

Contents iv

Table of figures v

Table of tables v

Section 1 Executive summary 1

Stroke clinical audit process: report 1

Early analysis 2

Responses to SCAP audit and feedback 3

Conclusions 3

Section 2 Introduction 4

Section 3 Method 6

Pilot phase 6

The process 8

Overview of analyses 9

Section 4 Results 11

Pilot study results 11

Clinical process adherence 11

Pilot conclusions 14

Stroke clinical audit process 14

Patient characteristics 14

Investigations 15

Recording of off-site investigations 15

Interim comparison of investigation rates 15

Brain imaging 16

Carotid imaging 16

Chest X-ray 17

ECG and cardiac monitoring 18

Echocardiography 18

Adherence with important bedside clinical processes 18

Unenhanced rural site audit results: clinical process adherence 18

Enhanced rural site audit results: clinical process adherence 19

Enhanced metropolitan site audit results: clinical process adherence 20

Pooled enhanced and unenhanced site audit results: clinical process adherence 21

Assessment of swallowing 22

Use of a stroke pathway 23

Medically guided processes: adherence with prescribing and ordering 23

ACI Stroke Network – Stroke clinical audit process: Initial report Page v

Changes in adherence over time 23

Adherence to clinical process and mortality 25

Improving patient flows 27

Post-audit quality improvement activities 29

Section 5 Conclusions 30

Section 6 Recommendations 31

Section 7 Appendix 1 – Clinical process scoring card 32

Section 8 Appendix 2 – Audit site outcomes 33

Section 9 References 34

Table of figures

Figure 1 ACI stroke clinical audit process 1

Figure 2 Age-sex standardised 30-day mortality rate, in hospital and out of hospital 4

Figure 3 30-day ischaemic stroke mortality 2009-2012, BHI 5

Figure 4 ACI stroke clinical audit process 6

Figure 5 The pilot timeline for responding to stroke care unwarranted clinical variation 7

Figure 6 A SCAP audit feedback session with managers and clinicians 7

Figure 7 Pilot hospital 4: Clinical process adherence and access (2012 vs 2013–14) 13

Figure 8 Baseline audit investigation rates (as at April 2016) 16

Figure 9 Causes of death in the weeks after stroke 17

Figure 10 Stroke complications 2000–2014 17

Figure 11 Clinical process adherence at the SCAP and baseline audit unenhanced rural sites 19

Figure 12 SCAP audit results for the enhanced rural sites showing adherence with key processes 19

Figure 13 Adherence with key clinical processes across the 12 metropolitan sites 20

Figure 14 Adherence with key clinical processes 21

Figure 15 Documented swallow ability within four hours by hospital 22

Figure 16 Pooled data analysis from enhanced rural sites 24

Figure 17 29 NSW hospitals ranked from left to right by BHI risk standardised mortality 25

Figure 18 12 Sydney Metropolitan Hospitals ranked left to right by BHI risk standardised mortality 25

Figure 19 17 Rural and regional NSW Hospitals ranked left to right by BHI risk standardised mortality 26

Table of tables

Table 1 The SCAP program timetable, as at April 2016 8

Table 2 Audit sites by location, type and number of patients audited 9

Table 3 Pilot hospital adherence to clinical processes 12

Table 4 Pilot sites, audit dates, hospital type and details of process adherence 13

Table 5 SCAP audit site outcomes, ranked on BHI 30-day mortality risk

(or crude audited rate if not available) 33

ACI Stroke Network – Stroke clinical audit process: Initial report Page 1

Stroke clinical audit process: report

NSW stroke outcomes compare favourably with those of other OECD countries and have been

improving with coordinated and locally initiated development of enhanced stroke care.

However, the Bureau of Health Information (BHI) reported in 2012 and 2013 significant

unwarranted clinical variation in stroke patient outcomes.

In response, following widespread consultation, a pilot project was initiated to investigate unwarranted clinical

variation in stroke care. The pilot was undertaken at three rural and three metropolitan hospitals with differing

levels of organised stroke care and differing estimates of 30-day mortality as reported by BHI in 2012. Analysis of

the six pilot audits suggested an explanation for the unwarranted clinical variation, with varying levels of adherence

with important clinical processes, and widely varying access to stroke unit (SU) beds. The lessons were heeded and

incorporated into the definitive stroke clinical audit process (SCAP) shown in Figure 1.

Figure 1. ACI stroke clinical audit process

Stroke clinical audit process

The pilot and the SCAP program involved a total of 30 hospitals. Each site agreed on local priorities and strategies

to address unwarranted clinical variation and these were formally communicated to the local chief executive

through the ACI chief executive.

A total of 1793 medical records were audited from 30 hospitals – 494 records from nine unenhanceda rural sites,

510 from nine enhancedb rural sites and 784 from 12 enhanced metropolitan sites. Hospital 30, an unenhanced rural

site, was excluded from the formal analyses as only five medical records were eligible for review.

Executive summary

Section 1

a Unenhanced hospital sites do not provide specialised stroke services. Care is usually delivered in a general ward bed by generalists.

b Enhanced sites in the reported analyses are those where there has been local or externally supported development of specialised stroke care.

This is either a stroke unit with co-localised stroke beds and a stroke multidisciplinary team or a stroke service providing some elements of

stroke unit care, including a stroke care co-ordinator and use of a stroke clinical pathway. In NSW the development of stroke units or services

has been shown to improve stroke patient outcomes.

COLLATED REPORT

SITE AUDIT

LOCAL EXECUTIVE

COMMUNICATIONS

LOCAL FEEDBACK

IMPROVEMENT PLAN

COLLABORATIVE FEEDBACK

(STATEWIDE)FLOREY

ANALYSIS


Responses to SCAP audit and feedback

After the local feedback sessions, clinical staff and

managers worked to develop a local improvement plan.

Hospitals typically chose several of the following:

• the development of a stroke clinical pathway of care

• improved implementation of existing stroke

pathways, including improved access to early

swallowing assessment at four hospitals, improved

access to allied health disciplines and the use of

blanket allied health referral

• better access to existing stroke unit or HDU beds

through improved bed management

• the creation of new stroke units, stroke services

and acute thrombolysis centres

• the adoption or better use of transfer protocols

and hospital bypass to facilitate ‘hub and spoke’

transfers and access to stroke beds

• the implementation of formal pharmacy reviews

for each stroke patient to ensure appropriate

secondary prevention prescribing of statins and

antithrombotics

• addressing staffing issues

• the exploration of hub and spoke models of stroke

patient care.

The program has identified effective strategies used by

exemplar sites and shared these across all sites involved

in the program. A state-wide collaborative forum held

in April 2016 provided a further opportunity to share

these improvement strategies.

The following 13 clinical processes make up the majority of adherence measures reported

from the SCAP analyses:

1. Direct admission to a stroke unit (SU), Coronary Care Unit (CCU) or intensive care unit (ICU)

2. Brain imaging within 24 hours

3. Use of a stroke clinical pathway

4. Regular neurological observations for 24 hours from admission

5. Swallow assessment within four hours

6. Physiotherapy within 24 hours

7. Speech therapy within 24 hours

8. Occupational therapy within 24 hours

9. Multidisciplinary family meeting within seven days

10. Aspirin within 24 hours of ischaemic stroke

11. Prophylactic heparin if unable to walk

12. Discharge on antithrombotic if ischaemic stroke

13. Discharged on a statin if ischaemic stroke (newly commenced).


Early analysis

This report describes an initial analysis showing that

hospitals without specialist (SCAP) stroke services:

• treated older patients, with lower levels

of preadmission independence and more

severe strokes

• admitted fewer haemorrhagic strokes, provided

less access to important stroke investigations and

had more missing data than hospitals with

specialist services

• admitted 12% of stroke patients to a HDU, ICU or

coronary care unit (CCU) bed.

Enhanced and unenhanced rural sites had a greater

proportion of stroke patients identifying as Australian

(88% and 71% respectively), compared with

metropolitan sites (51%).

Conclusions

No hospital, even those with relatively high standards

of care, performed consistently well in the SCAP audits

across all clinical care processes that are likely to

influence patient outcomes. There is room for

improvement at all sites.

At a number of sites, there needs to be improved access

to desired investigations (such as carotid imaging and

echocardiography) and engagement with clinicians

involved in the stroke journey to ensure reliable

ordering and prescribing of important investigations,

medications and hydration fluids.

The data strongly indicates a relationship between

good adherence to important stroke care processes and

BHI estimated and adjusted 30-day mortality. Where

outcomes appeared worse, the gaps in evidence-based

care were generally greater (Figure 17 and Figure 14)

and this pattern was clearer for metropolitan hospitals

than rural hospitals.

The SCAP program has shown that good access to a

stroke unit bed is associated with better patient

outcomes in NSW. Some of the variation arises because

patients with stroke:

• are admitted to a smaller hospital with no

organised stroke care and little prospect of

providing it

• are admitted to a hospital where stroke unit care

could reasonably be provided, but where no unit

has been established or

• fail to reach a stoke unit bed in a hospital with a

stroke unit.

There are also variations in adherence with important

clinical care processes at all sites. These variations are

likely to be correctable.

Early indications are that the SCAP program is

addressing unwarranted clinical variation by improving

stroke bed access and adherence with important

bedside clinical processes.

During feedback sessions, clinicians and managers

frequently commented that the SCAP process had

provided the most comprehensive and relevant

information they had received on their clinical practice

and health service delivery. By providing reliable service

data and reaching out face-to-face across NSW, the SCAP

process has increased the profile of unwarranted clinical

variation in general and demonstrated that unwarranted

clinical variation is a local issue with local solutions.


Section 2

Academic 3,4,5,6,7 and BHI data2 indicate that NSW stroke outcomes have been improving, and

compare favourably with OECD countries.

