Lismore Base Hospital’s Stroke Journey

Stroke Forum: Reducing Unwarranted Clinical Variation

Kim Hoffman, LBH Stroke Coordinator

Thursday 28 April 2016

The ACI acknowledges the traditional owners of the land that we work on -

the Gadigal People of the Eora Nation. We pay our respects to Elders past

and present and extend that respect to other Aboriginal peoples present

here today.

Acknowledgement

LBH Audits

LBH undertook NSRI stroke audit in Dec 2006 with 100

records audited from admissions July 2001 to September

2006, to assist in submissions for a stroke unit

LBH undertook UWCV pilot audit in July 2013 with 20 records

audited from admissions April 2012 to June 2012

LBH undertook UWCV audit in Feb 2016 with 80 records

audited from admissions Sept 2013 until March 2014

BHI 2009- 2012 results

BHI data for July 2009-June 2012 identified 183 index ischaemic stroke

hospitalisations and 108 haemorrhagic strokes, with 50 and 34 transferred to

another hospital, respectively.

From reviewing LBH ICD-10 stroke separations for this period- 196

strokes were coded as I64, and this data was not used in the BHI report

Thirty day ischaemic and haemorrhagic stroke mortality was 17% and 40%,

respectively, both within 90% confidence limits of the NSW mean.

The ischaemic stroke risk-standardised mortality ratio RSMR was 1.47

(Manly was 0.57 with a BHI 30 day mortality of 9%). Haemorrhagic RSMR

was 1.26.

Lismore 2016 SCAP audit (N=80) between Sept 2013 and March 2014; 12%

were haemorrhagic and 11% were coded I64 (stroke NOS).

Audit results 2006 audit: 100 records July 2001 –Sept 2006.12 transferred in. 9 documented

palliative. CT 83% < 24hours. No stroke unit. Neuro obs 19%. 9% Echo, 48%

Duplex. 27% clinical pathway. 64% on antithrombotics at D/C. 46%

commenced on aspirin at 24 hours. 69% documented swallow within 24 hours.

2013 audit: 20 records April 2012-June 2012. 7 transferred in. Nil documented

palliative. CT 95%<24 hours. No stroke unit. Neuro obs 55%. 5% Echo, 55%

Duplex. 80% clinical pathway. 71% on antithrombotics at D/C. 47% on aspirin in

24 hours. 10% swallowing documentation < 4 hrs.

2016 Audit: 80 records Sept 2013-March 2014. 29 transferred in (37%). 5

palliative. CT/MRI 95% <24hrs. SU Feb’14. 21/65% to SU. Neuro obs 99%, Echo

29%, Duplex 69%. Stroke pathway 99%, Clinical care plan 100%. 87% on

antithrombotics at D/C; 66% on aspirin at 24 hours. 5% documented swallow < 4

hours

Audit

results2012

N = 20

19 (95)

10 (50)

6 (30)

3 (15)

13 (65)

0 (0)

0 (0)

16 (80)

16

(80)

Audit results

Audit results

Audit results

0

10

20

30

40

50

60

70

80

90

100

Pilot 2012

SCAP 13-14

Lismore clinical process adherence and access 2012 Vs 2013-14

SU/HDU/ICU

24hr NeuroObs

Stroke Clinical Pathway

Speech path<24hrs

DC Antithrombotics

Asprin<24hrs

DC on Statin

VTE Prop.

Brain Imaging<24Hrs

Care plan

Physio<24

OT<24

Swallow<4hrs

Service Improvements over time

In 2006/7 interested AH and nursing staff participated in ROAST- 6 months of

stroke admissions in mid 2006 were audited. Main outcome was a stroke

clinical pathway re-implemented and patient stroke booklet developed.

Submissions developed for each rural stroke project funding period 2006/7

and 2007/8- unsuccessful both times.

NSW Health provided funding in 2011/12 for a stroke unit.

Stroke Coordinator employed in October 2012- provision of patient education,

care plans & D/C planning implemented. Monthly Stroke & TIA reports

provided to all staff involved on stroke care.

Stroke unit steering committee formed to oversee the implementation of the

stroke unit. General Physician became medical lead for stroke.

