NSS Information and Intelligence · 2019-07-09 · 2019 National Report - Scottish Stroke Improvement Programme v Chart 1.1: (Health Board) Percentage of stroke patients receiving

2019 report.

NSS Information and Intelligence

Scottish Stroke Improvement Programme

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2019 National Report - Scottish Stroke Improvement Programme

i

Contents

Introduction ......................................................................................................................... ii

1 Scottish Stroke Improvement Programme ................................................................. 1

2 Scottish Ambulance Service Stroke Improvement Plan ............................................ 5

3 Inpatients ....................................................................................................................... 6

4 Outpatients .................................................................................................................. 18Summary and key findings relating to outpatient data ................................................. 18

5 Atrial Fibrillation .......................................................................................................... 23

6 Thrombolysis and Thrombectomy ............................................................................. 25Emergency treatments to unblock arteries causing ischaemic stroke .......................... 25Thrombolysis ................................................................................................................. 25Thrombectomy .............................................................................................................. 30

7 Carotid Intervention .................................................................................................... 31

8 Rehabilitation ............................................................................................................... 35

9 Outcomes after admission with stroke ..................................................................... 36

10 Using SSCA data for research ................................................................................... 40

11 Where Next?................................................................................................................. 41

List of References ............................................................................................................ 42

Appendix A: Responses from Chief Executives ............................................................ 43NHS Ayrshire & Arran .................................................................................................... 43NHS Borders ................................................................................................................. 44NHS Dumfries & Galloway ............................................................................................ 44NHS Fife ........................................................................................................................ 45NHS Forth Valley .......................................................................................................... 46NHS Grampian .............................................................................................................. 47NHS Greater Glasgow & Clyde ..................................................................................... 48NHS Highland ................................................................................................................ 48NHS Lanarkshire ........................................................................................................... 49NHS Lothian .................................................................................................................. 50NHS Orkney .................................................................................................................. 51NHS Shetland ................................................................................................................ 51NHS Tayside .................................................................................................................. 52NHS Western Isles ........................................................................................................ 52

Appendix B: List of Tables and Charts ........................................................................... 54

Appendix C: Stroke Improvement Plan Priorities & Actions RAG ................................ 56

Appendix D: Additional Information ................................................................................ 63Acknowledgements ....................................................................................................... 63


ii

Introduction

Map of Scotland showing all hospitals in NHS boards contributing to the Scottish Stroke Care Audit

NHSGrampian

NHSTayside

NHSForth Valley

NHSLanarkshire

NHSBordersNHS

Ayrshireand Arran

NHSFife

NHSLothianNHS

Greater Glasgowand Clyde

NHSDumfries

and Galloway

NHSHighland

NHSShetland

NHSOrkney

NHSWestern Isles

NHSGrampian

NHSTayside

NHSForth Valley

NHSLanarkshire

NHSBordersNHS

Ayrshireand Arran

NHSFife

NHSLothianNHS

Greater Glasgowand Clyde

NHSDumfries

and Galloway

NHSHighland

NHSShetland

NHSOrkney

NHSWestern Isles

Ninewells Hospital DundeePerth Royal InfirmaryStracathro Hospital

Borders General Hospital

Queen Margaret HospitalVictoria Hospital,

Kirkcaldy

Raigmore HospitalBelford Hospital

Caithness HospitalLorn and Islands Hospital

Aberdeen Royal InfirmaryDr Gray’s, Elgin

Royal Infirmary of EdinburghSt Johns Hospital LivingstonWestern General Hospital

University Hospital HairmyresUniversity Hospital Monklands University Hospital Wishaw

Queen Elizabeth University HospitalGlasgow Royal Infirmary

Stobhill HospitalRoyal Alexandra Hospital

Vale of Leven HospitalInverclyde Royal Hospital

Forth Valley Royal HospitalStirling Community Hospital Falkirk Community Hospital

Dumfries and Galloway Royal InfirmaryGalloway Community Hospital

University Hospital Ayr University Hospital Crosshouse

Western Isles HospitalUist & Barra Hospital

Balfour Hospital

Gilbert Bain Hospital


iii

This year the report continues to move in the direction of online only reporting, which will produce a more interactive experience. As always, feedback on the layout and content of the Scottish Stroke Improvement Programme (SSIP) Annual Report would be much appreciated.

Stroke is a key health issue for the people of Scotland and the Scottish NHS. It is the third commonest cause of death in Scotland and the most common cause of severe physical disability amongst Scottish adults. Over nine and a half thousand stroke patients were admitted to Scottish hospitals in 2018. A further thousand stroke cases were seen at neurovascular (TIA) clinics and many cases may never present to medical attention. Stroke has a significant impact on NHS resources, accounting for approximately 5% of total NHS costs2. Societal costs are even higher. The economic cost of stroke to Scotland in terms of lost employment and the cost of support in the community are significant, whilst the impact on family members or friends who care for stroke survivors is massive. For these reasons it is important that all NHS boards across Scotland deliver high quality and equitable stroke care.