From academic studies and audit it is apparent that improvements have been achieved by projects intended

to improve stroke care in NSW. As well as hospital- and local health district (LHD) -led projects, more widely

implemented projects have included:

• the NSW Stroke Network audit process which has collected stroke care data from medical records since 2000

• metropolitan stroke unit roll-out and enhancement to 22 NSW stroke units to create Stroke Services NSW,

(SSNSW) the NSW Stroke Network, in 2003

• the Rural Stroke Project (RSP) 2007, which enhanced nine hospitals to create new rural stroke units and services and

the formation of the Rural Stroke Network

• the Early Access to Stroke Reperfusion project, which is a major pre-hospital and hospital redesign carried out

with Ambulance Service NSW (ASNSW) to create 22 acute thrombolysis centres (ATCs) to improve access to

clot-busting through ambulance identification of stroke, hospital bypass and improved site readiness.

• the State-wide Stroke Clinical Variation Strategy (SSCVS) and Stroke Clinical Audit Program (SCAP) which, while has

further increased; the number of stroke units and ATCs, stroke unit bed access, the use of hospital bypass and

improved adherence with good bedside process through extensive quality improvements at 30 NSW hospitals.

Age-standardised rate of mortality per 100 patients

aged 45 years and over

0

10

5

15

20

25

30

40

35

New Ze

aland

United K

ingdom

NSW

Nether

lands (

2010

)

Swed

en

Norway

Ishaemic stroke

Haemorrhagic stroke

NSW – Ishaemic stroke

NSW – Haemorrhagic stroke

Figure 2. Age-sex standardised 30-day mortality rate, in hospital and out of hospital

The Bureau of Health Information (BHI) analyses did not provide an explanation for the observed outcome

variation. In reviewing the BHI reports it was widely agreed that the causes of any such variation needed to be

explored and addressed site-by-site. This process is part of the statewide SSCVS developed as a constructive

response to the 2012 and 2013 BHI reports.1,2

Introduction


0.00 20 40 60 80 100 120 140 160 180 200 220

0.8

0.6

0.4

0.2

1.0

1.2

1.4

1.6

1.8

2.0

2.2

2.4

2.6

3.2

2.8

3.0

Ris

k-s

tan

dard

ised

mo

rtali

ty r

ati

o(O

bse

rved

/ exp

ect

ed

)

Expected number of deaths within 30 days

Higher mortality

No difference

Lower mortality

90% limits

95% limitsNSW

Manly Hospital

Belmont Hospital

Concord HospitalPrince of Wales Hospital

John Hunter Hospital

Moruya HospitalLismore Base Hospital

Tamworth Base HospitalDubbo Base HospitalCoffs Harbour Base Hospital

Nepean HospitalRoyal Prince Alfred Hospital

Westmead Hospital

Figure 3. 30-day ischaemic stroke mortality 2009–2012, BHI

Internationally the collection of patient-level data, through site audits, has been used to detect or investigate

unwarranted clinical variation and as a quality improvement tool. Analysis of patient-level data is the only effective

means of investigating and validating unwarranted clinical variation reported from the analyses of less granular

routinely collected data. The investigation of local sites was seen by the ACI, BHI, NSW Stroke Network and the

Reducing Unwarranted Clinical Variation (RUCV) Taskforce as the ‘next-step’ towards understanding the factors

that account for good and poorer outcomes reported in the screening analyses published by BHI.

It was thought that the source of BHI reported clinical variation, where it existed, would be multifaceted. Ensuring

access to stroke unit beds and the quality of care provided by stroke units is known to be challenging, even where

hospitals provided organised stroke care. Audit data from the UK National Sentinel Audit of Stroke found that only

46% of units (N=170) provided the audit’s five desired characteristics of a stroke unit, 26% provided four and 28%

offered three or less. Patient access to stroke unit beds at audited sites was found to be limited.8


The ACI NSW Stroke Network has used audit to assess quality of care for more than 10 years,

auditing over 5500 case records before undertaking the SCAP.

In ACI’s direct response to the BHI reports of clinical variation a senior clinical advisor (ACI stroke clinical lead) an

expert in both clinical stroke care and stroke outcomes analyses was appointed. The function to develop, implement

and test a widely applicable clinical network based methodology. In conjunction with the UCV Taskforce and ACI's

Stroke Network a proposal was developed for voluntary supervised site-by-site audits of stroke care. The audit was

supported by skilled data analysis and benchmarking by a Florey Institute team. This written report was provided to

local clinicians and managers prior to feedback sessions.

COLLATED REPORT

SITE AUDIT

LOCAL EXECUTIVE

COMMUNICATIONS

LOCAL FEEDBACK

IMPROVEMENT PLAN

COLLABORATIVE FEEDBACK

(STATEWIDE)FLOREY

ANALYSIS

Figure 4. ACI stroke clinical audit process

A further key element was face-to-face feedback of Florey-reported data and additional site relevant analyses and data

provided through the ACI stroke clinical lead. Peer feedback was intended to inform a discussion of local priorities and

the feasible local solutions needed to address unwarranted clinical variation.

Based on experience from ACIs Early Access to Reperfusion program in stroke thrombolysis, the site presentations

were to be made in a meeting of clinicians and managers (and where possible with representatives of ASNSW)

involved in, and responsible for, the local stroke patient journey (Figure 5). The senior peer presentation by the ACI

stroke clinical lead was to be followed by a discussion, facilitated by the stroke network manager and a senior local

clinician, to identify and commit to locally devised quality improvement processes intended to improve stroke care

and stroke outcomes. The collectively supported processes would be recorded and further facilitated by the SCAP

team. In the SCAP these locally devised quality improvement processes are provided to the ACI chief executive for

formal communication to the chief executives of the participating LHDs.

Pilot phase

In the development phase of the pilot (Table 1) the SCAP clinical lead and other senior NSW Stroke Network

clinicians, the stroke network manager and representatives from the Florey Institute substantially revised the

existing ACI stroke audit tool. Revisions ensured the SCAP tool:

• assessed the latest evidence-based practices in the investigation and clinical care of stroke patients (e.g. fever

management)

• collected relevant patient level outcomes assessable by medical record audit

• measured adherence to those clinical processes expected to improve clinical outcomes.

The SCAP tool was also modified to examine transfer processes, allow validation of the ICD-10 coding underlying

the BHI analyses and assess any impact of in-hospital strokes.

Method

Section 3


Figure 5. The pilot timeline for responding to stroke care unwarranted clinical variation

The proof of concept pilot project included six hospitals, three rural and three metropolitan, with differing levels of

organised stroke care and either a low or relatively high estimate of 30-day mortality in the 2012 BHI analysis. The

pilot analyses, presented separately, demonstrated variable adherence with clinical processes expected to impact on

patient outcomes and widely variable access to stroke unit beds. Lessons from the pilot led to refinements in the

process, especially to the site feedback sessions and informed the future BHI analyses published late in 2013. These

lessons and the pilot data were presented to the UCV Taskforce, including the chief executives of the BHI and ACI

prior to approval to proceed with the SCAP.

Figure 6. A SCAP audit feedback session with managers and clinicians

With the approval of the UCV Taskforce the pilot formed the basis of, and provided the impetus for, the resulting

ACI-funded SCAP program. The pilot also demonstrated that the BHI analyses should be altered from attributing

death to the last hospital providing care to the first hospital providing care.

DATA

LHDENGAGEMENT

AUDIT ANDANALYSIS

QI

• Identification of clinical variation in ischaemic stroke• Health Care in Focus (BHI) – published December 2012• Meeting with the UCV Taskforce• Ongoing process to refine ascertainment, analysis, reporting• Work group meetings of ACI and BHI representatives.

• ACI letters to LHD CEs and clinician leaders – 7 March 2013• Clinical Variation Workshop – ACI, BHI, UCV Taskforce – 3 April 2013• Workshop feedback on required reporting and QI processes.

• Expert Reference Group to discuss site audit tools and processes. BHI, ACI and SSNSW and the Florey and Ingham Institutes – first meeting 22 April 2013

• Updated ACI audit tool and access of other site data – 28 June 2013

• Implementation team plan pilot site visits – 10 May 2013• Invitation letter to LHDs for participation in the QI process• Pilot site audits began 7 July and site visits started 7 August 2013• Audit results and further consultation refined further BHI data analyses.


The process

A summary of the administrative progress of the SCAP program including ethics applications and site specific

assessment (SSA) applications to local health district governance, audit dates, completion of reports and dates of

local feedback presentations, as of April 2016 is presented in Table 1.

Table 1. The SCAP program timetable, as at April 2016

Ethics Date submitted

Ethics amendment submitted to Hunter New England Ethics Committee: allowed Cowra Hospital to have another audit cycle, as it was part of the Rural Stroke Project 16/7/2014

New low and negligible risk multi-site ethics application (AU/6/4A0C18) submitted to the Hunter New England Ethics Committee for all metropolitan sites and to cover rural sites moving forward 4/12/2014

Ethics amendment submitted to Hunter New England Ethics Committee to cover addition of two Hospitals 23/5/2015

Hospital SSA submitted Audited Report producedHospital presentation

Hospital 23 16/7/2014 July 2014 October 2014 November 2014

Hospital 3 16/7/2014 September 2014 October 2014 November 2014

Hospital 26 16/7/2014 July 2014 October 2014 November 2014

Hospital 29 16/7/2014 July 2014 October 2014 March 2015

Hospital 2 16/7/2014 September 2014 November 2014 February 2015

Hospital 22 16/7/2014 September 2014 November 2014 December 2015

Hospital 10 16/7/2014 November 2014 February 2015 March 2015

Hospital 6 16/7/2014 November 2014 February 2015 March 2015

Hospital 20 16/7/2014 November 2014 March 2015 May 2015

Hospital 21 16/7/2014 December 2014 March 2015 May 2015

Hospital 1 26/2/2015 March 2015 May 2015 July 2015

Hospital 11 29/4/2015 March 2015 October 2015 May 2016

Hospital 9 31/3/2015 April 2015 June 2015 June 2016

Hospital 5 3/3/2015 April 2015 June 2015 July 2015

Hospital 18 31/3/2015 May 2015 July 2015 October 2015

Hospital 24 27/5/2015 May 2015 October 2015 February 2016

Hospital 30 31/3/2015 May 2015 September 2015 October 2015

Hospital 8 13/5/2015 June 2015 August 2015 November 2015

Hospital 12 29/4/2015 September 2015 November 2015 March 2016

Hospital 7 28/5/2015 August 2015 October 2015 January 2016

Hospital 17 9/6/2015 August 2015 October 2015 November 2015

Hospital 15 16/3/2015 October 2015 December 2015 February 2016

Hospital 13 16/3/2015 October 2015 December 2015 April 2016

Hospital 19 9/12/2015 February 2015 March 2015 April 2016

Hospital 25 9/12/2015 February 2015 March 2015 April 2016


Overview of analyses

The pilot and SCAP process involved 30 hospitals and

the analyses for each site were completed by April 2016.

