Transcript National Review of Stroke Services in Hospitals and the

Irish National Audit of
Stroke Care (INASC)
Professor Hannah McGee RCSI
Professor Des O’Neill TCD
Dr Frances Horgan RCSI
Dr Anne Hickey RCSI
INASC Overview
Stroke – assembling the jigsaw
Dr Frances Horgan
INASC
Stroke in Ireland
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3rd most common cause of death
Leading cause of acquired major disability
Stroke - a singular and complex illness
Major concerns over adequacy of services
but very little data available Council on Stroke, 2001
• Aims of this project
• to conduct a national audit of stroke care across
the trajectory of care in hospital and the
community in the Republic of Ireland
INASC
First comprehensive audit
GPs
Prevention
Allied
Health
Professionals
PHN
Organisation
of Hospital
care
Nursing
Homes
Support
in the
Community
Actual
Hospital
Care
INASC
INASC PROJECT: Six Studies
March 2006-September 2007
HOSPITAL
- Organisational audit - 37 hospitals………. √
- Clinical (chart) audit - 2570 charts ………. √
[based on UK Sentinel audit system]
COMMUNITY
- GP Survey - 204 GPs……..………………. √
- AHP & PHN survey…75 professionals….. √
- Patient & carer survey…139 patients, 72 carers…√
- Nursing home survey…60 homes …….… √
INASC
Hospital Audit - Methods
• Organisational Audit:
• Aim - Audit of the organisational aspects of stroke care in
acute hospitals with regard to resources for organised
stroke care
• Structured face-to-face interview with Management Team
• Clinical Audit:
• Aim: Audit of Stroke Care - review clinical case notes
(2,570) for representative sample of patients
• Charts identified for Jan-March 2005 and July-Sept 2005
(HIPE ICD10 I61 I63 I64)
INASC
Emergency and acute hospital care
• Only one Irish hospital had a stroke unit
• Thrombolysis almost non-existent - 1%
• Swallow screening - available 5 sites
• 16% of hospitals had TIA clinics
INASC
Staffing and acute hospital care
• One third of hospitals had lead consultant
for stroke care (only 5 protected time)
• 5 clinical nurse specialists
• 2 clinical specialist therapists
• Availability of MDT limited
• Clinical psychology almost non-existent
INASC
Acute hospital care
Access to rehabilitation
• 35% of hospitals had access to on-site
rehabilitation
• Limited access to rehabilitation for younger
stroke patients
• Stroke specific MDT meetings in only 22%
hospitals
• 22% had documented rehabilitation goals
(76% UK06)
INASC
Who gets stroke?
- Men 52%
Women 47%
- 19% < 65 years
- 92% living at home at the time of the stroke
- 73% independent in activities of daily living
(ADL) pre-stroke
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On discharge…
56% discharged home
15% newly institutionalised
Only 28% independent in ADL at discharge
UK 06
(17%)
(13%)
(39%)
INASC
Co-morbidity Profile
Known co-m orbidi tiesprior to admission with stroke (Q2.1) (n=2173)
Co-morbidi ty
INASC 2006
Sentinel
Sentinel
%(N)
UK 2006
UK 1998
Atri al ifbrillation
Previous stroke/T IA
Impaired gl ucose tolerance
Diabetes m ellitus
Hyperlipidaemia*
Hypertension^
M I or angina
Valv ular heart disease
Other
None appl y/detected
22% (469)
25% (541)
1% (22)
12% (260)
17% (372)
51% (1108)
14% (307)
4% (92)
18% (388)
17% (362)
20%
29%
NA
16%
19%
53%
20%
3%
5%
21%
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
None of the above
1 of the above
2 of theabove
3 or more of the above
22% (479)
29% (626)
24% (524)
25% (544)
21%
29%
27%
23%
NA
NA
NA
NA
* Hyperlipidaemia = total cholesterol >5 or LDL >3.0mmo l/L
^ Hypertension = systolic > 140 or diastolic > 85
Other = Congestive cardiac failure (CCF) and Polymyalgia Rheumatica
NA not available
INASC
Acute hospital - diagnostics
• 71% admitted on day of stroke, 5% within 2 hours of stroke
(UK 39%)
• 30% did not have routine access to CT within 48hr of stroke
and only 41% emergency MR scanning
• Time from stroke to scan mean 2.6 days, median* 1 (1 day*
