Royal College of Physicians of Edinburgh

Scottish Stroke Collaboration Meeting

22nd September 2010

Queen Mother Conference Centre

Stroke Care in Scotland 2009

Structure of inpatient stroke services in Scotland

Hospitals admitting acute stroke 32

Stroke admissions ~8000

No. per hospital 16 to 601

No. (%) admitted to hospital without SU 227 (2.8%)

SU bed days available 285,000

SU bed days required for 100% access 214,000

Mean length of stay in hospital (range) 27 (13-42)

Access to stroke unit care

• NHSQIS standards– 60% on day of admission– 90% by the following day

• Rationale– Stroke unit care reduces risk of death/disability– Some patients more appropriate for non SU bed

• ? HEAT target coming– 90% by the following day

Access to stroke unit care2005 to 2009

28 30 3235 37

615756

5449

81777776

71

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

2005 2006 2007 2008 2009

Numberof

Patients(columns)

0

10

20

30

40

50

60

70

80

90

100

%against

standards(lines)

Stroke Patients % SU day 0 % SU <=1 day

% Admitted to a SU during stay NHS QIS 60% day 0 NHS QIS 90% <=1 day

Access to stroke unit care

0

10

20

30

40

50

60

70

80

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NHSQIS 90%

NHSQIS 60%

Issues

• Enough stroke beds locally?• Efficient processes to ensure early admission?• Medical cover to ensure patient safety• Protection of beds and working with bed

manager• Efficient moving on policies

– Daily discharge rounds– Joint working with social services– Early supported discharge

• HEAT target?

Early swallow screens

• NHS QIS standard– All patients admitted with stroke should have

a swallow screen documented on the day of admission

• Rationale– Swallowing problems affect about 50% of

admitted stroke patients– Oral fluids and food may cause pneumonia

Early swallow screen

47 4951

55

61

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

2005 2006 2007 2008 2009

Numberof

Patients(columns)

0

10

20

30

40

50

60

70

80

90

100

%against

standards(lines)

Stroke Patients % Swallow Screen day 0 NHS QIS 100% day 0 (swallow screen)

Early swallow screens

0

10

20

30

40

50

60

70

80

90

100

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Same Day

NHSQIS

Issues

• Robust recording of screening process– Paper proformas– Electronic records

• Training of front door staff

• Early access to stroke unit

• Feedback of performance to staff

Early access to brain imaging

• NHS QIS standard– 80% on the day of admission

• Rationale– Early scanning is most cost-effective strategy

Early access to brain imaging

2732

3742

49

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

2005 2006 2007 2008 2009

Numberof

Patients(columns)

0

10

20

30

40

50

60

70

80

90

100

%against

standards(lines)

Stroke Patients % Scanned day 0 NHS QIS 80% day 0 (scan)

Early access to brain imaging

0

10

20

30

40

50

60

70

80

90

100

Per

cent

age

2 Days

1 Day

Same Day

NHSQIS

Issues

• Staff to request scans early after admission

• Protocol driven requests

• Adequate capacity

• Partnership with radiology – make them aware of targets and performance

• Reporting

Early aspirin administration

• NHSQIS standard– All patients with ischaemic stroke should

receive aspirin on day of admission, or following day

• Rationale– Aspirin within 48 hours of ischaemic stroke

improves outcomes

Early aspirin administration

41

51

59

67 68

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

2005 2006 2007 2008 2009

Numberof

Patients(columns)

0

10

20

30

40

50

60

70

80

90

100

%against

standard(line)

Aspirin Denominator (excl CIs) % Aspirin <=1 day NHS QIS 100% <=1 day

Early aspirin administration

0

10

20

30

40

50

60

70

80

90

100

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cent

age

2 Days

1 Day

Same Day

NHSQIS

Issues

• Early scanning and reporting

• Protocol driven prescribing

• Nurse prescribing – patient group prescribing

• Documentation of definite contraindications

Early assessment in NV clinic

• NHSQIS standard– 80% of patients should be seen within 7 days

of receipt of referral

• Rationale– Diagnosis and secondary prevention are more

effective soon after the TIA/stroke

Early assessment in NV clinic

30

4043

58

80

0

1000

2000

3000

4000

5000

6000

7000

2005 2006 2007 2008 2009

Numberof

Patients(columns)

0

10

20

30

40

50

60

70

80

90

100

%against

standard(line)

Outpatients % Outpatients <= 7 days NHS QIS 80% <=7 days

Early assessment in NV clinic

0

10

20

30

40

50

60

70

80

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100

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2009

NHSQIS

Early assessment in NV clinic

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3 Days

2 Days

1 Day

Same Day

Issues

• Patient awareness

• GP awareness

• Streamlined referral processes

• Demand management

• Adequate clinic capacity

• Capacity spread through week

Summary

• Indicators of stroke service performance are improving

• Particular improvement in access to TIA clinics

• Still marked variation and room to improve further in most places

International Comparisons

Acknowledgement to: Erin Lalor, Dawn Harris, Anthony Rudd, Sònia Abilleira, Martin Dennis, Frances Horgan, Mark Vivian, Hazel Dodds, Alex Hoffman, Monique Kilkenny, Dominique A Cadilhac

International Comparisons

Acknowledgement to: Erin Lalor, Dawn Harris, Anthony Rudd, Sònia Abilleira, Martin Dennis, Frances Horgan, Mark Vivian, Hazel Dodds, Alex Hoffman, Monique Kilkenny, Dominique A Cadilhac

International comparisons

Acknowledgement to: Erin Lalor, Dawn Harris, Anthony Rudd, Sònia Abilleira, Martin Dennis, Frances Horgan, Mark Vivian, Hazel Dodds, Alex Hoffman, Monique Kilkenny, Dominique A Cadilhac

International comparisons

Acknowledgement to: Erin Lalor, Dawn Harris, Anthony Rudd, Sònia Abilleira, Martin Dennis, Frances Horgan, Mark Vivian, Hazel Dodds, Alex Hoffman, Monique Kilkenny, Dominique A Cadilhac

Questions?

Royal College of Physicians of Edinburgh

Scottish Stroke Collaboration Meeting

22nd September 2010

Queen Mother Conference Centre