In this report hospitals have been de-identified and

numbered from 1 to 26 in a ranking from lowest 30-day

mortality estimate to highest estimate using the BHI

estimates (where available). The four low-volume sites

without a BHI estimate have high crude mortalities

calculated from audit data and are ranked from 27 to

30 according to crude mortality. Hospital 30 is included

in the discussion of patient flows and excluded from

the analyses owing to a very small number of patients

eligible for audit (N=5).

In all, six sites underwent pilot audits, 24 sites were

audited with the SCAP tool including three original

pilot sites and three sites underwent a baseline audit.

The baseline audit tool is very similar to the SCAP audit

tool but does not address some measures such as rate

of discharge antithrombotic prescription (although this

was available from one site) and swallow assessment

within four hours.

Enhanced sites in the analyses are those where there

has been a local or externally supported development

of specialised stroke care to create a stroke unit or a

stroke service (Table 2). There were 12 metropolitan

hospitals, all of which were enhanced with acute stroke

units (ASUs) (N=784 record audits); two of the 12 have

only undergone a pilot audit. There were 18 audited

rural hospitals, one only underwent a pilot audit. Nine

rural sites were enhanced (N=510 record audits) and

nine were unenhanced (N=499).

Table 2. Audit sites by location, type and number of patients audited

Hospital

Enhanced(number of audited patients)

Unenhanced(number of audited patients) Total*

Rural 9 (510) 9 (499) 18 (1009)

Metropolitan 12 (784) – 12 (784)

All sites 21 (1294) 9 (499) 30 (1793)

* One site is not included in the analysis due to small patient volume

For the purpose of this draft report, pilot results are

presented separately and may also (where stated) be

combined with SCAP audit results in analyses, graphs

and figures. Some analyses will (where stated) include

earlier ACI stroke audit results, including data from the

earlier Rural Stroke Project 3, reports of the BHI on

clinical variation in stroke 1,2 and Health Information

Exchange (HIE)-based admission data, provided by the

ACI’s Health Economics and Evaluation Team (HEET).

The following 13 clinical processes make up the majority

of adherence measures in the SCAP analyses.

1. Direct admission to an ASU, CCU or ICU

2. Brain imaging within 24 hours

3. Use of a stroke clinical pathway

4. Regular neurological observations for 24 hours

from admission

5. Swallow assessment within 4 hours

6. Physiotherapy within 24 hours

7. Speech therapy within 24 hours

8. Occupational therapy within 24 hours

9. Multidisciplinary family meeting within seven days

10. Aspirin within 24 hours of ischaemic stroke

11. Prophylactic heparin if unable to walk

12. Discharge on antithrombotic if ischaemic stroke

13. Discharged on a statin if ischaemic stroke

(newly commenced).

An analysis was subsequently conducted and an

average clinical process percentage has been

calculated for each hospital (Appendix 1). A score of

100% is an indication of adherence to all bedside

evidence-based care (Appendix 1). The average clinical

process score was measured across 8 domains of

clinical care with equal weighting provided to each

domain. This has then been plotted against 30 day

mortality following hospitalisation for ischaemic

stroke data from BHI Insight Series: July 2009 to June

2012. Clinical audit mortality data was used for

hospitals 27, 28, 29 due to BHI data not available as

less than 50 patients in timeframe.


The following eight clinical process indicators were

used in the calculation and plotted in the reticular

graphs on page 25 and 26:

1. admission to a stroke unit/ICU/HDU bed

2. the use of a stroke pathway

3. regular neurological observations for 24 hours

4. swallow assessment within 4 hours

5. administration of aspirin within 24 hours

6. venous thromboembolism prophylaxis (VTE),

heparin if unable to walk independently

7. discharge prescribing of antithrombotics

8. discharge prescribing of statins (newly

commenced).

Full site audit outcomes data for all the sites can be

found in Appendix 2. Data for the following five care

processes was not fully available for inclusion in the

calculation: brain imaging (within 24 hours);

physiotherapy, speech therapy and occupational

therapy within 24 hours; and multidisciplinary family

meeting within seven days.


Pilot study results

Clinical process adherence

The pilot study carried out audits on six volunteer

hospitals: three metropolitan (numbered 1–3) and three

rural (numbered 4–6). The pilot hospital numbering

does not relate to the numbering of hospitals in the

SCAP analyses shown elsewhere in the summary. The

sites were selected for their widely-differing BHI

mortality estimates and widely-varying levels of

organised stroke care. As the pilot was a proof of

concept it was hoped that audit of bedside processes

would provide an explanation for unwarranted clinical

variation suggested by BHI published 30-day mortality

reports, identifying factors that need to be addressed

to improve stroke patient outcomes, site-by-site and

across the whole health service.

The BHI ischaemic stroke mortality estimates from 20121

attribute the mortality to the final hospital in the

patient journey (contiguous with an acute stroke

presentation), adjusted for patient age, sex and co-

morbidities to produce an adjusted mortality rate

presented as a risk-standardised mortality ratio (RSMR),

which is a hospital-specific risk of death benchmarked

against the arithmetic mean for NSW.

The tabulation of pilot audits in Table 4 suggests that

hospitals with higher mortality estimates had lower

adherence with important processes of care such as access

to a stroke unit bed (known to improve outcomes by

30%),4 use of a stroke pathway (known to reduce severe

stroke complications),15 as well as observations, swallow

assessment, prescribing and other factors expected to

impact on outcomes and patient experience.

Pilot hospital 1, a major metropolitan hospital providing

a stroke unit and 24/7 thrombolysis had a high 30-day

mortality estimate of 21%. It did not use a stroke

pathway, had lower rates of early swallow assessment,

aspirin and statin prescribing, and low rates of carotid

ultrasound. However, it had a number of processes with

very high adherence including 100% access to stroke

unit beds among audited cases, which would be

expected to result in favourable outcomes (Tables 3 and

4). This raised the question of the impact of individual

factors including the use of a stroke pathway on

mortality estimates.

Pilot hospital 2 (another major metropolitan hospital)

provides a stroke unit and 24/7 thrombolysis. This

hospital had a relatively good 30-day mortality in BHI

estimates (8.2%) and relatively good adherence with

process. However, from the audit it became apparent

that patients receiving palliative care were often

transferred off-site and these deaths were not being

captured in the BHI estimates. The BHI has subsequently

attributed mortality to the hospital of first

presentation. Using the latter method the mortality

estimate was 11%, which remains favourable, and in

line with good process adherence seen in the audit

(Tables 3 and 4).

Analysing the mortality rate according to the hospital

of first arrival has a number of advantages. It

acknowledges that ambulances can be tasked to bypass

hospitals without organised stroke care and transfers

can be facilitated for those arriving by private transport

to ensure better access to hospitals with stroke units. It

also excludes the impact of transfers from other

hospitals on mortality estimates.

A summary of adherence with clinical processes from

site audits of the six pilot hospitals is presented in Table

3. Red numbers indicate either high mortality estimates

or low adherence with important stroke care processes,

such as direct access to stroke beds, use of a stroke

pathway and adherence with neurological observations.

Pilot hospital 3 a non-tertiary referral metropolitan

hospital that provides a stroke unit for itself and a

neighbouring hospital; and pilot hospital 6 is an

enhanced rural site with a SU and ATC, providing 24/7

thrombolysis. Both hospitals had favourable levels of

adherence with important processes of stroke care and

favourable outcome estimates.

Section 4

Results


Pilot hospitals 4 and 5 were rural hospitals with poor levels of adherence with process and high 30-day mortality

estimates. Neither hospital had organised stroke care. Hospital 5 had no on-site CT scan and only 36% of pilot

hospital 5’s stroke patients had a record of receiving an urgent brain CT scan. As a result of audit feedback provided

to pilot hospital 5, clinicians and managers immediately undertook a quality improvement program. Within weeks,

the hospital introduced a stroke pathway and initiated local solutions to address other sources of unwarranted

clinical variation. As result of the pilot, hospital 4 undertook a major service enhancement, establishing a new

stroke unit and ATC, greatly improving stroke bed access and adherence with key bedside processes.

Table 3. Pilot hospital adherence to clinical processes

Hospital(mean age)

BHI 30-daymortality

SU/HDUbed(%)

24 hrNeuroObs (%)

StrokeClinicalP’way (%)

Swallow test < 4 hrs (%)

Discharged (D/C) on A’thrombotics(%)

Aspirin at 24 hrs (% IS)

PalliativeCare (N)

D/C on Statin (%)

1(71 yrs) 20.7 100 100 0 25 78 44 0 28

2(69 yrs) 8.2 100 95 45 70 84 58 3 63

3(80 yrs) 9.2 63 63 85 20 93 60 2 60

4(74 yrs) 19.1 0 55 80 10 71 47 0 43

5(81 yrs) 30.6 0 9 0 0 80 20 3 20

6(71 yrs) 9.6 100 100 75 40 100 72 0 67

This second audit included a period either side of the inception of its stroke beds but shows substantial improvement

in process adherence (Figure 7). In further auditing, using the National Stroke Foundation tool (completed to

February 2015), 95% of patients were reaching pilot hospital 4’s new stroke unit beds. However, the average time on

the stroke unit was limited and this is now being addressed in a local process. Specific process adherence had further

improved by the time of the Stroke Foundation (SF) audit. For example, estimated aspirin prescribing within 24 hours

was 95% and discharge antithrombotics prescribing was 100% in the small sample audit.