UK06)
• INASC 4% scanned within 3 hours (9% UK06)
INASC
Standards within 72 hours
UK 06
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SLT swallow screen 26%
(66%)
SLT swallow assessment 25%
(67%)
Physiotherapy assessment 43%
(71%)
Nutrition assessment 81%
(93%)
Aspirin within 48 hours 43%
(67%)
INASC
Standards within 7 days
UK 06
• SLT communication assessment 29%
(69%)
• OT assessment 22%
(68%)
• Continence plan 13%
(54%)
INASC
INASC - Onset/Hospital Stay
INASC 2006
% (N)
Sentinel 2006
Sentinel 1998
Died in hospital
Unknown
19% (408)
4%
26%
1%
NA
30-day mortality
Unknown
15% (317)
13%
22%
5%
29%
Length of stay
mean 29.8
days
median 14
Mean 27.7
days
median 15
INASC
Communication patients and carers
UK 06
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Discussion stroke diagnosis 22%
Discussion stroke prognosis 18%
Assessment of carers needs 24%
Skills taught to carers 12%
7% Irish patients had a home visit
(69%)
(59%)
(68%)
(71%)
(63%)
• Only 4 hospitals had a hospital/community liaison person
INASC
Medications
Cardiov ascular medication prof ile pre-admission (Q2.3i)
INASC 2006
% (N)
Antihypertensives
56% (1219)
Antiplatelet/antithrombotic
52% (1133)
Lipid lowering treatment
25% (546)
Sentinel 2006
57%
51%
33%
Cardiov ascularmedication profile at discharge (Q6.3)
INASC 2006 % (N)
Sentinel 2006
Antihy pertensiv es
Antiplatelet/antithrombotic
Lipid lowering treatment
57%
86%
79%
78% (1306)
85% (1423)
70% (1177)
INASC
Acute hospital care - secondary
prevention
UK 06
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51% cause stroke identified/documented
Smoking cessation 9%
Reduce alcohol 7%
Exercise 8%
Diet advice 14%
67% Blood cholesterol documented
(73%)
(79%)
(80%)
(41%)
(42%)
(NA)
INASC
Discharge from hospital & follow-up
• GP informed of patient’s discharge
• 56% of GPs notified on day of discharge
• 24% of discharge summaries indicated functional status
• 35% had carotid imaging within 3 months
INASC
Audits and improvement - INASC vs. Sentinel Rounds UK
INASC
Ireland 2006
UK 2002
UK 2004
UK 2006
Stroke unit*
3%
73%
79%
91%
Rapid transfer
to hospital
3%
NA
4%
12%
Routine
Thrombolysis
0%
NA
NA
18%
Neurovascular
clinic
16%
NA
65%
78%
Mobile stroke
team*
14%
NA
23%
29%
Early support
discharge team*
0%
NA
14%
22%
Specialist
community rehab
team (CRT)*
0%
NA
25%
32%
Consultant with
responsibility for
stroke*
32%
80%
90%
98%
INASC
12 Key standards and indi cators of stroke care INASC vs. Sentinel
Key standards
INASC
Sentinel
% Compliance wit h indi cator
2006
2004
Q1.2iii
Q1.7
Q1.9
Q3.1
Q3.3
Q3.5
Q4.2
Q5.1
Q5.3
Q6.3
Q5.5
Q7.4
Sentinel
2006
Patients
2173
%
8697
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13625
%
Brain scan within 24 hours
Treated on a stroke unit during their stay
> 50% stay on a stroke unit
Screened for swallow within 24 hours
Aspirin started by 48 hours
Phy siotherapy assessment within 72
hours of admission
Occupational therapy assessment within
7 day sof admission
Weighed at least once during admission
Mood assessed bydischarge
On anti-thrombotic therapy by discharge
Rehabilitation goals agreed by MDT
Home v isit perf ormed by discharge
Average for 12 indicators
40
2
1
26
45
43
59
46
40
63
68
63
42
62
54
66
71
71
22
57
68
41
28
85
22
7
30
52
47
95
68
69
61
57
55
100
76
63
65
INASC
INASC Main findings:
community stroke management
Dr Anne Hickey
Community Surveys: Methods
• National GP survey:
• Randomly selected (n=204: 46% response), postal survey
• Allied health professional (AHP) & public health
nurse (PHN) survey (3 phases):
• N=75 interviews/postal survey involving Local Health
Office managers, AHP/PHN managers and frontline staff
across 8 disciplines
• Patient & carer survey:
• Interviews with 139 (55% response) patients and 72 carers
• Nursing home survey:
• Interviews with proprietor/manager in 60 nursing homes
(20 Dublin, 40 outside Dublin) and residents with stroke
