Slide 1 All Wales Stroke Services Improvement Collaborative Stroke Services in Wales An Update Anne...

All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative

Stroke Services in WalesStroke Services in WalesAn UpdateAn Update

Anne FreemanAnne Freeman

Consultant Physician Royal Gwent Consultant Physician Royal Gwent HospitalHospital

Clinical Lead AWSSICClinical Lead AWSSIC


RCP Audit 2008RCP Audit 2008Organisational Report August 2008Organisational Report August 2008

Stroke Unit provision in UK Hospitals

% of sites with stroke unit 2006 2008England 98% 96%Wales 50% 45%N Ireland 92% 92%

% of sites with stroke units who have all 5 SUTC characteristicsEngland 73%Wales 80%N Ireland 64%


Criteria for judging quality of acute and Criteria for judging quality of acute and combined stroke unitscombined stroke units(SUTC characteristics)(SUTC characteristics)`̀

These characteristics are not all evidence based but were developed using the consensus of an expert working group – the Intercollegiate Stroke Working Party:

• Continuous physiological monitoring (ECG, oximetry, blood pressure)

• Access to scanning within 3 hours of admission• Policy for direct admission from A&E/front door• Specialist ward rounds at least 5 times a week• Acute stroke protocols/guidelines


ORGANISATION OF STROKE CARE BY ORGANISATION OF STROKE CARE BY DOMAINSDOMAINS

8 areas assessed by the proforma1. Acute Stroke Care2. Organisation of Care3. Consultant physician time (overall)4. Inter disciplinary Services (for sites with a

stroke unit)5. TIA/neurovascular Services6. Continuing Education in stroke7. Team working –Team meetings8. Communication with Patients and Carers


Range of Scores for WalesRange of Scores for Wales

Wales Range across 20 units: 23 -77 (evenly

distribributed)

EnglandMedian about 75 (50-90)

Northern IrelandRange about 15 - 78


Changes from 2006 in WalesChanges from 2006 in Wales

2008• 13 sites in bottom range• 6 sites in middle range• 1 top range

Change from 2006• 1 site moved up to top• 3 sites moved up to middle• 1 site moved down to bottom• All others stayed the same


Top Ten RecommendationsTop Ten Recommendations

1. All patients with acute stroke should be admitted directly to an acute stroke unit

2. Thrombolysis should only be provided when all the other components of acute stroke care are of high quality

3. Comply with the recommendations in the NICE guidelines for Acute Stroke and TIA

4. Development of seven day rehabilitation services should be made a priority

5. Stroke services should urgently review policies that exclude certain groups from admission to the stroke unit


Recommendations continuedRecommendations continued

6. Patients without stroke should not occupy beds on the stroke unit while stroke patients are managed off the unit

7. Levels of nurse staffing on acute stroke units needs to be increased in many units

8. Social worker involvement as an integral part of the stroke team is essential and should be mandatory for every stroke service

9. Early supported discharge services should be made available for all patients

10. All services managing patients with TIA should have systems in place in line with the recommendations in the National Stroke Strategy and the NICE guidelines for Acute Stroke and TIA.


Further detailsFurther details

http://sentinelstrokeaudit.rcplondon.ac.uk


RCP Process Audit 2008RCP Process Audit 2008 Clinico-demographic resultsClinico-demographic results

National England Wales N. Ireland

Sites 216 184 18 11

(Patients) 11,369 10,007 863 355

% new institutionalised on D/C 11 12 7 11

% D/C Barthel of 20 39 39 45 41

% D/C Barthel of <10 17 17 12 19

Mean Age 76.5 75.6 74.7 73.6

Mean LOS to D/C or death 24 23 25 25

All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement CollaborativeRCP Process Audit 2008RCP Process Audit 2008

Overall results for 9 key process indicators in Overall results for 9 key process indicators in 20082008

National England Wales N. Ireland

Patients- 90% stay in a stroke unit 58 59 41 59

Screened for swallow within 24 hrs adm 72 74 52 70

Brain Scan < 24hrs 59 59 54 56

Aspirin < 24hrs 85 85 85 82

PT Assessment <72 hours adm 84 85 70 85

OT Assessment < 4 working days adm 66 68 43 73

Weighed 72 73 59 68

Mood Assessed by discharge 65 66 46 80

Rehab Goals set by MDT 86 87 74 83

Average for 9 indicators 72 73 58 73


Results in Wales since 2004Results in Wales since 2004

2004 2006 2008

Patients 667 925 863

1 Patients – 90% stay in a stroke unit

N/A 39 41

2 Swallow screen within 24 hrs of admission

51 55 52

3 Brain scan < 24 hours of stroke not comparable

38 50

4 Aspirin by 48 hours of stroke

73 76 85

5 PT assessment < 72 hrs of admission

49 54 70

6 OT assessment < 4 working days of admission

N/A 30 43

7 Weighed 51 54 59

8 Mood assessment by discharge

47 53 46

9 Rehab goals agreed by MDT

67 70 74


Site variation for the process domains in 2008Site variation for the process domains in 2008


How domain scores are obtainedHow domain scores are obtained

D1 Initial patient assessment Screen for swallowing 24 hours Visual Fields Sensory Testing Brain scan within 24 hours of stroke

D2 Multi-disciplinary assessment Swallow assessment by SALT within 72 hours PT assessment within 72 hours Initial assessment of communication by 7

days OT assessment within 4 working days SW assessment within 7 days of referral



D3 Screening and functional assessment Patient weighed at least once Evidence of mood assessed Cognitive status assessed Screening for malnutrition D4 Care Planning Evidence of rehab goals Plan to promote urinary continence Receiving nutrition within 72 hours