Table 1.1: Numbers of confirmed stroke patients by NHS Board of Residence, showing percentage by age, sex, stroke type, case mix and deprivation category, 2018 data (final diagnosis).

NHS board of ResidenceConfirmed

Strokes admitted

during 2018

Crude rate per 100,000

residents

Mean Age Males (years)

Mean Age Females (years)

Males Ischaemic Strokes

Case Mix Scottish Index of Multiple Deprivation

Independent in Activities

of Daily Living?

Lived alone at normal place of

residence?

Can talk at first

assessment?

Orientated to time, place and person

at first assessment?

Can lift both arms off the bed at first

assessment?

Can walk without help from another

person?

SIMD 1 (Most

deprived)

SIMD 2 SIMD 3 SIMD 4 SIMD 5 (Least

deprived)

Percentage of Confirmed Strokes

Total 9 641 178 71 76 51 87 83 37 74 64 60 42 24 22 19 18 15

Ayrshire & Arran 856 232 70 75 50 88 79 36 67 63 68 46 34 24 18 13 12

Borders 191 166 74 77 53 86 83 32 74 54 71 66 8 16 30 40 6

Dumfries & Galloway 244 164 74 78 52 84 84 39 70 65 57 32 12 26 38 20 4

Fife 865 233 71 76 51 90 82 38 81 65 69 47 23 25 22 15 16

Forth Valley 502 164 72 76 56 87 93 37 78 63 41 39 20 30 17 19 14

Grampian 820 140 73 76 53 84 85 35 66 64 57 32 6 16 20 30 27

Greater Glasgow & Clyde 2 062 175 69 74 51 89 80 38 73 64 62 50 45 18 11 11 14

Highland 509 158 72 76 52 85 84 37 69 67 54 44 8 23 30 30 9

Lanarkshire 1 097 166 70 75 52 90 81 34 75 65 55 44 30 30 19 13 8

Lothian 1 398 156 71 77 48 83 83 39 80 60 65 33 14 24 17 17 28

Orkney 35 158 74 75 51 80 86 29 71 63 51 37 0 37 26 31 6

Shetland 34 148 67 80 65 71 88 29 65 35 53 24 0 6 29 65 0

Tayside 717 172 71 77 52 82 89 35 82 76 49 34 18 18 23 27 15

Western Isles 42 157 68 80 45 79 69 43 62 43 31 21 0 38 57 5 0

Outside Scotland/ Not Known/ Other

269 - 69 75 56 88 88 27 71 71 55 42 - - - - -

Notes regarding Table 1.1:1 NHS board of residence derived from postcode. A small proportion of records cannot be assigned to specific NHS boards because of

insufficient information (e.g. part postcode) or because patient was a non-Scottish resident.2 Some patients may not be treated within their resident NHS board and may travel to other NHS boards for treatment.3 The column ‘Confirmed strokes’ excludes a small proportion of records for in-hospital wake-up strokes (where the patient was already in

hospital for other reasons and had a stroke during their hospital stay but with doubt about whether they woke from sleep with symptoms of stroke).

4 For further information on the Scottish Index of Multiple Deprivation (SIMD) see the Scottish Government web site at http://www.gov.scot/Topics/Statistics/SIMD and http://www.gov.scot/Resource/0050/00504809.pdf.

Table 1.1 provides information on stroke admissions across Scotland including details on age, stroke type, deprivation and other case mix factors.

Table 3.1 describes the provision of stroke unit beds across Scotland. The vast majority of patients are managed in integrated stroke units which provide both acute care and rehabilitation. In the developed world many areas have developed comprehensive stroke centres (centres that deliver all aspects of stroke care, including stroke thrombectomy). Currently there are no comprehensive stroke centres in Scotland.


iv

The Scottish Stroke Care Audit (SSCA) has been collecting information about stroke care since 2002. Since its inception the SSCA has helped to drive evidence-based improvements in stroke care which have contributed to falling mortality rates and improved outcomes for Scottish stroke patients. The SSCA has moved its focus more towards service improvement and safety over the last few years. As improvements in performance against most of the Scottish Stroke Care Standards have occurred across Scotland, the focus has moved towards measuring stroke care ‘bundles’. Instead of measuring how an individual fares against any one stroke standard, bundles measure how that individual fares against all relevant Scottish Stroke Care Standards. Achieving this care bundle is associated with reduced mortality and increased likelihood of discharge to usual residence after stroke10.

Across Scotland Stroke Bundle compliance has improved from 65% in 2017 to 68% in 2018. This is some way short of the 80% standard. The majority of NHS boards have seen improvement over this time, with both Tayside and Dumfries and Galloway making statistically significant gains. However, performance in NHS Highland continues to give rise to concern. With a change in the CT Standard beginning from the start of 2019, it will be challenging to maintain or even improve on Bundle performance in next year’s report.

