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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