Table 4. Pilot sites, audit dates, hospital type and details of process adherence

Site and date Type

Adjusted mortality % Selection of audit characteristics

Hospital 114 August

Principal referral ATCN=353 20.7

July–Aug 20113 transfers in. Nil reported palliative. Rapid CT brain; rate 100%. 100% reached stroke unit or HDU. 100% neuro obs in 1st 24 hours. Low rate of cardiac ultrasound 30%. No use of a clinical pathway. Only 78% on antithrombotics at discharge. 44% on aspirin in 24 hours. Documentation of swallowing at 4 hours 25%.

Hospital 27 August

Principal referral ATC N=289 8.2

Aug–Nov 20111 transfer in. 1 documented for palliative care and 2 transfers to a palliative care facility. Rapid CT brain; rate 100%. 100% reached stroke unit or HDU. 95% neuro obs. Cardiac ultrasound TOE + TTE 76%. Clinical pathway 45%. 84% on antithrombotic on discharge. 58% on aspirin in 24 hours. Swallowing documentation < 4 hrs 70%.

Hospital 314 August

Non-principalMetro. SU N=138 9.2

July 2011–Jan 2012Note: major service changes. No transfers in. Two documented as palliative care. 63% reached the stroke unit. TOE + TTE 97%. 63% neuro obs. 85% on a clinical pathway. 93% on antithrombotics at discharge. 60% on aspirin at 24 hours. Swallowing documentation < 4 hrs 20%.

Hospital 415 August

Rural no SU N=197 19.1

April–June 20127 transferred in. Nil documented palliative. CT 95% < 24 hours. No stroke unit. Neuro obs 55%. Low rate of cardiac echo. 80% clinical pathway (new stroke co-ordinator). 71% on antithrombotics at discharge. 47% on aspirin in 24 hours. Swallowing documentation < 4 hrs 10%.

Hospital 529 August

Rural no SU N=83 30.6

July 2011–May 2012 (N=11). High rate of missing data.1 transfer. 3 palliative care. No on-site CT. 36% documented CT < 24 hours. No stroke unit. Neuro obs 9%. No cardiac echo. No documented carotid imaging. No clinical pathway. 80% on antithrombotics at discharge. 20% on aspirin at 24 hours. Documentation of swallowing < 4 hours 0.

Hospital 630 August

Rural ATC N=213 9.6

Aug–Nov 2012 55% transferred in. All with protocols. Delays in transfer post onset. No documented palliative care. CT 100% < 24 hours. 100% reached stroke unit. Cardiac echo > 95%. 100% neuro obs. 75% clinical pathway. 100% on antithrombotics at discharge. 72% on aspirin at 24 hours. Documentation of swallowing < 4 hrs 40%.

Lismore clinical process adherence and access 2012 vs 2013-14

SU/HDU/ICU

24 hr NeuroObs

Stroke Clinical Pathway

Speech path < 24 hrs

DC Antithrombotics

Aspirin < 24 hrs

DC on Statin

VTE Prop.

Brain imaging < 24 hrs

Care plan

Physio < 24 hrs

OT < 24 hrs

Swallow < 24 hrsPilot 2012

%adherence

SCAP 2013–14

20

0

40

30

10

60

50

80

100

90

70

Figure 7. Pilot hospital 4: Clinical process adherence and access (2012 vs 2013-14)


Pilot conclusions

No single audited site in the pilot process had uniformly

good adherence with important processes likely to

impact on patient outcomes, including those sites with

relatively favourable BHI estimates of 30-day ischaemic

stroke mortality. The pattern seen in the pilot suggests

that outcomes can be improved at all hospitals

providing stroke care in NSW.

The pilot process indicated that clinical variation in

stroke was also explicable unwarranted clinical

variation. At present, stroke patients do not always

receive evidenced-based care. This may be the result of:

• being admitted to a smaller hospital with no

organised stroke care and little prospect of

providing it

• admission to a hospital where stroke unit care

could reasonably be provided but no unit has been

established

• patients failing to reach stroke unit beds in a

hospital with a stroke unit or

• variations in the quality of care delivered in existing

stroke units.

By identifying variation in adherence with important

clinical processes, in the pilot, local clinicians and

managers have improved access to stroke beds and

improved bedside care.

Stroke clinical audit process

All SCAP audits, analyses and hospital feedback sessions

were completed by August 2016 (Table 1).

Patient characteristics

Compared with enhanced sites providing specialised

stroke care the unenhanced sites audited in the SCAP

program treated older patients, with lesser levels of

preadmission independence and more severe strokes.

The unenhanced hospitals admitted a greater

proportion of haemorrhagic strokes, had less access to

important stroke investigations and more missing data

than enhanced sites. Twelve per cent of stroke patients

at the unenhanced sites were admitted to a HDU, CCU

or ICU bed, the remainder were managed in a general

ward bed.

The greater severity of stroke at unenhanced sites may

reflect relatively low use of MRI scanning (as explained

below). Additionally, a lack of organised stroke care is

expected to result in more severe stroke and more

frequent stroke progression. The apparent difference in

severity may also reflect unaccounted-for factors, such

socioeconomic status (SES).

Our SCAP analyses do not take account of SES.

Although SES has been shown to influence

intracerebral haemorrhage (ICH) outcomes in a state-

wide NSW cohort.5 At a hospital level BHI has not

shown an impact of SES in their site by site outcome

data for ischaemic stroke.

Enhanced and unenhanced rural sites had a greater

proportion of stroke patients identifying as Australian

(88 and 71% respectively) compared with audited

metropolitan sites (51%).

Where MRI brain imaging is used more frequently,

there is a risk that patients with clinical transient

ischaemic attack (TIA) diagnoses, having no disability

and no risk for usual stroke complications, are being

reclassified as strokes. (Over 30% of TIAs will have small

stroke changes on MRI.) With increasing use of MRI this

reclassification would reduce the average stroke

severity across audits. Improved primary and secondary

prevention (which in AF-related stroke reduces both

stroke rate and stroke severity) may also explain the

observed reduction in stroke severity seen at most sites.


Investigations

The ACI stroke audits have long measured the use of

desired investigations for stroke patients as a quality

measure. The SCAP audit measures the percentage with:

• CT brain

• MRI, brain imaging within 24 hours

• chest X-ray (CXR)

• 12 lead ECG

• echocardiography (TTE and TOE)

• imaging with carotid ultrasound and angiography.

The timely use of these tests may depend on their

inclusion in pathways, including nominated electronic

medical record orders, individual physician practice and

often the availability of these tests, in and out of hours.

The results of the recommended investigations can have

important impacts on acute and subsequent

management of stroke patients.

Recording of off-site investigations

At some sites some imaging is accessed off-site, which

can include privately-provided services performed on

the hospital site. These off-site investigations included

MRI, and stroke-associated cardiac investigations (TTE

and TOE) and carotid ultrasound. Off-site investigations

were recorded in the audit if they were documented in

the medical record. At several sites (including hospitals

13 and 20) local clinicians and managers reported

significant use of off-site echocardiography and carotid

duplex services. However, it was not clear from the

audit or discussion in the feedback session as to who

received or acted on the results, which were not

documented in the audited patient record. This was a

quality improvement issue at several hospitals.

Interim comparison of investigation rates

On average at unenhanced sites:

• 90% of patients received a CT scan at some times,

with 74% of patients receiving brain imaging

within 24 hours

• 1% of patients received an MRI

• 92% an ECG

• 24% an echocardiogram

• 36% a carotid ultrasound.

Overall there is highly variable and generally low

documentation of carotid imaging and cardiac

echocardiography at both enhanced and unenhanced

sites. Investigation with CXR and ECG is likely lower

than appropriate across the three groups.

Figure 8 indicates investigation rates from rural

unenhanced and unenhanced site audits and

metropolitan enhanced sites analysed to April 2016. In

this analysis, the average percentage undergoing

echocardiography and carotid ultrasound was low

across all groups, enhanced and unenhanced, being no

higher than 49 or 72%, respectively, and as low as 21

and 31%, across unenhanced sites. Rates were variable:

some individual sites such as hospital 1 (metro) and

hospital 6 (rural) had rates over 90% for carotid

imaging and echocardiography. Two sites had no

documented carotid ultrasounds (hospitals 28 and 29)

and two sites had no documented echocardiography

(hospitals 20 and 29). Although these tests may have

been accessed off-site they were not reported in the

clinical record.

Overall there is highly variable and generally low

documentation of carotid imaging and cardiac

echocardiography at both enhanced and unenhanced

sites. Investigation with CXR and ECG is likely lower

than appropriate across the three groups.


Percentage%

0%

20%

40%

60%

80%

100%

MRI

Angiogra

m

CT sca

n

Carotid

ultras

ound

Echoca

rdio

graph

ECG

Chest x

ray

Metropolitan Enhanced

Rural Enhanced

Rural Non-enhanced

Figure 8. Baseline audit investigation rates (as at April 2016)

Brain imaging

On-site urgent brain imaging, with 24/7 CT scanning

availability is an absolute requirement for stroke unit

inception. In the Early Access to Stroke Thrombolysis

program, acute thrombolysis implementation requires a

CT radiographer to be on-site at all times. In the audit

reports, both CT brain and MRI brain are combined to

measure brain imaging completed within 24 hours. At

enhanced sites documented brain imaging within 24

hours is generally over 95% and often reaches 100%. At

unenhanced sites the average documented access to CT

is 90% with MRI access of 1%. Variation in urgent CT

scanning was high. At unenhanced hospitals 28 and 29,

only 36 and 43% had documentation of brain imaging

within 24 hours.