Enhancement to Allied Health staffing included: 0.4 FTE PT & OT, 0.50 FTE

SP (including 4 hr Sat shift), 0.2 FTE SW & DT, 0.28 FTE AHA (4hrs per day,

7 days per week)

Service Improvements over time Stroke unit (4 bed room on C7 medical ward) opened in mid Feb 2014, hospital ward

reconfiguration occurred April 2014.

Weekly case conferences held with full acute AH stroke team, medical stroke lead,

JMOs, NUM. Journal article or topic of interest discussed at the end of each meeting.

Regular provision of stroke education to LBH ED, ICU and medical ward staff.

Education also provided to peripheral hospitals and Ballina Rehab a few times each

year.

LBH had been performing thrombolysis adhoc prior to 2012. Stroke Coordinator

developed/ implemented stroke thrombolysis pathway 2013. Procedure developed in

2014

Stroke Thrombolysis working group developed (including ASNSW rep) in 2014 and

case reviews provided to all staff (ED; ICU; Medical; ASNSW; Radiology) for

feedback.

Nov 2015 LBH credentialed as an Acute Thrombolytic Centre- redirection to LBH now

occurring for FAST +ve patients < 3hrs time of onset.

Service Improvements over time

Education provide to LBH Coders in 2013 and 2016 to improve stroke coding

Richmond Network Stroke & TIA Pathway updated in 2014 and Nov 2015.

Now includes an Emergency Page which includes transfer protocol at

peripheral sites.

2013 NNSW LHD Stroke Working Group developed to develop a Referral,

Retrieval and Return Pathway for High Risk Stroke Patients to GCUH.

Pathway finalised/ approved by NNSW LHD Ex and GCUH Ex in Feb 2014

(2 patients transferred up for clot retrieval in past 5 months).

NNSW LHD Stroke Clinicians Advisory Group established in 2015

Outcomes- NSF Acute Stroke Audit 20152015: 4% of all IS thrombolysed; 20% of those arriving under 4.5 hrs. None with a door-to-

needle<60 minutes; Admission to the stroke unit 95%; 48% spent 90% on the SU. Antithrombotic on

discharge in IS was 100%.

Strategy developed/ solution(s)

Last SCAP site visit 6th April 2016- QI Plan

1. Increase number of patients having documented swallowing assessment in 4 hrs (ASSIST):

ASSIST swallow screen education commenced in March 2016 to select nurses in ED, C7 and

Clinical Resource Nurses.

2. Improve admission to and time spent on C7 Stroke Unit: Second room (4 beds) on C7 turned in

stroke unit; education to after-hours NM re importance of admitting to stroke unit; get stroke unit

beds classified as Type 69 for future incentive ABF

3. Increase in Echo service/ availability: ongoing feedback to LBH Ex re need for increased echo

service. Trial of LBH Outpt echo service began Nov 2015

4. Aim Door - to – needle time < 60mins: ongoing provision of case reviews and WG continues to

look at processes

5. Ongoing regular stroke coding education: available to assist coders with complex cases

6. Increase number of family mtgs within first week of admission for complex stroke cases

7. Oral Care Project being developed and implemented by Stroke CNS and SPs: to assist in

improving oral care of NBM/ little oral intake stroke patients and to assist preventing asp

pneumonia rates.

What we learned? Employment of a Stroke Coordinator has allowed the stroke service to be developed and

continually improved by having a person dedicated to stroke

Implementation of a stroke unit , employment of increased AH staff , General Physician becoming a

Stroke Medical Leader has allowed for an acute stroke team to be created and improved stroke

care to be achieved

Ongoing and regular staff education increase staff knowledge and specialisation (ED/ medical ward/

ICU)

Monthly stroke reports provided to all staff (ED/ Stroke Unit- medical ward) involved with stroke care

keeps stroke being discussed/ improvements made

Provision of stroke thrombolysis case reviews and ongoing regular stroke thrombolysis group

meetings (ED, ICU, General Physicians, Radiology and NSWAS members) allows thrombolysis

rates to increase, processes to be reviewed regularly and improvements made