The numbers of patients being thrombolysed has now stabilised at around 13% of all ischaemic stroke admission. Unfortunately improvements in door to needle times against the 30 and 60 minute standards have stalled over the last 12 months, emphasizing the need for more work here in preparation for the development of a thrombectomy services in Scotland.


v

Chart 1.1: (Health Board) Percentage of stroke patients receiving an ‘appropriate’ Stroke Care Bundle (i.e. Stroke Unit admission, swallow screen, brain scan and aspirin), 2017 and 2018 data (based on final diagnosis).

Horizontal line reflects Scottish Stroke Care Standard (2016) of 80% of stroke patients to receive the appropriate elements of the stroke care bundle (i.e. Stroke Unit admission, swallow screen, brain scan and aspirin).

2017 (%)

2018 (%) statistically signi�cant improvement

2018 (%)statistically signi�cant decline

2018 (%)no statistically signi�cant change

Stroke Standard (2016)

0

10

20

30

40

50

60

70

80

90

100

Sco

tland

Ayr

shire

& A

rran

Wes

tern

Isl

es

Gra

mp

ian

Lan

arks

hire

Ork

ney

Fife

Bor

der

s

Tay

sid

e

She

tland

Gre

ater

Gla

sgow

& C

lyd

e

Fort

h V

alle

y

Lot

hia

n

Dum

frie

s &

Ga

llow

ay

Hig

hlan

d

%

Notes regarding Chart 1.1:1. A ‘bundle’ involves a group of specific interventions/ processes of care that significantly improve patient outcome if done together

rather than separately and this also improves the consistency with which patients are managed. The Stroke Care Bundle involves four components: admission to a Stroke Unit, swallow screen, brain scan and aspirin. Not all patients are

eligible for all four components. An aspirin allergy, for example, would preclude the prescribing of aspirin, so the term ‘appropriate’ refers to patients receiving the components for which they were eligible. A flow chart in section 1 of this report describes the different categories of bundle depending on patients’ eligibility.

For the specific components, exclusions are as follows: (1) Stroke Unit admission excludes patients with in-hospital strokes, patients transferred in from another acute hospital or patients discharged within 1 day of admission to hospital (2) aspirin excludes patients with valid contraindications to aspirin and also those receiving a ‘non-stroke’ final diagnosis who are discharged within 1 day of admission to hospital.

In measuring the proportion of patients receiving an ‘appropriate’ bundle, patients ineligible for, and therefore not receiving, specific components of the bundle are counted as having received their appropriate bundle provided they received the remaining components for which they were eligible.

2. Due to the number of beds within some hospitals indicated and the small numbers of stroke admissions to these hospitals it is not practical to have a defined Stroke Unit. We have confirmed however that a defined stroke pathway is in place in these hospitals and that the Scottish Stroke Care Standard criteria are established within that pathway.

3. Uist & Barra Hospital, NHS Western Isles does not have a CT scanner but patients are airlifted to Western Isles Hospital and a proportion may arrive in sufficient time to have brain imaging within 24 hours of admission.

4. During 2017 NHS Dumfries & Galloway opened the new Dumfries & Galloway Royal Infirmary.


vi

Chart 1.2: (Hospital) Percentage of stroke patients receiving an ‘appropriate’ Stroke Care Bundle (i.e. Stroke Unit admission, swallow screen, brain scan and aspirin), 2017 and 2018 data (based on final diagnosis).

Horizontal line reflects Scottish Stroke Care Standard (2016) of 80% of stroke patients to receive the appropriate elements of the stroke care bundle (i.e. Stroke Unit admission, swallow screen, brain scan and aspirin).

2017 (%)




Stroke Standard (2016)0

10

20

30

40

50

60

70

80

90

100

Sco

tland

GC

H*

Cro

ssho

use

IRH

Ha

irmyr

es

Wes

tern

Isl

es

GR

I

AR

I

Mon

kla

nds

SJH

Nin

ewel

ls

Ba

lfour

VH

K

Bor

der

s

Cai

thne

ss*

Gilb

ert B

ain*

Wis

haw

QU

EH

FVR

H

Dr

Gra

ys

RIE

PR

I

DG

RI

Bel

ford

*

RA

H

L&

I

Ra

igm

ore

WG

H

Ayr

%

Notes regarding Chart 1.2:1. A ‘bundle’ involves a group of specific interventions/ processes of care that significantly improve patient outcome if done together

rather than separately and this also improves the consistency with which patients are managed. The Stroke Care Bundle involves four components: admission to a Stroke Unit, swallow screen, brain scan and aspirin. Not all patients are

eligible for all four components. An aspirin allergy, for example, would preclude the prescribing of aspirin, so the term ‘appropriate’ refers to patients receiving the components for which they were eligible. A flow chart in section 1 of this report describes the different categories of bundle depending on patients’ eligibility.