Carotid imaging

Imaging of the carotid arteries in ischaemic stroke and

TIA patients is regarded as important and urgent for

identifying those needing rapid revascularisation with

carotid endarterectomy,9,10 and less commonly carotid

stenting. In the case of TIA, endarterectomy can be an

emergency procedure,11 and in non-disabling stroke

revascularisation is usually recommended within two

weeks. Accordingly, in Denmark there is an audited

time limit for carotid imaging in acute stroke and TIA of

four days. Mandated urgency has greatly increased the

timely access to revascularisation in Denmark from 13%

to 47%.12 Delays in revascularisation, such as occur with

limited access to carotid imaging, will worsen average

patient outcomes.

In the SCAP audit tool, carotid imaging is indicated by

documented completion of a carotid ultrasound or

angiogram, usually a CT angiogram. However, at some

sites the SCAP audit measures may underestimate

carotid imaging. Those investigated with MRI often

undergo a coincident magnetic resonance angiogram

(MRA) of the carotids. As an example, hospital 5 has

good access to urgent MRI (49%), with carotid

ultrasound and angiography rates of 16% each. In some

cases MRI may have replaced other specific carotid

imaging. Considering this possibility, we have asked

clinicians at hospital 5, and other sites with an apparent

fall in carotid imaging, to confirm if MRI with carotid

MRA is making up for some of the apparent carotid

imaging shortfall.


Chest X-ray

Patient access to CXR varies between 40 and 100% across sites. CXR changes in stroke are both common and

important. CXR is a desired investigation in all suspected stroke patients at presentation. Over 60% of stroke

patients have oxygen desaturation 13 as a result of central and obstructive apnoea, stroke related Cheyne-Stokes

breathing and underlying end organ injury or decompensation, such as chronic airway limitation, fibrotic lung

changes, cardiac failure and malignancy. As well as underlying and acute-on-chronic pulmonary disease and

breathing disorders, aspiration pneumonia is a major, often fatal, complication of acute stroke requiring urgent

identification and care (Figure 9 and 10).4,6,13,14,15 All of these factors are important considerations when providing

acute and long-term management of stroke patients, and routine investigation with CXR has considerable value.

Source: Silver et al. 28

Figure 9. Causes of death in the weeks after stroke

Figure 10 highlights data from the NSW Stroke Network’s retrospective medical record audit of 5413 stroke patients

in acute NSW public hospitals throughout 2000–2014 [median age 78 years (Q1: 68, Q3: 84), 51% male and 93% with

ischaemic stroke].14 It shows that pneumonia is a common and often fatal complication of stroke.

Percentage

>1 sev

ere

com

plicat

ion

Seco

nd

strokeSt

roke

proges

sion

Pneu

monia

Urinar

y

infe

ctionFa

ll0

10

20

30

40

50

Stroke progression can be mimicked by raised intracranial pressure, dehydration, other metabolic disturbance and sepsis and is observed to be relatively low in well organised services.

Figure 10. Stroke complications 2000–2014


ECG and cardiac monitoring

A 12-lead ECG is an essential investigation, although

rates varied and this possibly explains differences in

atrial fibrillation ascertainment observed between

audit sites. About 60% of stroke and TIA patients have

an ECG abnormality,17 with the ECG assisting in the

diagnosis of atrial fibrillation, heart block and other

end-organ injury such as left ventricular hypertrophy,

transmural infarction and coronary ischaemia. The

additional of cardiac monitoring, using Holter or

telemetry increases the important detection of atrial

fibrillation which requires very specific management.

Echocardiography

Emboli from the heart (cardioembolic strokes) are the

major source of fatal and disabling stroke and those

with cardioembolic strokes have high rates of

recurrence. Cardioembolic stroke from atrial fibrillation

and ventricular wall motion abnormalities due to heart

attack and cardiac failure can be prevented by selective

use of anticoagulants. Management choices are guided

by echocardiography (transthoracic and

transoesophageal), 12-lead ECG, cardiac monitoring and

diagnostic judgement. Importantly the identification of

a cardioembolic source and subsequent use of

anticoagulants reduces the relative risk of stroke by

70% compared with 38% for standard antiplatelet

agents. TTE and TOE allow detection of:

• abnormal blood flow and in situ thrombus

• structural abnormalities of valves and chambers

• atrial septal defects and patent foramen ovale

(PFO)

• infective and marantic cardiac valve vegetations.

All of these are important when selecting the most

effective blood thinner and other secondary

prevention treatment.

Adherence with important bedside clinical processes

As well as assessing stroke investigations the SCAP audit

tool used in the pilot and SCAP audits has a major focus

on assessing adherence with bedside clinical processes

expected to improve outcomes and improve the stroke

patient’s journey. These processes reflect on the quality

of stroke care provided by our hospitals and broader

health service. The SCAP audit tool measures and

analyses a large number of processes and highlights:

• early admission to a stroke unit/ICU/CCU bed

• brain imaging within 24 hours

• regular neurological observations for 24 hours

• administration of aspirin within 24 hours

• allied health assessment by physiotherapist, OT and

speech pathologist within 24 hours

• the use of a clinical care plan and a stroke pathway

• prophylaxis of VTE

• multidisciplinary team family meetings

• discharge prescribing of antithrombotics and statins.

In addition other processes such as discharge planning

and education, patient transfers, use of transfer

protocols, fever management, and the providing of IV

and NG fluids in NBM patients are reported in feedback

to SCAP audited sites.

Unenhanced rural site audit results: clinical process adherence

None of the unenhanced rural hospital sites have stroke

units or are expected to use a stroke pathway, and

these two factors cannot be used to explain

unwarranted clinical variation within this group.

However, adherence with important bedside measures

including 24 hour neurological observations and VTE

prophylaxis (trendlines in Figure 11) seem to relate to

the mortality estimates. On average, in analyses up to

June 2015, adherence with 11 of 12 clinical care

processes was significantly worse at unenhanced rural

sites, compared with enhanced rural and metropolitan

enhanced audit sites (Figure 11 and 12). The hospitals

are all unenhanced rural sites, without organised stroke

care in the form of either a stroke unit or stroke service.

Hospitals are ranked left to right by increasing

estimated 30-day ischaemic stroke mortality.


Enhanced rural site audit results: clinical process adherence

The enhanced rural sites (N=9) have better overall mortality than unenhanced rural sites and are expected to

provide good access to stroke unit/HDU/ICU beds and have higher use of stroke pathways to guide bedside

treatment. However, both access to stroke unit beds and stroke pathway use is variable. In sites with lowest

estimated 30-day ischaemic stroke rates there is greater access to stroke unit/HDU/ICU beds and greater use of a

stroke pathway, as indicated in the two trendlines in Figure 12.

SU/HDU/ICU

24 hr NeuroObs

Stroke Clinical Pathway

Swallow < 24 hrs

DC Antithrombotics

Aspirin < 24 hrs

DC on Statin

VTE Proph.

Linear (24 hr NeuroObs)

Linear (VTE Proph.) * Ranked by crude mortality

Hospital16

Hospital19

Hospital21

Hospital22

Hospital25

Hospital27*

Hospital28*

Hospital29*

20

0

40

60

80

100

Ranked left to right from lowest to highest mortality

%

Clinical process adherence in 8 unenhanced rural sites

Figure 11. Clinical process adherence at the SCAP and baseline audit unenhanced rural sites

Process measures: 9 enhanced rural sites

Brain imaging*

Physio*

Speech*

OT*

Documented swallow*

Documented swallow**

MDT family meeting

Any SU/HDU

Stroke pathway

Clinical care plan

Linear (Any SU/HDU)

Linear (Stroke pathway)

* = < 24 hours

** = < 4 hours

20

0

40

60

80

100

Hospitals ranked from right to left by increasing estimated mortality

%

Hospita

l 20

Hospita

l 23

Hospita

l 26

Hospita

l 18

Hospita

l 17

Hospita

l 10

Hospita

l 6

Hospita

l 3

Hospita

l 2

Figure 12. SCAP audit results for the enhanced rural sites showing adherence with key processes


Enhanced metropolitan site audit results: clinical process adherence

All 12 metropolitan hospitals in the SCAP analyses were enhanced sites. Generally, across both the audited rural and

metropolitan enhanced sites, stroke patients had better access to a stroke unit/CCU/ICU bed, allied health disciplines

and family meetings with a multidisciplinary team, they were more likely to be placed on a stroke pathway, and

more likely to receive a new statin prescription at discharge than at unenhanced sites. However, not all enhanced

sites used a stroke pathway (e.g. hospitals 5 and 14) and direct access to a stroke unit/CCU/ICU bed was highly

variable. The trendlines for bed access and for use of a stroke pathway shown in Figure 13 suggest an association

with outcomes, declining across the 12 metropolitan hospitals as mortality estimates increase from left to right.

Overall adherence with important Stroke Clinical Processes declines from left to right. The solid red linear trend-line

indicates direct access to a stroke unit/HDU/ICU bed and the broken blue line the use of a stroke pathway, across

the 12 metropolitan sites. As mortality estimates rise from left to right, access to a SU/HDU/ICU bed and use of a

stroke pathway falls. Process measures: SCAP audits of 12 metropolitan hospitals

SU/HDU/CCU

24 hr Neuro obs

Stroke pathway

Swallow test < 24 hrs

% Discharged on Antithrombotics

Aspirin < 24 hrs

DC on new statin

%VTE P’laxis if mobile

Linear (SU/HDU/CCU)

Linear (Stroke pathway)

20

0

40

60

80

100

Ranked by increasing BHI 30-day mortality

%

Hospita

l 11

Hospita

l 12

Hospita

l 13

Hospita

l 14

Hospita

l 15

Hospita

l 24

Hospita

l 9

Hospita

l 8

Hospita

l 7

Hospita

l 5

Hospita

l 4

Hospita

l 1

Figure 13. Adherence with key clinical processes across the 12 metropolitan sites

Admission to a stroke bed is expected from academic work to improve NSW stroke outcomes by 30%,4 and the use

of a stroke pathway has been shown to reduce severe complications in NSW hospitals.15


Pooled enhanced and unenhanced site audit results: clinical process adherence

There were 30 unenhanced and stroke enhanced rural and metropolitan sites audited in the SCAP. A total of 1793

medical records were audited from 30 hospitals: 494 medical records from nine rural unenhanced sites, 510 records

from nine enhanced rural sites and 784 medical records were audited from the 12 enhanced metropolitan sites.