INASC
GP Survey - Stroke Management
• Information letter at discharge focused almost entirely on
diagnosis; little information on functional ability,
rehabilitation or community services organised
• Staff shortages most significant barrier to rehabilitation lack of OT, SLT, physiotherapy and home help
• GP stroke patients residing in nursing homes - c. 25%
INASC
AHP/PHN Survey - Stroke
Management/Service Provision
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PLANNING:
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DISCHARGE:
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Communication at discharge absent, delayed or limited
Equipment / support often not in place at discharge
TEAMWORK:
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No stroke statistics/registers - Absence of information on
prevalence of stroke in community makes planning for
comprehensive community-based stroke service very difficult
Separate notes; few team meetings
Multidisciplinary service, not operating as multidisciplinary team
Access to dietetics, social work & psychology largely non-existent
LIMITS:
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Services age-related (younger have limited access)
Limited input to nursing homes
INASC
AHP/PHN Survey - Conclusions
• Inequitable access to rehabilitation - no
programmes in some areas
• Community AHP staffing levels do not reflect
availability for stroke-related service provision
• Need for key worker to ensure streamlined
services
• Current staffing levels and employment ceilings
restrict service development - complete absence
of some disciplines in some areas (notably social
work, speech & language therapy, dietetics,
psychology)
INASC
Patient/carer perspectives on
hospital discharge
• Inconsistent, haphazard discharge planning:
• 75% no family conference prior to discharge
• 67% no contact name after discharge
• 33% necessary services not in place on
discharge
• 34% no information on purpose of medication,
70% not informed of potential medication sideeffects
INASC
Patient/carer perspectives on
community stroke care
• Poor community rehabilitation
• 50%+ not getting sufficient mobility
treatment
• Approx. 50% not getting sufficient SLT
treatment
• 75% no support with emotional difficulties
• Less likely to receive services if under 65 years
INASC
Stroke carers
• Need for information and support about
diagnosis, prognosis and post-hospital care
• Carer expected to become ‘expert’ once
patient came home
• Need for ‘key worker’ to provide contact if
needed
• One in 10 carers classified as ‘at risk’ of
health problems; all women, predominantly
over 65
INASC
Nursing Home Residents and
Stroke
N= 570 residents with stroke:
83% > 75yrs; 2% < 65yrs
Percentage of nursing home residents with
stroke
<65 yrs 65-74 yrs 75+ yrs
Affected
by stroke
8%
23%
18%
INASC
Stroke Resident Impairments
Overall (% of the
total number)
N=570
Communication Difficulty
51
Swallow difficulty
52
Cognitive impairment
64
Positioning needs
85
Limited independence
86
Risk of falls
87
Decreased independence in transfers
(bed to chair and back)
88
Decreased balance
86
Poor mobility / Mobility needs
83
Residual weakness after stroke
92
INASC
Nursing Homes: Access to
Services
• Access to GP ‘very good’
• Access to rehabilitation professionals-’POOR’
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Stroke patients described as ‘discharged from
active rehabilitation services’
- some access to physiotherapy
- very limited access to SLT, OT, dietician, social
work; no access to psychology
• Many challenges appear similar to those of nursing
home residents generally
INASC
Preventing and Managing Stroke
in the Community
• Little or no organised system of care for the
management of stroke in the community
• Little systematic or organised primary prevention
of stroke
• Lack of awareness evident in other Irish research