For the specific components, exclusions are as follows: (1) Stroke Unit admission excludes patients with in-hospital strokes, patients transferred in from another acute hospital or patients discharged within 1 day of admission to hospital (2) aspirin excludes patients with valid contraindications to aspirin and also those receiving a ‘non-stroke’ final diagnosis who are discharged within 1 day of admission to hospital.

In measuring the proportion of patients receiving an ‘appropriate’ bundle, patients ineligible for, and therefore not receiving, specific components of the bundle are counted as having received their appropriate bundle provided they received the remaining components for which they were eligible.

2. Due to the number of beds within some hospitals indicated (*) and the small numbers of stroke admissions to these hospitals it is not practical to have a defined Stroke Unit. We have confirmed however that a defined stroke pathway is in place in these hospitals and that the Scottish Stroke Care Standard criteria are established within that pathway.

3. Uist & Barra Hospital, NHS Western Isles does not have a CT scanner but patients are airlifted to Western Isles Hospital and a proportion may arrive in sufficient time to have brain imaging within 24 hours of admission.

4. During 2017 NHS Dumfries & Galloway opened the new Dumfries & Galloway Royal Infirmary.5. Uist and Barra Hospital has been excluded from this chart due to very low patient numbers.


1

1 Scottish Stroke Improvement ProgrammeThe NHS Scotland Quality Strategy1 is the NHS Scotland Blueprint for improving the quality of care that patients and carers receive from the NHS across Scotland. It sets out an ambition for health care that is person centred, safe and effective, underpinned by the need to “embed the mutual approach of shared rights and responsibilities into every interaction between patients, their families and those providing health services.” The Scottish Stroke Improvement Programme (SSIP) works with stroke Managed Clinical Networks (MCNs)/ NHS boards to focus on building capacity for all staff to ensure that they have the knowledge, skills and attitudes necessary to deliver high quality services. Stroke remains the third biggest killer in Scotland and the leading cause of disability. Further reducing the number of deaths from stroke has been a clinical priority for NHS Scotland since the mid 1990s. Scotland continues to have exceptionally high levels of stroke related deaths compared to the rest of Western Europe. The SSIP has set out ambitions to deliver world-leading stroke care which is consistently person-centred, clinically effective and safe. One of the key factors for success is that there is commitment

to patient safety and, in particular, to avoiding infection and harm, using consistent and reliable improvement methods. One of the triple aims of the 2020 vision2 is to further improve the quality of care provided, with one of the focuses being to improve the approach to supporting and treating people with stroke.

To improve services effectively the SSIP recognises the need to set clear aims which have been established through the Scottish Stroke Care Standards (2016) and the priority actions from the Stroke Improvement Plan4. Through the Scottish Stroke Care Audit (SSCA) and the regular monitoring against the priority actions, performance is mapped and the Stroke MCNs develop action plans, test change and implement improvement methodologies. The Stroke Improvement Programme Lead and SSCA National Clinical Coordinator work closely with the NHS boards to ensure the key priorities from the Improvement Plan and the Scottish Stroke Care Standards are implemented and monitored. However, it is ultimately the responsibility of each NHS board’s Chief Executive to ensure that services improve

Scottish Stroke Care Standards Implemented 1st April 2016 (Following review of Scottish Stroke Care Standards 2013)

Topic Standard

Access to Stroke Unit 90% within 1 day of admission (Day 0 and 1).

Brain imaging 95% within 24 hours of admission.

Swallow screen 100% within 4 hours of arrival at hospital

Aspirin administration 95% of ischaemic strokes within 1 day of admission (Days 0 and 1).

Delay from receipt of referral to specialist stroke/TIA clinic

80% are assessed within 4 days of receipt of referral (Day 0 being day of receipt of referral).

Thrombolysis 50% of patients receive the bolus within 30 mins of arrival. 80% of patients receive the bolus within one hour of arrival.

Carotid Intervention 80% undergoing carotid endarterectomy for symptomatic carotid stenosis have the operation within 14 days of the event that first led them to seek medical assistance.


2

The national standards are recommended by the SSCA steering group and ratified by the National Advisory Committee for Stroke. The standards should not be used to guide the care of individual patients since there may be very legitimate reasons for NOT treating a patient according to the standard. The standards are used to assess the performance of stroke services, at a Scotland wide, NHS board or individual hospital level, not at the level of the individual patients.

The standards are set at a level which aims to be both challenging but potentially achievable by some hospitals. This is done to encourage improvements in performance. Once a standard is routinely exceeded by all hospitals then it is likely that the SSCA group will recommend that the standard is raised, or if already at an ideal level, it may actually be removed from the audit. It is therefore inevitable that many stroke services will not meet some of the standards. Stroke services need to use appropriate Quality Improvement methods to optimise their own performance. The audit aims to focus its resources on those areas where improvement will enhance patient outcomes and experience.