Hospital 30 was excluded from the formal analyses as only five records were eligible for review.

Hospitals are ranked 1–29 by increasing ischaemic stroke mortality (Figure 14). Overall there is reduced adherence

with key stroke care processes as estimated mortality rises across the 29 sites, from left to right on Figure 14. The

solid red linear trend-line represents direct access to a SU/CCU/ICU bed and the dashed blue line the use of a stroke

pathway. Both specialised bed access and use of a stroke pathway decline as estimated mortality rises. Clinical process adherence: Pilot and SCAP audited hospitals

20

0

-5

40

60

80

100

Hospital ranking by estimated 30-day mortality

Adherence%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Colours represent the key processes

Figure 14. Adherence with key clinical processes

The pooled audit results for key clinical processes are shown in Figure 14. An overall decline in adherence with

important bedside processes can be seen from left to right.


Assessment of swallowing

Stroke patients are often at risk of aspiration pneumonia due to stroke-related swallowing difficulty. Aspiration

pneumonia is a major cause of stroke patient mortality (Figure 9) and morbidity, and it is usually reduced by well-

organised stroke care.4,6,13 The SCAP audit tool uses two measures of swallowing assessment: swallow screening within

four hours and speech pathologist review within 24 hours. The assessment of swallowing within four hours, usually

performed by ED staff using the ASSIST swallow tool, was highly variable across sites, and often low (Figure 15).

This 4-hour benchmark and the speech pathology assessment within 24 hours benchmark are important quality

measures in the detection and reduction of aspiration pneumonia risk. A major reason for providing evidence-

based systems to provide early swallow screening is to ensure that in the first few hours individual clinicians do not

use unreliable ad hoc methods to decide if a stroke patient should or should not be nil by mouth.

There is high variability in the proportion of patients with documentation of their swallow ability or screening

within four hours of hospital arrival in interim analyses. In the SCAP audit analysis to June 2015, the rates of speech

therapy review within 24 hours at unenhanced sites, and post-enhancement metropolitan and rural sites were 32%,

68% and 57%, respectively, despite the importance of adherence with this process.

Pro

po

rtio

n w

ith

do

cum

en

ted

sw

all

ow

ab

ilit

yw

ith

in 4

ho

urs

of

arr

ival

at

ho

spit

al

(%)

Number of cases audited by hospital

20

0

40

30

10

60

50

80

100

90

70

20 40 60 80

Non-enhanced hospitals

Rural enhanced hospitals

Metro enhanced hospitals

Average

2SD limits

3SD limits

Figure 15. Documented swallow ability within four hours by hospital

There is high-level evidence that dehydration is associated with poor outcomes in stroke. When swallowing

assessments indicate a patient should be nil by mouth, replacement fluid by IV or naso-gastric tube is needed. In

the SCAP audit some patients at several sites did not receive fluid replacement for 48 hours, likely impacting on

patient outcomes.


Use of a stroke pathway

Stroke pathways have been shown to be associated

with a reduction in serious stroke complications in an

analysis of pooled ACI stroke audit data (N=5413).15

Pathway use was unexpectedly low in the SCAP audits

of unenhanced rural and enhanced metropolitan and

rural sites with an average of 8%, 45% and 83%,

respectively, in analyses up to June 2015. Only four of

the 30 SCAP audited sites used a stroke pathway in

more than 90% of their stroke patients.

Two major metropolitan hospitals, hospital 5 and

hospital 14 did not use a stroke pathway and two other

metropolitan sites had minimal use at 6 and 13%.

An issue identified at most enhanced sites was reduced

stroke pathway use when stroke patients went to

non-SU beds such as CCU, HDU and ICU.

Medically guided processes: adherence with

prescribing and ordering

It may be important that in early longitudinal analysis

some medically determined factors such as prescribing

and investigations did not maintain the improved

adherence initially seen with earlier site enhancement

or did not reach appropriate levels.

The use of VTE prophylaxis in those unable to walk is

poor. Hospital 13 was the best performing site using

VTE prophylaxis in 88% of those with difficulty walking.

Thirteen sites used VTE prophylaxis less than 50% of

the time and four sites including three with stroke units

(hospitals 4, 8 and 14) used VTE prophylaxis less than

30% of the time.

The acute commencement of aspirin after ischaemic

stroke has a strong evidence base and is expected to

modestly reduce stroke recurrence and venous

thrombosis with some risk of haemorrhage.18

Prescribing of aspirin within 24 hours of an ischaemic

stroke and of antithrombotics at discharge was often

less than ideal. Only one hospital, hospital 10,

commenced aspirin on the first day in more than 80%

of cases and prescribing was as low as 14% at hospital

29, an unenhanced rural site. Most commonly the rate

of aspirin commencement in the first 24 hours was

between 50-60%. A follow-up audit of hospital 25 has

shown that quality improvement processes around

prescribing can be effective, with early aspirin

prescribing increasing from 47% to 95%.

The prescribing of antiplatelet agents is expected to

reduce stroke recurrence by 13-27% and in those with

AF the use of an anticoagulant such as warfarin or a

new oral anticoagulant (NOAC) is expected to reduce

the risk of stroke by approximately 60-70%. Almost all

ischaemic strokes would be expected to be prescribed

antithrombotics (either antiplatelet or anticoagulant

agents) at discharge. Four of the 30 SCAP sites had

antithrombotic on discharge prescribing rates above

80%: hospital 1 (93%), hospital 4, hospital 26 and

hospital 28. Most SCAP audited sites were in the 70-80%

range and one unenhanced site, hospital 29, had a

prescribing rate of 46%.

The new prescribing of statins, appropriate treatment

for almost all ischaemic stroke patients, varied widely

between a high of 75% at hospital 1 to a low of 30%

at hospitals 14 and 28.

Changes in adherence over time

As some SCAP sites have been audited twice using the

SCAP audit program, some impacts of the pilot and

SCAP programs can be reported.

Pilot hospital 4 (hospital 25 in the SCAP analyses) is one

of four SCAP/pilot hospitals without a stroke unit,

including hospitals 16, 19 and 26, whose clinicians and

managers have committed to establish new stroke units

following SCAP program audit and feedback. Hospital 4

is the first of these hospitals to be re-audited after

inception of a new stroke unit, just 18 months after

their pilot audit.

A comparison of clinical process adherence between

hospital 4’s pilot audit (April–June 2012) and the

follow-up SCAP audit (January 2012–March 2014) is

shown in Figure 7. Although the follow-up audit period

fell either side of stroke unit inception there was

substantial improvement in access to stroke unit beds,

stroke pathway use and adherence, along with

improved adherence with other important individual

clinical processes (Figure 7); 65% of stroke patients

accessed stroke units within weeks of hospital 4/25’s

stroke unit opening and access has continued to rise on

subsequent review.

Longitudinal comparisons have validity although some

SCAP measured variables were not assessed in earlier

NSW Stroke Network tools. Comparisons can be reliably

made across the majority of SCAP variables as the


criteria for audit answers have been carefully mapped over time and the Stroke Network Manager has supervised

the past and recent audits.

Six of the nine enhanced rural sites had undergone baseline audit prior to participation in the Rural Stroke Project,

a post-enhancement audit as well as a more recent SCAP audit. Although the local implementation of RSP

enhancement was variable there were substantial overall improvements for the eight participating sites. There was

an increase in stroke unit bed access from 0 to 59%, discharge to home improved by 89%, aspirin prescribing within

24 hours increased from 59 to 71% and there was improved clinical pathway use and access to allied health.3

Figure 16 compares pooled data for the six enhanced rural sites in the SCAP analyses (hospitals 2, 6, 10, 17, 18 and

26) at each of three audit points: baseline (pre-RSP), post enhancement audit (post-RSP) and a recent SCAP audit.

Although enhancement did, on average, significantly improve clinical process adherence, not every improvement

was maintained or reached an acceptable level in these six hospitals.

0

20

40

60

80

100

OT in 24

hrs

of adm

issio

n

Clinica

l pat

hway

DVT pro

phalyxis

Fam

ily m

eetin

g

Dischar

ged o

n anti-

thro

mbotic

+

Spee

ch in

24 h

rs of a

dmiss

ion

Phys

ioth

erap

hy in 24

hrs

of a

dmiss

ion

Asprin

in 24

hrs+

Regular

neu

ro o

bserv

atio

ns

of a

dmiss

ion

Brain

imag

ing in

24 h

rs

of a

dmiss

ion

Admit

SU/IC

U/CCU

Pre-RSP

Post-RSP

SCAP

+ patients with ischaemic stroke

* signi�cant p < 0.05 in linear trend across audit periods

^ signi�cant p < 0.05 between post-RSP and current-RSP

*^ ^ * * *^ * *^ *^ * *^ ^

Figure 16. Pooled data analysis from enhanced rural sites (N=6)

In the six RSP program enhanced rural hospitals (Figure 16) included in the SCAP analysis, there were initial

improvements in brain imaging within 24 hours, aspirin commencement within 24 hours and antithrombotics

prescribing at discharge, which were not maintained at initial post-enhancement levels. These processes require

medical decision making. Initial improvement with maintained adherence was observed with 24-hour neurological

observations (nursing practice), access to speech therapy within 24 hours (allied health resource commitment) and

DVT/VTE prophylaxis which is a medically prescribed therapy. However prescribing of DVT/VTE prophylaxis, which

improved to an average of 57%, did not reach desired levels.

Processes which improved with enhancement and continued to improve through two post enhancement audits were:

• stroke patient admission to a SU/HDU/ICU bed (bed management and resources)

• access to physiotherapy and occupational therapy (allied health resources)

• use of clinical care and stroke pathways (nursing adherence)

• family meetings with the multidisciplinary team.

