Transcript Scottish Stroke Care Audit System

Scottish Stroke Care
Audit System
NHS Fife
2012 data
Dr Sue Pound, Stroke Consultant
Hazel Fraser Stroke Co-ordinator
Isla McBain, Stroke Audit assistant
Nov 2013
National Scottish Stroke Care Audit
System (SSCAS)
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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 2012
Patients discharged with a final diagnosis of stroke
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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
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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
100
97
94
90
89
target
<= day 1
89
86
80
81
81
83
82
82
79
78
73
75
70
target
<= day 0
60
55
53
50
<= day 0
49
48
41
40
49
<= day 1
47
39
37
36
36
32
30
32
31
20
16
14
10
0
YEAR
2010
YEAR
2011
YEAR
2012
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
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
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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
100
90
80
target
75
73
71
70
68
69
69
67
65
65
64
63
60
60
59
64
60
50
40
YEAR
2010
YEAR
2011
YEAR
2012
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
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
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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
100
target
90
80
80
80
77
70
71
70
68
66
66
65
60
69
64
60
58
56
50
44
40
YEAR
2010
YEAR
2011
YEAR
2012
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
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
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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
2011
80%
77%
% Given Aspirin <= 1 day
100
100
target
90
88
84
85
84
80
80
81
81
82
79
79
79
75
71
70
67
60
50
40
YEAR
2010
YEAR
2011
YEAR
2012
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
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
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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 & E
Thrombolysis governance meetings
A & E Alerted by SAS
CT prewarned stroke admission
STAT (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
100
100
90
80
100
100
96
100
100
96
88
85
81
80
76
83
79
82
80
100
86
86
83
83
82
79
80
target
77
70
65
63
60
53
50
QMH
VHK
42
40
30
26
20
10
0
YEAR
2010
YEAR
2011
YEAR
2012
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Actions to improve waiting times
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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
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To improve stroke care
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“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
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NHS Fife failed the target, performance had
dropped in Nov and Dec 2012
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Jan – March 2012 : 71%
Apr – June 2012 : 85%
Jul – Sep 2012 : 91%
Oct – Dec 2012 : 79%
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Jan – March 2013: 95%
Apr – June 2013: 95%
July – Sept 2013: 97%
New Challenges
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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
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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 inhospital stroke related needs are met.
*it is expected where possible and safe, all patients with a stroke be
directly admitted to the stroke unit
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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
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90% of patients are screened by a standardised
assessment to identify and difficulty swallowing
on day of admission
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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.)
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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
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MCN monitors delay between arrival and
administration of thrombolysis. 80% of patients
should receive bolus within one hour of arrival
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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
100
98
95
95
97
97
95
92
90
83
80
81
81
79
70
60
50
40
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
100
93
91
90
80
90
91
81
80
70
70
68
66
66
60
50
40
YEAR 2011
YEAR 2012
40
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
100
100
98
96
92
95
93
93
98
96
94
90
88
80
70
60
50
40
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
100
97
98
94
92
91
90
91
86
84
83
81
80
75
70
60
50
40
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 the
neurovascular clinic
100
95
90
84
84
84
80
78
70
62
60
60
56
57
56
QMH
50
VHK
46
47
47
46
45
40
34
35
33
30
20
19
10
21
10
0
YEAR 2011 YEAR 2012
Jan-13
Feb-13
Mar-13
Apr-13
0
May-13
Jun-13
Jul-13
Aug-13
Sep-13
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.
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Carotid Endarterectomy within 14 days
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Numbers small
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33% for last 12 months
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14 CEA since Jan 2013 data not complete
yet
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Further information available at
www.strokeaudit.scot.nhs.uk
Any local queries please contact Hazel Fraser
Stroke Co-ordinator
[email protected]