The following table represents the self evaluated performance of NHS boards when benchmarking themselves against the Stroke Improvement Plan priorities, displayed in Red, Amber, Green (RAG), Blue or Black with further detailed information in Appendix C.

Generic key for RAG chart and RAG status pages 3 and 4:

Complete and embedded in practice

Implemented but not delivered consistently

Plan to implement or partially implemented

Available but not implemented

No process or pathway in place


3

NHS Board Priority Area / Action

1.1 Public FAST campaign

1.2 Early

identification of stroke by SAS/ Primary Care/

Emergency Dept

2.1 Scottish

Ambulance Service (SAS)

Pre-Alert

2.3 Thrombolysis

Process & Pathway

3 Stroke Bundle

Delivery: Intermittent Pneumatic

Compression

4 Trained

Workforce: Education Template &

Training

5.1 Early Diagnosis:

TIA Access

5.2 Early Diagnosis:

TIA Imaging

Ayrshire and Arran

GREEN GREEN GREEN GREEN GREEN GREEN BLUE BLUE

Borders GREEN GREEN GREEN AMBER GREEN GREEN AMBER BLUE

Dumfries and Galloway

GREEN GREEN GREEN AMBER GREEN GREEN GREEN GREEN

Fife BLUE GREEN AMBER AMBER GREEN GREEN AMBER AMBER

Forth Valley AMBER AMBER AMBER AMBER GREEN GREEN GREEN GREEN

Grampian BLUE GREEN AMBER GREEN GREEN GREEN BLUE BLUE

Greater Glasgow and Clyde

GREEN GREEN AMBER AMBER GREEN GREEN AMBER RED

Highland GREEN GREEN AMBER AMBER GREEN GREEN AMBER AMBER

Lanarkshire BLUE BLUE AMBER GREEN GREEN BLUE AMBER AMBER

Lothian GREEN GREEN GREEN GREEN GREEN GREEN BLUE BLUE

Orkney GREEN AMBER GREEN GREEN GREEN AMBER BLUE GREEN

Shetland BLUE GREEN GREEN AMBER GREEN GREEN AMBER AMBER

Tayside GREEN GREEN GREEN AMBER GREEN GREEN AMBER AMBER

Western Isles BLUE GREEN AMBER GREEN GREEN GREEN AMBER AMBER


4

NHS Board Priority Area / Action6

Secondary Prevention: Anticoagula-tion for AF

7.1.1 Transition to Community:

Access to Stroke Therapy

7.1.2 Transition to Community:

Access to Stroke

Rehabilitation Services

7.2 Transition to Commu-nity: Goal Setting

7.3.1 Transition to Community: Specialist

Visual Assessment

and Rehabilitation

7.3.2 Transition to Community: Access to Specialist

Clinical Neuro-psychological

Services

7.3.3 Transition to Community: Specialist

Driving Assessment

8.1 Living with Stroke: Self

Manage-ment sup-port after discharge

8.2 Living with

Stroke: Access to Exercise

support after discharge

8.3 Living with

Stroke: Access to vocational rehabilita-

tion

8.4 Living with

Stroke: Stroke

Spasticity Manage-

ment

Ayrshire and Arran

AMBER GREEN AMBER AMBER BLUE AMBER BLUE GREEN BLUE GREEN AMBER

Borders AMBER GREEN AMBER GREEN BLUE RED BLUE AMBER AMBER AMBER GREEN

Dumfries and Galloway

AMBER BLUE AMBER AMBER BLUE GREEN BLUE GREEN AMBER GREEN AMBER

Fife GREEN AMBER GREEN GREEN GREEN AMBER GREEN GREEN BLUE BLUE AMBER

Forth Valley AMBER GREEN GREEN AMBER BLUE RED BLUE AMBER GREEN AMBER GREEN

Grampian AMBER AMBER AMBER AMBER BLUE AMBER BLUE GREEN GREEN AMBER GREEN

Greater Glasgow and Clyde

AMBER GREEN GREEN GREEN BLUE AMBER GREEN GREEN BLUE AMBER AMBER

Highland AMBER AMBER AMBER GREEN GREEN AMBER BLUE BLUE BLUE AMBER GREEN

Lanarkshire AMBER GREEN GREEN AMBER BLUE GREEN BLUE BLUE BLUE BLUE BLUE

Lothian RED AMBER AMBER BLUE AMBER GREEN BLUE GREEN GREEN GREEN GREEN

Orkney AMBER AMBER GREEN BLUE BLUE BLUE BLUE AMBER GREEN BLUE GREEN

Shetland BLUE AMBER AMBER BLUE RED RED AMBER GREEN BLUE BLUE GREEN

Tayside GREEN AMBER AMBER GREEN GREEN GREEN GREEN GREEN BLUE AMBER AMBER

Western Isles GREEN GREEN AMBER GREEN GREEN AMBER GREEN AMBER GREEN AMBER AMBER

Clearly there is variability across the country and NHS boards should strive to improve access to high quality services to ensure the best treatment and support is available to people living with stroke.