Although adherence with some processes improved after RSP enhancement they have not always reached

acceptable levels, even at sites with generally better adherence rates. According to the results shown in Figure 13 a

new strategy to target medical prescribing and ordering may be needed. At several sites there was good medical

attendance when feedback meetings were also held after hours, catered and with CPD points on offer.


Adherence to clinical process and mortality

The methodology for developing plots in Figure 17, 18 and 19 is outlined on page 10 of the methods. The ideal

score for clinical processes adherence is 100%

Sites with lower % mortality follow a general trend of having adhered to best practice clinical processes. As

mortality worsens adherence to clinical processes reduces. The series of figures 17, 18 and 19 demonstrate that no

hospital adhered fully to all clinical processes across either rural or metropolitan sites. They also demonstrate the

trend that adherence to clinical processes (measured across 8 domains) reduces your 30 day mortality % following

hospitalisation for ischaemic stroke.

Clinical process score (%)

30-day mortality following hospitalisation for ischaemic stroke (%)

Poly. (Clinical process score %)

*BHI 30 day mortality data not available audit mortality % used

0%

80%

70%

60%

50%

40%

30%

20%

10%

90%

100%

Hospita

l 13

Hospita

l 15

Hospita

l 17

Hospita

l 19

Hospita

l 21

Hospita

l 23

Hospita

l 25

Hospita

l 27*

Hospita

l 29*

Hospita

l 11

Hospita

l 9

Hospita

l 7

Hospita

l 5

Hospita

l 3

Hospita

l 1

Hospita

l 14

Hospita

l 16

Hospita

l 18

Hospita

l 20

Hospita

l 22

Hospita

l 24

Hospita

l 26

Hospita

l 28*

Hospita

l 12

Hospita

l 10

Hospita

l 8

Hospita

l 6

Hospita

l 4

Hospita

l 2

Figure 17. 29 NSW hospitals ranked from left to right by BHI risk standardised mortality

Unweighted Clinical Process adherence v’s BHI 30 day mortality % following hospitalisation for ischaemic stroke




0%

80%

70%

60%

50%

40%

30%

20%

10%

90%

100%

Hospita

l 11

Hospita

l 12

Hospita

l 13

Hospita

l 14

Hospita

l 15

Hospita

l 24

Hospita

l 9

Hospita

l 8

Hospita

l 7

Hospita

l 5

Hospita

l 4

Hospita

l 1

Figure 18. 12 Sydney Metropolitan Hospitals ranked left to right by BHI risk standardised mortality

Unweighted Clinical Process adherence for ischaemic stroke v’s BHI 30 day mortality % following hospitalisation for ischaemic stroke for 12 Sydney Metropolitan hospitals





*BHI 30 day mortality data not available audit mortality % used

0%

80%

70%

60%

50%

40%

30%

20%

10%

90%

100%

Hospita

l 20

Hospita

l 22

Hospita

l 25

Hospita

l 27*

Hospita

l 29*

Hospita

l 18

Hospita

l 16

Hospita

l 6

Hospita

l 2

Hospita

l 21

Hospita

l 23

Hospita

l 26

Hospita

l 28*

Hospita

l 19

Hospita

l 17

Hospita

l 10

Hospita

l 3

Figure 19. 17 Rural and regional NSW Hospitals ranked left to right by BHI risk standardised mortality

Unweighted Clinical Process adherence v’s BHI 30 day mortality % following hospitalisation for ischaemic stroke


Improving patient flows

NSW hospitals look after 11,000 strokes of all types per

year and only a minority of hospitals provide organised

stroke care.

There are 186 sites in NSW with some ED role

delineation, 79 of these with level 3–6 role delineation.

Forty nine NSW hospitals see more than 50 strokes of

all types a year, 33 hospitals see more than 100 strokes a

year and seven see more than 400 a year. At the

commencement of the SCAP process there were 30

acute stroke units across NSW and 9 other hospitals

providing stroke services. In January 2013, 22 ATCs,

nested among the 30 stroke units, went live to provide

24/7 ‘clot-busting’.

A stated goal of the SSCVS and its SCAP was to improve

access to organised evidence-based stroke care,

although access to such care can be a challenge.

There is a large numerical discrepancy between the 186

sites receiving acute patients and the 41 sites with

organised stroke care in NSW. Difficulty accessing

organised stroke care is an important source of

unwarranted clinical variation in stroke, given the 30%

outcome benefit of reaching such care.4 The pilot and

SCAP projects have engaged with local clinicians and

managers and the ASNSW to review patient flows with

a view to establishing hub and spoke models of care

needed to better access stroke unit beds, stroke services

and ATCs. When discussing stroke patient flow and hub

and spoke relationships, both clinicians and managers

have placed an emphasis on the importance of high

quality post-acute care and reverse flows.

In some areas of NSW, access to stroke unit bed after

arrival by private transport will require rapid transfer

away from a hospital of first presentation to a hub site

with organised stroke care. Where possible, best stroke

patient management should involve ambulance bypass

of hospitals without specialised stroke, following

identification of stroke in ambulance. In the SCAP

audits to date, the proportion of stroke presentations

arriving by private transport varied widely, between 2%

at hospital 22 to 49% at hospital 1. At spoke sites with

private transport arrivals the transfer processes to hub

sites with specialised stroke care need to be efficient to

minimise delays known to worsen outcomes.

Even at sites where inter-hospital transfers are regarded

as routine transfer, delays can be both common and

lengthy; the longest SCAP-documented transfer delay

was 23 hours. In the SCAP audits analysed to June 2015,

transfers were often informally arranged and usually

made without a transfer protocol. Only a minority of

sites used a transfer protocol.

The issues around inter-hospital flows, hospital bypass

and inter-hospital transfers have occupied considerable

discussion during the feedback at both hub and spoke

sites, including hospital 10 and hospital 29.

It is known that many stroke patients reach hospitals

without organised stroke management, such as the

unenhanced sites audited in the SCAP process: hospitals

16, 19, 21, 22, 25, 27, 28, 29 and 30. On average the

unenhanced sites in the SCAP analyses have low

adherence with the key clinical processes needed for

favourable outcomes. Improving access of local stroke

patients to organised care in these locations would

depend on either site enhancement or hospital bypass

to a nearby hub site, using a hub and spoke model.

Evidence-based practice, local data and factors

(including geography), and the preferences of local

managers and clinicians, are central in determining the

appropriate choice.

A detailed discussion of flows and enhancements in

two regional LHDs has been removed due to difficulty

de-identifying the individual hospitals in the detailed

maps and tables supporting the discussion.

Hospital 21 and hospital 3

The highest observed rate of transfers into an audited

hub site was 55% at hospital 3, and this is the closest

stroke unit and ATC to hospital 21. Hospital 21, an

unenhanced site, sees 67 strokes a year and received 12

transfers from other hospitals in the 2013–14 audit

period. According to BHI data, hospital 21 transferred

10 strokes out during the period 2009–12. The driving

distance to hospital 2 is 189 km. Hospital 21 is a low-

volume site, generally below the level of a sustainable

stroke unit. At this stage, hospital 21 is attempting to

adopt a model where most strokes are admitted to the

CCU unit, hospital 2 uses this model and has good

process adherence and favourable mortality. The

alternative strategy (bypass or transfer to hospital 3)

may be indicated depending on the success of locally-

led stroke care enhancements.



Hospital 29 is an unenhanced site which sees

approximately 24 strokes a year. It has limited access to

on-site investigations. Hospital 29 is the largest hospital

around its hub hospital (hospital 10), which is around

100 km away. Hospital 29 and hospital 10 results were

presented first at hospital 10 and again at hospital 29,

in two sessions with acute clinicians and managers from

both hospitals. A visiting rehabilitation physician

serving both sites was at both presentations. At the

hospital 29 feedback sessions, local hospital 29 clinicians

accepted, based on presented evidence for organised

stroke and TIA care, that transfer of stroke patients to

hospital 10 was preferred. At the hospital 29 feedback

session, considerable barriers to timely transfer were

identified and discussed.


Hospital 22 data was presented at hospital 9 with

managers and clinicians from hospital 22 present.

Hospital 22 is unenhanced and sees 105 strokes a year

with few reaching off-site organised stroke unit care.

Hospital 9 is 20 km away and has a stroke unit which

sees 425 strokes a year and is now providing

thrombolysis 24/7 prior to its inception as an ATC. The

agreed local response was to establish a hub and spoke

model, reviewing the processes of both transfers and

bypass between hospital 22 and hospital 9. It was

acknowledged that as the community around hospital

22 grows and the hospital’s services evolve a local

stroke unit may be considered in the future.

Hospital 6 and spoke A

Hospital 6 has a stroke unit and is an ATC which

currently sees 102 strokes a year. It has a risk

standardised mortality rate within 90% confidence

limits of the NSW mean and a 10% thrombolysis rate in

the SCAP audit period. At present it only receives 3% of

strokes by transfer and has two small surrounding

hospitals which see five and three strokes per year,

respectively. At the hospital 6 feedback session the

SCAP team identified that spoke A in an adjoining LHD

sees approximately 40 strokes a year, has no organised

stroke care and refers to hospital 24, 90 km and 90

minutes away on a difficult road. Hospital 6 is 60 km

and 48 minutes from spoke A on easier roads.

Ambulance bypass or facilitated transfer from spoke A

to hospital 6 would save at least 40 minutes in travel

and onset to treatment time (in the case of

thrombolysis). Hospital 6 managers and clinicians

recognised the utility of providing hub services for

spoke A and this has been raised with hospital 24

clinicians at their feedback session. Additional

involvement of managers and ASNSW is required to

establish more timely flow of stroke patients from

spoke A to organised stroke care.

