scottish stroke care audit system nhs fife 2012 data dr sue pound, stroke consultant hazel fraser...
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Scottish Stroke Care Audit System
NHS Fife 2012 dataDr Sue Pound, Stroke ConsultantHazel Fraser Stroke Co-ordinatorIsla McBain, Stroke Audit assistantNov 2013
National Scottish Stroke Care Audit System (SSCAS)
Facilitates collection of data which reflects the quality of stroke services
Acts as a stroke register Ensures routine outcomes adjusted for casemix Monitors health boards performance against national
standards Monitors health board performance against HEAT target HEAT target ended March 2013 however remains a
Scottish Stroke Standard Scottish Stroke Standards were updated for 2013
Data Period January 1st to December 31st 2012Patients discharged with a final diagnosis of stroke
Inpatient data based on stroke patients only Victoria Hospital: 538 Out patients for analysis of waiting times for
audit only those with a Definite cerebrovascular diagnosis are included
VHK 193 (417 seen at clinic) QMH 218 (433 seen at clinic)
Through out the year data is reported on early diagnosis of stroke. Final figures are based on patients discharged in that time period with a final diagnosis of stroke so may vary slightly
Actions to improve delivery of stroke care in relation to NHS QIS
Care bundle proforma comprising ASU,CT,WSST and Aspirin initiation to be commenced in A & E
Exception reporting and regular feedback weekly to A & E, AU1and ASU to continue
Outreach service – includes senior nursing staff from the stroke unit
Initiation of incident forms if appropriate Raise awareness and educate staff on stroke
Stroke Admission Standard 60% of all patients admitted to hospital with diagnosis of stroke are admitted to the stroke unit on the day of presentation, and remain in specialist stroke care until in-hospital stroke related needs are met. 90% of all patients admitted to hospital with a diagnosis of stroke are admitted to the stroke unit on day of admission, or the day following presentation at hospital, and remain in specialist stroke care until in hospital stroke related needs are met.
2012 – day 0: 37%, day <=1 : 83%2011 data day 0: 31% day<=1: 65%
% Admitted to Stroke Unit
48
4137
16
3639
32
55
49 49
3632
47
14
31
81 8183
53
8279
82
94
78
97
8986
89
7375
0
10
20
30
40
50
60
70
80
90
100
YEAR2010
YEAR2011
YEAR2012
Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12
<= day 0
<= day 1
target <= day 0
target <= day 1
Additional Actions to improve access
Direct Access to stroke unit where possible Regular visits to A & E and AU Encourage staff to phone outreach team Care Bundle includes query stroke/TIA Review rehab pathway & explore ESD Implementation of a standard operating
procedure for the acute stroke unit Working with capacity team
Access to brain imaging standard
80% of patients have CT/MRI imaging on day of admission, unless there is documented contraindication. 2012: 67% 2011: 57%
% Brain Imaging on Day Admitted
60
6867
63
73
65
7169
5960
69
65
75
64 64
40
50
60
70
80
90
100
YEAR2010
YEAR2011
YEAR2012
Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12
target
Additional Actions to improve times to scanning Raise awareness of availability of
scanning – up to 10pm OOH A & E Dr’s to request CT scans early Outreach team to encourage early
scanning Radiology training radiographers in CT Pre alerting Xray
Swallow Screening Standard All patients are screened by a standardised assessment method to identify any difficulty in swallowing safely due to low conscious level and/or the presence of signs of dysphagia. This can be carried out on the day of admission and before giving food/drink and oral medications and is clearly documented. (100%) 2012: 66% 2011: 68%
% Swallow screen day 0
70
80
66
44
65
60
66
77
6869
71
64
80
5856
40
50
60
70
80
90
100
YEAR2010
YEAR2011
YEAR2012
Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12
target
Additional actions to improve % WSST
Train the trainers – champions of WSST Care bundle completion A & E and AU1 training and awareness Weekly feedback on performance Dysphagia subgroup of MCN Outreach team to ensure WSST
performed
Aspirin standard Aspirin treatment is initiated on the day of admission or the following day and continued for all patients in whom a haemorrhagic stroke, or other contraindication, as specified in the national audit, has been excluded. (100% ischaemic) 2012 80% 2011 77%
% Given Aspirin <= 1 day
8485
80
67
100
7981
88
7981
82
71
84
75
79
40
50
60
70
80
90
100
YEAR2010
YEAR2011
YEAR2012
Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12
target
Additional actions to improve aspirin results
Outreach team encourage stat dose to be given
Care bundle completion Ensure patients with same day discharge are
given STAT dose Prescribe alternative routes CT scan results more timely Developed Patient Group Directive for Aspirin
Thrombolysis Standard The MCN monitors the use of thrombolysis for acute ischaemic stroke and will administer this according to current SIGN guidelines to at least 5 patients per 100,000 population each year. The MCN monitors the delay between arrival at the first hospital and administration of the bolus of recombinant plasminogen activator 80% of patients receive the bolus within one hour of arrival Performance 2012 – 32 patients thrombolysed. 25% within one hour, 75% within one and a half hours door to needle time