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2 Scottish Ambulance Service Stroke Improvement Plan

The Scottish Ambulance Service triaged 3,643 suspected Hyper Acute Stroke patients of which the Service achieved a median 96.3% compliance rate with the pre-hospital stroke bundle.

The pre-hospital stroke bundle ensures that ambulance clinicians across the country are meeting at a minimum, set clinical quality indicators in all occurrences of suspected hyper acute stroke.

The Scottish Ambulance Service is divided into three distinct regional areas, North, East and West which traverses the fourteen health boards across Scotland. Each region is facilitated with a clinical manager with co-responsibility for stroke alongside a Clinical Lead and Associate Medical Director within the National Clinical Directorate.

Health Board Locality/Council Ward area of incident

Number of Suspected Hyper Acute Strokes

% of Pre-hospital Stroke Bundle compliance

Median time from resource allocation to ED admission

(mins)

Ayrshire and Arran 274 95.3 51Borders 85 97.6 65Dumfries and Galloway 113 93.8 54Fife 362 96.7 44Forth Valley 189 93.1 51Grampian 383 97.4 57Greater Glasgow & Clyde 718 95.8 47Grampian 216 94.9 71Lanarkshire 349 96.6 49Lothian 630 98.1 50Orkney 7 100.0 70Shetland 12 100.0 40Tayside 256 94.0 51Western Isles 16 100.0 68

Note 33 incidents are unrecorded against a geographical health board.

The patient numbers represented in the table are patients who present with signs and symptoms of stroke and are deemed to be suitable for thrombolysis screening in the most appropriate and nearest emergency department. These patients in our care have not had a CT scan at this stage and it is therefore only possible to make an informed ‘working diagnosis’ of hyper acute stroke based on the history available to them of the immediate event and the presenting ‘condition’ of the patient.

Not all of these patients will therefore be included in the Scottish Stroke Care Audit as following a CT scan and assessment by a stroke physician, it may be deemed that the patient is not suffering from stroke.

To further improve our Clinician’s understanding, triage, assessment and care of patients suspected of suffering from hyper acute stroke, the Scottish Ambulance Service is embarking on an ambitious plan to link pre-hospital data with hospital and Scottish Stroke Care Audit data through collaboration with NHS Scotland’s Information Services Division (ISD) and the Unscheduled Care Datamart where this joint data is held.

It is anticipated that by having this 360˚ review process of the patient journey, we will be able to ascertain the effectiveness and sensitivity of our clinical pathways and treatment and care of our service users. Through collaboration with our partners and colleagues across the stroke and wider health care communities, we hope to further improve and build on the high level of care that we provide to patients in the pre-hospital setting.


6

3 InpatientsDuring 2018 over 9,000 patients were admitted to hospital with a final diagnosis of stroke and entered into the SSCA. This is a similar number to 2017. The characteristics of patients admitted to hospital are shown in Table 1.1. Ischaemic stroke was identified in 87% of patients and haemorrhagic stroke in 11%. There were similar numbers of men and women with a mean age of 71 years for men and 76 years for women; mean ages varied across NHS boards but the mean age of stroke was always greater in women. When patients in the audit were divided according to socio-economic factors, the areas of highest levels of deprivation, as measured by the Scottish Index of Multiple Deprivation (SIMD), had the highest percentage of the patient group. This reflects the recognised association between social deprivation and risk of stroke and emphasises the need to identify and address the factors contributing to stroke risk in this population.

Variations in case mix between NHS boards were observed as in previous years and this was particularly marked for the variable relating to ability to walk. This apparent variation in case mix emphasises the need to correct any patient outcome results for variations in stroke severity.

Table 3.1 lists the numbers of patients discharged from each hospital along with availability of specialist stroke unit beds in that hospital. Glasgow Royal Infirmary and the Queen Elizabeth University Hospital Glasgow are the only two settings to have adopted the Hyper-Acute Stroke Unit (HASU) model involving a small number of beds with a short length of stay aiming to facilitate early assessment, diagnosis, and treatment before moving patients to another ward. The majority of hospitals have an integrated stroke unit, which aims to combine both acute care and ongoing rehabilitation. Several hospitals also have stroke rehabilitation unit beds in an off-site hospital.

The most important overall indicator of the performance of stroke services within NHS Boards or hospitals is their performance against the stroke care bundle as described in the introduction. The cumulative proportions of patients with a final diagnosis of stroke who were managed in accordance with all four standards, which comprised the care bundle, was 68% across Scotland, a significant improvement on the 2017 performance of 65%. Chart 1.1 shows that Tayside, Dumfries and Galloway and Lanarkshire Health Boards showed a significant improvement; no Boards had a significant decline in performance.

