Moving Forward from the Sentinel Stroke Audit

Tony Rudd

Royal College of Physicians, London

or…. How to Use the Audit Data to Improve Stroke Care?

History of Stroke Audit in England/Wales and Northern Ireland

Intercollegiate Stroke Working Party established 1995

1st audit 1998Every 2 years since then with round 6 happening

nowEvolution of audit questions over time but core

dataset remained unchanged to enable year on year comparisons

100% participation since round 3Public release of data since round 4

National Stroke Audit

5 cycles audit completedAuditing Organisation of Care and Clinical Process.

Not OutcomeRetrospective case note audit done every 2 yearsConsecutive admissions over defined time periodAuditing against standards defined by

National Clinical GuidelinesIntercollegiate Stroke Working PartyNSF for Older People Standard 5National stroke Strategy

National Stroke Audit

100% participation in England, Wales and Northern Ireland

Reports back to clinicians within 2 months of data submission

Benchmarked against national standards and other hospitals

Separate reports forCountriesSHAsParliamentarians

How Precise Does One Measure of Performance Need To Be?

To detect small differences reliablyover timebetween units

for example: to confirm an increase in % given aspirin (50% to

80%) - 80pts to confirm an increase in % admitted to stroke unit

(50% to 60%) -800pts to confirm a 4% absolute difference in mortality (24%

to 20%) - 3400ptsMartin Dennis (Personal Communication)

Early Stroke Audit Results (1998/9)

18% of patients through stroke unit23% cognitive assessment44% visual fields recorded55% rehabilitation goals set41% G.P. contacted within 3 days of discharge

  

Increase as a result of audit

 

New stroke unit 8 

Increase in size of stroke unit 6 

Consultant stroke physician 10 

Specialist nurse for stroke 10 

Physiotherapists 6 

Occupational therapist 5 

Interdisciplinary care pathways 30 

Multidisciplinary documentation 39  

Information for patients and relatives 52  

Effect of First Audit

12 Key Indicators over Time2002 (%) 2004 (%) 2006 (%)

Stroke Unit 36 46 62

>50% time SU 27 40 54

Swallow screen <24 hours

64 63 66

Brain scan <24 hours

58 59 42

Aspirin < 48 hours 65 68 71

PT < 72 hours 59 63 71

12 Key Indicators over Time2002 (%) 2004

(%)2006 (%)

Weighed 49 52 57

Mood assessed by discharge

52 47 55

Antithrombotic by discharge

91 95 100

Rehab goals documented

61 68 76

Home visit 73 69 63

Average for 12 indicators

57 61 65

Stroke: Aggregated Audit Score: Country Comparison

100908070605040302010

Total organisational score 2006

England

Northern Ireland

Wales

The Islands

Variable performance within SHAs

Using National Audit to Effect Change

Regional WorkshopsSlide toolkitsPerformance indicatorsPublicity and peer reviewed publicationsProviding information to general publicPeer reviewInforming policy

Stroke Workshops

Up to 17 regional workshops after each cycle of audit

Local and national presentations with examples of good practice and how to effect change

Slide Toolkits e.g. Mean % Patients having brain scan within

24 hours of stroke

28

42

33

Performance Management

Healthcare Commission uses for performance indicators

To identify ‘problem trusts’Peer review

Publicity

Any publicity is good publicityPress releases after each auditBad news works better!“I’ve been trying to get the trust to offer scanning for stroke

patients for 5 years, within a day of receiving the audit report the chief executive had convened a meeting with stroke service and radiology” A stroke physician after publication of performance indicators 2004 audit

Peer reviewed publications

Peer Review

Detailed documentation submitted by the trust before the visit

1-2 day visit from multidisciplinary team including patient representative, manager, physician, therapists, nurses

Oral feedback at end of visitWritten report1 year follow-up questionnaire

The Peer Review Process

Trust approaches BASP or RCP Steering Group

appoints visit Chairman

Terms of Reference are agreed Preliminary data

are requested

11 2233

44

The Peer Review Process

Chairman constitutes Visit Team

Previsit data reviewed;

Arrangements for visit agreed

One-day visit takes place Report is completed and

returned to the Trust

55 6677 88

Peer Review

Targeting hospitals performing less well on auditInvited visits to hospitalsTrusts pay to cover the costsOnly with the specific agreement of senior

managementDefined topic for review e.g. acute care/TIA

services/ Rehabilitation/Early Supported Discharge

Informing Policy

E.g. DH Stroke Strategy, National Audit Office, National Service Frameworks

Welsh Assembly

National Audit Office 2005

Highly critical of stroke services in England Low levels of knowledge about strokeVariability of services around the UKInadequate access to acute careDifficulty getting urgent brain imagingLow levels of specialist stroke staffDischarge and longer term care problemsManagement of TIA

TIA and Minor Stroke

Case History: Transient Ischaemic Attack

20 year old womanRight sided weakness; full resolution in 1

hourInitial CT normal

MRI Diffusion Weighted Image at 24 Hours

CT Angiogram

Neurovascular clinics

England, Northern Ireland and Islands

(218 sites)

Wales

(20 sites)

Neurovascular clinic

81% (177) 45% (9)

Service which enables patients

seen and investigated within

7 days

36% (79) 15% (3)

Key Recommendations:TIA and Minor Stroke

Immediate aspirinImmediate referral for urgent specialist assessment

and investigation (base level of urgency on ABCD2 score e.g. 4 or greater within 24 hours)

Lower risk TIA (ABCD2 <4) patients within 7 days

If symptoms not resolved when first seen take directly to acute stroke service

Key Recommendations:TIA and Minor Stroke

Access to carotid imagingCarotid surgery should be regarded as urgent

procedure and should be performed within 48 hours of symptom onset (7 days in NICE guidance)

Where brain imaging required use MR DWI and available within 24 hours

Follow-up one month after the event

Possible Model for TIA Management

Admit high risk TIA patients or see same day on CDUCarotid dopplers and MRI where indicatedMaybe suitable for thrombolysis if stroke while in

hospitalTwice weekly clinics with no waiting listSame day brain and carotid imagingCooperative hard working vascular surgeons!Maximum 2 week wait (from symptoms) for

carotid endarterectomy 48 hours Stoke Strategy)

‘Hyper-acute’ Care