D5 Communication with patients and carers Discussion with patient about diagnosis Carer needs for support assessed separately Skills taught to care for patient at home Follow up appointment at 6 weeks Driving advice D6 Acute Care Aspirin <48 hours of stroke 90% of care in a SU Admitted to an acute or combined SU < 4

hours Receiving fluids < 24 hours % of applicable patients thrombolysed


9 key indicators9 key indicators

Comparing sites in Wales/regions


Mid and West WalesMid and West Wales•

2008 score 2008 2006 * 75 Middle Upper * 35 Lower Lower * 59 Middle Middle * 42 Lower Lower * 53 Lower Lower * 36 Lower Middle * 31 Lower Lower * 64 Middle Middle•


North WalesNorth Wales

2006 2008

* 60 Middle Middle * 61 Middle Upper * 66 Middle N/A


South East WalesSouth East Wales


Top Ten Areas with recommendations Top Ten Areas with recommendations for change in Process of Carefor change in Process of Care

1. Work with all agencies to raise the public awareness of stroke to speed up access to hospital following stroke

2. Organise hospital care so that patients are admitted directly to an acute stroke unit from A&E and all suitable patients can be treated with thrombolysis as

quickly as possible

3. Improve the training and support given to junior doctors and staff from non stroke disciplines who undertake initial clerking of stroke patients

4. There should be regular quality control to ensure that documentation is complete

5. Brain scanning should be speeded up in many units


5. Ensure that all acute stroke units have effective multidisciplinary teams and working

6. Find the 25% of patients who do not currently get to a stroke unit and do something for them

7. Take urinary continence more seriously

8. Manage all patients so as to avoid chest infection and urinary tract infection and identify and treat infections early when they do occur

9. Communicate better with patients and relatives, particularly about the stroke diagnosis and prognosis and how to prevent further strokes

10. Give the correct advice is given to patients who drive


Profession Specific AuditProfession Specific Audit

• Autumn 2008• Second Pilot for RCP• Tools provided by RCP but modified by the

Rehab subgroup of WSA• 20 sets of notes per discipline


Involved….Involved….

• Nursing• PT• OT• SALT• Dietetics• Psychology

• Podiatry• Social work


ProgressProgress

• Results not ready yet• To be presented to RCP later this

year• Will become part of the National

Sentinel Audit as from 2010


Proposed RCP acute auditProposed RCP acute audit

• First 3 days• On line audit • Prospective• Detailed audit of process in first 72 hours• Pilot still to be done to assess tool• Unlikely to be UK wide until later this year• RCP have reassured us that we can defer

until at least after September


AOF Target- April 2009AOF Target- April 2009

• AOF Target for Stroke Services • WAG has set the following target in the Annual

Operating Framework for stroke services. • By March 2009, each patient suspected of or

confirmed as having had a stroke must be admitted to dedicated and co-located acute stroke beds staffed by a specialist multi-disciplinary medical and acute rehabilitation stroke team.


Detailed DefinitionDetailed Definition“dedicated and co-located acute stroke “dedicated and co-located acute stroke

beds”beds”

These are hospital beds in a ward or part of a ward that are located very near one another (subject to issues of dignity and gender) and are guaranteed for admitting stroke patients who should have access to high quality specialist acute medical and rehabilitation stroke care.


Such a service must satisfy the following quality indicators;

* Access to continuous physiology monitoring * Access to brain imaging within 24 hours;* A policy in place and adhered to for direct

admission from A & E;* Access to specialist ward rounds at least 5 times

a week;* Consultant physician with responsibility for

stroke;* Formal links with patient and carer organisations;* Multi-disciplinary meetings, at least weekly, to

plan patient care;* Provision of information to patients, about stroke;* Continuing education programmes for staff.


AOF Monitoring ToolAOF Monitoring Tool• Developed by Sarah Jones on behalf of SSIP• Based on the elements of the AOF • Reviewed by the team at NHH• Will be on the nww.stroke.wales.nhs.uk website• To be completed by end of April• Letter to service will be coming out very soon• Letter from Minister regarding assurance of AOF target

by 13th March• Informal visits in March/early April• Formal visits in May/June to verify compliance with

AOF and to assess any shortfall• Report to WAG by Mid June??


Interim Organisational Audit RCP Interim Organisational Audit RCP 20092009

• Same format as 2008• Just the organisational element• No clinical audit on process of care• Agreed to participate• Timescale much the same as AOF

monitoring – end of April 2009• Hopefully will see improvement following

HM resources allocated to fund additional staff, etc


Intelligent Targets

• Organisational• Process• Outcome


Organisational- Uptake IndicatorsOrganisational- Uptake Indicators

• Use of Monitoring Tool

• Identified Clinical Champion and Specialist Stroke Team

• Evidence of progress on all intelligent targets


Process Measures- Intelligent Process Measures- Intelligent TargetsTargets

• Demonstrate an ongoing improvement in compliance rate with 10 stroke care bundles

•4 TIA•4 Acute Stroke•2 Early Recovery and Rehabilitation


Outcome MeasuresOutcome Measures

• Percentage of people with suspected TIA who go on to have a full stroke within 7 days

• Mortality Rates• Change in Functional Outcome• Average Length of Stay

• in hospital• on stroke unit• within stroke service

• Percentage of people who return to their usual place of residence

• Percentage of people who are re-admitted within 28 days


Acute Phase Acute Phase Driver Driver

DiagramDiagram


TIA


Early Recovery and Rehabilitation


Managing a complex system


Count the black dots !!Count the black dots !!

Any questions??

Slide 1 All Wales Stroke Services Improvement Collaborative Stroke Services in Wales An Update Anne...

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