Chart 1.2 shows similar data presented by hospital, with significant improvements in Glasgow Royal Infirmary, University Hospital Monklands, Ninewells Hospital and Dumfries and Galloway Royal Infirmary.

The proportion of patients across Scotland with a final diagnosis of stroke who accessed a stroke unit on the day of admission or the day after (82%) was the same in 2018 as in 2016 and 2017, and thus continues to fall below the standard of 90% (see chart 3.1). This indicator is important because early admission to a stroke unit has been associated with a reduced likelihood of dying after stroke. Ninewells Hospital, Dundee and Aberdeen Royal Infirmary both achieved statistically significant improvement in performance in 2018, with Ninewells now performing above the 90% target. It should be noted that small hospitals such as those on the Islands and in rural NHS boards perform well against this standard because their only medical ward fulfils our definition of a stroke unit.

For larger hospitals, the standard can be challenging because stroke patients are often boarded into medical wards and stroke unit beds filled with non-stroke patients particularly during periods of high bed demand. The number of stroke unit beds appears to be an important determinant of performance but there is also considerable variation in how well hospitals can manage these stroke beds. The degree of priority attached to achieving this standard appears to vary between hospitals.

A stroke often affects the patient’s ability to swallow food, fluids and medication safely so if a patient is identified as having a possible stroke a swallow assessment should be done as soon as possible and clearly recorded in the patient’s case-notes. Previous research has suggested that the greater the delay to swallow screen the higher the risk of stroke-associated pneumonia. Chart 3.2 shows the proportion of patients with a final diagnosis of stroke in Scotland who had a swallow screen within 4 hours of admission with the hospitals ranked from the highest to the lowest. Overall, 80% of patients


7

were treated in accordance with this standard which is a small but significant improvement since 2017 (76%). However, this still falls short of the target of 100%. University Hospital Crosshouse, University Hospital Monklands and Glasgow Royal Infirmary all showed a statistically significant improvement; elsewhere performance remained static. Chart 3.5 shows the percentage of patients who had a swallow screen within 4, 12, and 24 hours of admission which allows assessment of the extent to which units are missing the target – in some units there are many ‘near misses’ which might be fairly readily addressed.

Important measures to improve swallow screen performance include early identification of stroke patients and ensuring nurses are trained to undertake a swallow screen promptly and record the result clearly in the notes in the admission wards.

An early brain scan is required to exclude alternative causes of stroke symptoms such as brain tumours and to distinguish stroke due to bleeding into the brain from those caused by blocked arteries. This is important to allow treatment with thrombolysis, anticoagulants, and antiplatelet drugs. In 2018, 95% of stroke patients received a brain scan within 24 hours of admission, which was similar to 2017 (93%). The national standard is currently 95% of stroke patients receiving a brain scan within 24 hours of admission (chart 3.3). 12 individual hospitals met or exceeded the standard, including Dumfries and Galloway Royal Infirmary which achieved a significant improvement from 89% to 98%. Very early scanning is an important factor for patients who can benefit from thrombolysis and thrombectomy. Most hospitals operate a fast track brain scanning process for patients potentially suitable for thrombolysis.

After a brain scan has excluded bleeding on the brain patients should receive aspirin as soon as possible since this has been shown to improve outcomes. Exceptions are those who are given thrombolysis, or taking an anticoagulant, or are on an alternative antiplatelet drug, and also those who are allergic to aspirin. 95% of patients without contra-indications should receive aspirin on the day of admission or the day after. In 2018 92% of patients with a final diagnosis of ischaemic stroke and no clear contra-indication received aspirin on the day of admission or the day after compared with 91% in 2017.


8

Chart 3.1: Percentage of stroke patients admitted to a Stroke Unit within 1 day of admission to hospital, 2017 and 2018 data (based on final diagnosis).

Horizontal line reflects Scottish Stroke Care Standard (2013) of 90% of stroke patients admitted to a Stroke Unit within 1 day of admission.

2017 (%)





10

20

30

40

50

60

70

80

90

100

Sco

tland

Ba

lfour

Bel

ford

*

Cai

thne

ss*

GC

H*

Gilb

ert B

ain*

Cro

ssho

use

Nin

ewel

ls

Wes

tern

Isl

es

Mon

kla

nds

IRH

Ha

irmyr

es

AR

I

QU

EH GR

I

Wis

haw

VH

K

FVR

H

PR

I

DG

RI

SJH

Dr

Gra

ys

Bor

der

s

RIE

Ayr

RA

H

L&

I

Ra

igm

ore

WG

H

%

Notes regarding Chart 3.1:1. The denominator for the admission to Stroke Unit excludes: in-hospital strokes, patients discharged within 1 day and transfers in from

another hospital.2. Due to the number of beds within some of the hospitals indicated (*) and the small numbers of stroke admissions to these hospitals it is not

practical to have a defined Stroke Unit. We have confirmed however that a defined stroke pathway is in place in these hospitals and that the Scottish Stroke Care Standards criteria are established within that pathway.