Hospital 1 and spoke B

The hospital 1 stroke unit was established in 2003 with

the express purpose of providing stroke unit care for all

stroke patients in its metropolitan area. It used a

common stroke on-call roster for hospital 1 and spoke B

and rapid transfer arrangements, which worked

effectively for almost a decade. When hospital 1 was

audited with five other pilot sites, the transfer

arrangements were no longer in place and the

approximately 100 strokes presenting to spoke B were

no longer reaching the hospital 1 stroke unit. Following

feedback of pilot audit results the local clinicians and

managers have successfully reinstated the rapid transfer

of spoke B stroke patients to hospital 1. In turn, most of

hospital 1’s post-acute stroke patients receive their

rehabilitation at spoke B.


Post-audit quality improvement activities

During the feedback sessions at each site, the Stroke

Network Manager and a senior local clinician facilitated

a discussion among clinicians and managers to

determine local priorities and the local response

needed to address them. During discussions the Stroke

Network Manager and the ACI Stroke Clinical Lead

shared the experience and local solutions undertaken

by other sites and facilitated peer support.

Typical improvement activities at audited sites include:

• development of a stroke pathway of care at four

hospitals (e.g. hospital 28, hospital 26, hospital 21

and hospital 5)

• improved implementation of existing stroke

pathways at a further four hospitals (hospital 23,

hospital 6, hospital 17 and hospital 2)

• improved access to early swallowing assessment at

four sites (hospital 27, hospital 21, hospital 2 and

hospital 17)

• improved access to allied health disciplines (hospital

23, hospital 2 , hospital 21 and hospital 27)

• wider use of blanket allied health referral

• better access to stroke unit or HDU beds through

improved bed management (undertaken at most

sites with existing co-localised stroke unit beds)

• the adoption or better use of transfer protocols to

facilitate hub and spoke transfers at eight hospitals

(hospital 23, hospital 2, hospital 26, hospital 10,

hospital 29, hospital 6, hospital 21 and hospital 17)

and the introduction of hospital bypass in

conjunction with ASNSW being considered at

several sites

• addressing staffing issues at three hospitals

• creation of new stroke units and ATCs

• implementation of formal pharmacy reviews of

each stroke patient at five hospitals to ensure

appropriate secondary prevention prescribing of

statins and antithrombotics at four hospitals.

Additionally, hospital 2 is specifically addressing the

initial prescribing of aspirin within 24 hours and several

sites are addressing or reviewing their investigations of

stroke patients to ensure better and timelier access

(hospital 23, hospital 2, hospital 10 and hospital 6).

Other sites had undertaken this as part of a review or

development of their local stroke pathways (e.g.

hospital 5).

Hospital 10 is recruiting a consultant neurologist to lead

their stroke program, hospital 2 is seeking the

appointment of a stroke co-ordinator and hospital 27 is

identifying a local stroke champion.

The SCAP team has met with, and is supporting, a new

neurology consultant appointee at hospital 26 to

further develop the hospital 26 stroke service to stroke

unit status and ultimately ATC status.

Two regional LHDs have undertaken a program of rapid

stroke service development and an associated review of

patient flows to complement those enhancements.

Service enhancements are being considered for hospital

2, and hospital 25 has opened a new stroke unit and

recently became an ATC.

Hospital 17 and hospital 9 are progressing to ATC status

in the short-term and hospital 16 (a new referral

hospital) and hospital 19 have been selected for stroke

unit development; a new stroke unit at hospital 19 is

likely to open during 2016, following the appointment

of a stroke co-ordinator. Additional rehabilitation beds

have been opened in one of the LHDs in response to

the SCAP project and another hospital, visited by the

SCAP team, has been ear-marked as a new stroke

service. New hub and spoke flows are being considered

around hospital 2, and are expected to improve the

care of 40 stroke patients a year.

To ensure access to both organised acute stroke care

and high quality post-acute care, hub and spoke models

of stroke patient care are being assessed or enhanced

or implemented between:

• hospital 29 and hospital 10

• spoke A and hospital 6

• spoke C and hospital 2, hospital 22 and hospital 9

in conjunction with ASNSW.

Hospital 1 and spoke B re-established their previous hub

and spoke relationship after the pilot audit of hospital 1.


The ACI-funded SCAP has engaged with more

than 600 clinicians and managers across NSW,

providing information and peer support to

identify and locally address unwarranted

clinical variation. The SCAP program has

identified explanations for unwarranted

clinical variation and in a multifaceted process

has been improving stroke patient access to

acute and post-acute care. The SCAP process

has facilitated development of new sites with

organised stroke care and improved stroke

patient flows towards sites offering organised

stroke care. The program has identified

effective strategies used by exemplar sites

and shared these across all sites involved in

the program. Through the locally-developed

responses facilitated in the SCAP feedback

sessions, those involved in the stroke patient

journey are addressing access to desired

investigations, better prescribing, access

to stroke unit beds, the use of stroke care

pathways and adherence with other

processes known to improve patient outcomes

and experience.

There may need to be improved access to desired

investigations, such carotid imaging and

echocardiography, across a number of sites. Further and

ongoing engagement with clinicians involved in the

stroke journey may be needed, to ensure reliable

ordering and prescribing of important investigations,

medications and hydration fluids.

In the SCAP audits no hospital, even those with

relatively high standards of care, performed

consistently well across all clinical care processes that

are likely to influence patient outcomes. The data

shown in figure 14 strongly indicate a relationship

between good adherence to important stroke care

processes and the BHI estimated 30-day mortality,

which was adjusted for age and co-morbidities and

benchmarked against the arithmetic mean of 30-day

stroke mortality in NSW.

The SCAP program has shown that unwarranted clinical

variation, as measured by the BHI analysis, can be

explained. At present stroke patients do not always

receive evidence-based care at hospitals caring for

acute stroke patients in NSW. This may be the result of

being admitted to a smaller hospital with no organised

stroke care and little prospect of providing it, admission

to a hospital where stroke unit care could reasonably be

provided but where no unit has been established or

because patients fail to reach a stoke unit bed in a

hospital with a stroke unit. Importantly good access to

a stroke unit bed is associated with better patient

outcomes, although there are variations in adherence

with important clinical care processes at all sites and the

identified variations in bedside care are likely to be a

correctable source of unwarranted clinical variation.

Early indications are that the SCAP program is

addressing unwarranted clinical variation by improving

stroke bed access and adherence with important clinical

processes.

By providing reliable service data and reaching out,

face-to-face across NSW, the SCAP process has increased

the profile of unwarranted clinical variation in general,

demonstrating it is a local issue with local solutions.

During feedback sessions, clinicians and managers

frequently commented that the SCAP process had

provided the most comprehensive and relevant

information they had received on their clinical practice

and health service delivery.

The interim results of the SCAP program and local

responses have been presented at a second UCV

workshop on 28 April 2016. The goal of this workshop

was to further engage hospital managers and clinicians

as well as LHD representatives. Stakeholder feedback

and leadership are required to set the future directions

needed to address unwarranted clinical variation in

stroke care.

Conclusions

Section 5


Recommendations

Section 6

1. ACI and the NSW Stroke Network will continue to work with local teams to support the implementation of locally agreed improvement plans.

2. ACI and the NSW Stroke Network will review locally developed improvement plans to determine any state-wide projects.

3. ACI and the NSW Stroke Network will progress the development of a stroke quality improvement collaborative to promote shared learning.


A scoring card was developed where all indicators were considered equal to each other (that is, no indicator was

considered more important than another). A two-step process was used:

1. The scoring card was developed using an index approach. For each indicator, a hospital could score between

0–100%.

% admitted to SU/HDU/CCU 0–10 11–20 21–30 31–40 41–50 51–60 61–70 71–80 81–90 91–100

>> Score 1 2 3 4 5 6 7 8 9 10

2. An average clinical process score (%) across all indicators was calculated for each hospital. The resulting score

for each hospital is summarised figure 17 and 18 on page 25.

Appendix 1 – Clinical process scoring card

Section 7


Adherence % 80–100 60–79 40–59 20–39 > 20

Table 5. SCAP audit site adherence outcomes, ranked on BHI 30-day mortality risk

Hospital no

BHI mortality

SU / HDU / CCU

24 hr Neuroobs

Strokepathway

Swallow test < 4 hrs

% Discharged on Antithrombotics

Aspirin < 24 hrs

DC on new Statin

% VTE P'laxis if immobile

1 0.57 91 96 97 45 78 63 75 50

2 0.72 77 80 85 87 72 68 68 68

3 0.74 96 100 100 44 79 52 52 52

4 0.78 100 95 45 70 84 58 63 0

5 0.84 89 94 0 10 93 56 53 58

6 0.87 86 93 68 70 64 69 58 58

7 0.89 85 3 65 55 75 59 44 35

8 0.98 77 91 79 20 74 70 42 25

9 0.99 86 89 63 20 77 70 75 37

10 1 95 83 81 51 70 87 81 81

11 1.02 85 78 81 29 77 60 54 73

12 1.06 90 95 70 37 78 58 51 71

13 1.1 85 68 13 31 74 64 44 88

14 1.22 100 100 0 25 78 44 28 28

15 1.24 82 94 0 26 72 46 46 42

16 1.27 19 100 0 0 0 68 35 35

17 1.28 90 88 94 27 68 58 54 54

18 1.29 98 98 96 86 77 72 56 56

19 1.3 2 24 0 0 0 51 42 42

20 1.31 95 77 61 50 80 56 32 32

21 1.32 37 53 0 14 75 56 58 58

22 1.32 0 35 11 12 77 30 43 43

23 1.33 75 69 86 56 73 22 54 54

24 1.4 80 89 6 29 66 38 45 56

25 1.47 0 55 80 10 71 47 43 43

26 1.53 7 65 62 65 80 60 58 58

27 0 47 13 NA 65 39 39 39

28 0 9 0 0 80 20 20 20

29 7 29 7 7 46 14 42 42

Green is favourable and red less favourable. Ranking within columns are indicated by one of 5 colours in each

square with dark green for good results, ranging through light green to orange for worse results through to red,

which represents a poor adherence to the clinical process result in the audit. The numbers within the square are

indicative of the exact adherence percentage.

Appendix 2 – Audit site outcomes

Section 8


References

Section 9

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REPORT · Changes in adherence over time 23 Adherence to clinical process and mortality 25...

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