• Major awareness and education campaign needed
(rapid response essential):
• Public and those working with public
• Primary care professionals
• Hospital and rehabilitation professionals
INASC
Primary prevention of stroke
• Barriers to implementation of stroke
primary prevention strategies in primary
care:
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Inadequate staffing
Time pressures
Lack of designated funding
Lack of screening protocols
Lack of risk factor management protocols
INASC
Potential for Stroke Prevention and
Screening in General Practice
• Heartwatch (heart disease management) GP practices
much more likely to have:
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Registers of patients with hypertension
Registers of patients with diabetes
Registers of patients with atrial fibrillation
Registers of patients with stroke
Regular practice audits
• Potential to expand to Cardiovascular Watch, to
include key stroke-related variables (e.g., screening
for atrial fibrillation)
INASC
INASC Implications of findings
for stroke services in Ireland
Professor Desmond O’Neill
‘After I got home, there should have been
someone to help from the start’. (Patient)
‘No one seemed to know who was
looking after him; there was no
follow-up, and very little support
was available’. (Carer)
‘I was only 52 and had my own business.
I miss the contact with work colleagues
and can go for weeks without seeing
anyone’. (Patient)
‘A contact person would have been nice, someone
to talk to’. (Patient)
INASC
INASC Summary
• Allows quality of care comparisons against
professional guidelines and neighbouring
jurisdiction (UK National Sentinel Audit)
• Provides comprehensive profile of stroke care
across primary and secondary prevention, acute
treatment, rehabilitation and longer-term care
• Enables evidence-based planning and evaluation
of strategies to improve service delivery
INASC
INASC Implications
• National strategy for stroke
• Regional governance, implementation of stroke
care
• Stroke register
• Primary prevention - supportive structures
• Reconfiguration hospital services
• Urgent development STROKE UNITS with
appropriate services and staff
• Rehabilitation at all stages of care
INASC
Implications…
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Systems for sharing information and follow-up
Ongoing support and community rehab
Information on stroke patients and carers
Major developments staffing and specialist
training for all disciplines
Equitable needs based access to care
Public awareness programmes
Transportation
Repeat audit cycle
INASC
INASC
Acknowledgments
Hospital staff; physicians, management team, HIPE staff, Medical Records.
Chart auditors
ESRI Health Policy Unit
National Hospitals Office
Sentinel team UK - Dr Tony Rudd and Mrs Alex Hoffman
Stroke patients and their carers
Nursing home staff
Community PHNs AHPs, AHP Managers and Frontline staff, LHOMs
General Practitioners
Professional organisational submissions
Ms Imelda Noone and Ms Aisling Creed
INASC
INASC Project Steering Group
• Professor Hannah McGee - Psychology RCSI (Co-PI)
• Professor Des O’Neill - Gerontology TCD (Co-PI)
• Dr Frances Horgan - Physiotherapy RCSI (Project Manager/Lead
Hospital audit)
• Dr Anne Hickey - Psychology RCSI (Lead Community Projects)
• Professor Seamus Cowman - Nursing RCSI
• Professor David Whitford - General Practice RCSI
• Dr Emer Shelley - Epidemiology RCSI
• Dr Sean Murphy - Midland Regional Hospital Mullingar
• Professor Miriam Wiley - Economic & Social Research Institute
• INASC Project Research Staff
• Research Staff at the Division of Population Health Sciences (Psychology),
RCSI: Ms Karen Galligan, Ms Helen Corrigan, Ms Maeve Royston, Ms
Maeve Proctor, Ms Oonagh Mullan, Ms Abigail Henderick, Ms Anna-May
Fitzgerald, Ms Philippa Coughlan, Dr Bernadette O’Sullivan, Ms Claire
Donnellan and Dr Maja Barker
INASC