ACTIONS
Audit delays Education SAS and A & EThrombolysis governance meetingsA & E Alerted by SASCT prewarned stroke admissionSTAT (stroke and TIA assessment training)
Outpatient referral to seen at clinic standard 80% of new patients with a stroke or TIA are seen within 7 days of receipt of referral to the neurovascular clinic QMH 81%, VHK 82% 2011 data Fife wide 78%
% Outpatients Examination <= 7 days
81 80 80
26
7983
88
96
8279
83
100 100
86
53
85
76
82
42
83
100 100 100 100
63
77
86
80
96
65
0
10
20
30
40
50
60
70
80
90
100
YEAR2010
YEAR2011
YEAR2012
Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12
QMH
VHK
target
Actions to improve waiting times Increased one stop TIA clinics to 4 a week Additional clinic with no CT/Doppler access TIA Hotline Improve GP awareness through campaigns and PLTs Developed and continued update of TIA clinic referral
form and pick up points in A & E and AU which are accessed daily
Screening of all referrals Introduction of RMS had led to delays though this is
improving
HEAT target To improve stroke care “90% of all patients admitted with a diagnosis of stroke
will be admitted to a stroke unit on the day of admission, or the day following presentation” by March 2013
NHS Fife failed the target, performance had dropped in Nov and Dec 2012
Jan – March 2012 : 71% Jan – March 2013: 95% Apr – June 2012 : 85% Apr – June 2013: 95% Jul – Sep 2012 : 91% July – Sept 2013: 97% Oct – Dec 2012 : 79%
New Challenges
To continue to improve performance against updated stroke care standards
HEAT target has been adapted as a national stroke standard
Continuation of outreach service Downstream bed availability Possible development of a HEAT target to reflect
a bundle of care Collection of additional information – pilot site for
rehabilitation audit.
Stroke Care Standards Update for 2013 90%of all patients are admitted to the stroke unit on
the day of, or the day following presentation, and remain in specialist stroke care until in-hospital stroke related needs are met.
*it is expected where possible and safe, all patients with a stroke be directly admitted to the stroke unit
90% of patients have CT/MRI imaging within 24 hours of admission
*expectation is that all patients with suspected stroke will have imaging as soon as possible. This standard will be reviewed and may be changed to within 12 hours.
Clinical Standards Update for 2013 cont’d 1
90% of patients are screened by a standardised assessment to identify and difficulty swallowing on day of admission
Aspirin is given on the day of admission or the following day (for all patients in whom a haemorrhagic stroke, or other contraindication, as specified in national audit, has been excluded.)
80% of new patients with stroke or TIA are seen within 4 days of receipt of referral to the TIA clinic
Clinical Standards Update for 2013 cont’d 2
MCN monitors delay between arrival and administration of thrombolysis. 80% of patients should receive bolus within one hour of arrival
80% of patients undergoing carotid endarterectomy have the operation within 14 days of the stroke event
2013 performance up to 30th September Access to stroke unit <= 1day target 90%
TARGET: 90% of all patients admitted to hospital with a diagnosis of stroke are admitted to the stroke unit on the day of admission, or the day following presentation at hospital
8183
7981
92
95 95 95
9897 97
40
50
60
70
80
90
100
YEAR 2011 YEAR 2012 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13
Water Swallow screening test day 0
TARGET: 90% of patients are screened by a standardised assessment method on the day of admission
80
66
40
6870
66
81
9193
9091
40
50
60
70
80
90
100
YEAR 2011 YEAR 2012 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13
Brain imaging <= 24 hours
TARGET: 90% of patients have CT/ MRI imaging within 24 hours of admission
9293
96
88
9395
94
98100
9896
40
50
60
70
80
90
100
YEAR 2011 YEAR 2012 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13
Aspirin given as per SSCAS <= 1day
TARGET: Aspirin is given on the day of admission or the following day for all patients in whom a haemorrhagic stroke, or other contraindication, as specified in the national audit, has been excluded
84
81
75
83
92
86
91
9798
91
94
40
50
60
70
80
90
100
YEAR 2011 YEAR 2012 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13
Seen TIA clinics <= 4days (from receipt of referral)
TARGET: 80% of new patients with a stroke or TIA are seen within 4 days of receipt of referral to theneurovascular clinic
34 35
46
10
47 46
0
1921
57
33
56
62
84
47
84
95
45
56
60
84
78
0
10
20
30
40
50
60
70
80
90
100
YEAR 2011 YEAR 2012 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13
QMH
VHK
Thrombolysed <= 60 mins
27.3% for last 12 months Since January thrombolysed 49 patients 3 were in patients 8 thrombolysed for a non index event
(door/needle time does reflect actual time) 10 under 1 hour Further 15 under 1hr 30mins.
Carotid Endarterectomy within 14 days
Numbers small
33% for last 12 months
14 CEA since Jan 2013 data not complete yet
Further information available at www.strokeaudit.scot.nhs.uk
Any local queries please contact Hazel Fraser Stroke Co-ordinator