3. The data included in Chart 3.1 were extracted from eSSCA on the 21st March 2019. Changes/ updates to the data following this date will therefore not feature in this analysis. The data relate to patients with final diagnosis of stroke and are for calendar years 2017 and 2018 (i.e. 1 January - 31 December).

4. In some instances, data entered into eSSCA are assigned to admitting hospitals other than the main acute hospitals participating in the Scottish Stroke Care Audit. Data for these hospitals are combined with data for their respective main acute hospitals.

5. During 2017 NHS Dumfries & Galloway opened the New Dumfries & Galloway Royal Infirmary.6. Uist and Barra Hospital has been excluded from this chart due to very low patient numbers.


9

Chart 3.2: Percentage of stroke patients with a swallow screening within 4 hours of admission, 2017 and 2018 data (based on final diagnosis).

Horizontal line reflects Scottish Stroke Care Standard (2016) of 100% of stroke patients swallow screened within 4 hours of admission.

2017 (%)





0

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20

30

40

50

60

70

80

90

100

Sco

tland L&

I

Cro

ssho

use

IRH

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der

s

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GC

H

Dr

Gra

ys

GR

I

RA

H

VH

K

RIE

Wes

tern

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Mon

kla

nds

AR

I

FVR

H

Ha

irmyr

es

Cai

thne

ss

Ra

igm

ore

Nin

ewel

ls

Wis

haw

Gilb

ert B

ain

Ba

lfour

QU

EH PR

I

DG

RI

WG

H

Bel

ford Ayr

%

Notes regarding Chart 3.2:1. The data included in Chart 3.2 were extracted from eSSCA on the 21st March 2019. Changes/ updates to the data following this date will

therefore not feature in this analysis. The data relate to patients with final diagnosis of stroke and are for calendar years 2017 and 2018 (i.e. 1 January - 31 December).


3. During 2017 NHS Dumfries & Galloway opened the New Dumfries & Galloway Royal Infirmary.4. A small proportion of patients with query in-hospital wake-up strokes are excluded from the chart.5. Uist and Barra Hospital has been excluded from this chart due to very low patient numbers. 6. Excludes a small proportion of in-hospital events where the date of onset is recorded but the time of onset is missing.


10

Chart 3.3: Percentage of stroke patients with a brain scan within 24 hours of admission, 2017 and 2018 data (based on final diagnosis).

Horizontal line reflects Scottish Stroke Care Standard (2016) of 95% of stroke patients to receive a brain scan within 24 hours of admission. * The Scottish Stroke Care Standard for swallow screen within 4 hours was introduced from April 2016 and complete data are unavailable prior to this date because swallow screen time was only recorded from April 2016. Prior to April 2016 only swallow screen date was recorded.

2017 (%)





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50

60

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90

100

Sco

tland

Bel

ford

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Ha

irmyr

es

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tern

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RI

QU

EH

VH

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SJH

FVR

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AR

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IRH

Dr

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igm

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Mon

kla

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use

Cai

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PR

I

Gilb

ert B

ain

RA

H

Nin

ewel

ls

Ayr

L&

I

%

Notes regarding Chart 3.3:1. Uist & Barra Hospital, NHS Western Isles does not have a CT scanner but patients are airlifted to Western Isles Hospital and a proportion may

arrive in sufficient time to have brain imaging within 24 hours of admission.2. The data included in Chart 3.3 were extracted from eSSCA on the 21st March 2019. Changes/ updates to the data following this date will

therefore not feature in this analysis. The data relate to patients with final diagnosis of stroke and are for calendar years 2017 and 2018 (i.e. 1 January - 31 December).


4. During 2017 NHS Dumfries & Galloway opened the New Dumfries & Galloway Royal Infirmary.5. A small proportion of patients with query in-hospital wake-up strokes are excluded from the chart.6. Uist and Barra Hospital has been excluded from this chart due to very low patient numbers.7. Excludes a small proportion of in-hospital events where the date of onset is recorded but the time of onset is missing


11

Chart 3.4: Percentage of acute ischaemic stroke patients given aspirin in hospital within 1 day of admission, 2017 and 2018 data (based on final diagnosis).

Horizontal line reflects Scottish Stroke Care Standard (2013) of 95% ischaemic stroke patients to receive aspirin within 1 day of admission.

2017 (%)





0

10

20

30

40

50

60

70

80

90

100

Sco

tland

Gilb

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ain

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tern

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Mon

kla

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EH AR

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Nin

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RI

Ayr

PR

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RIE

WG

H

L&

I

Ba

lfour

%

Notes regarding Chart 3.4:1. The denominator for the percentages excludes patients with valid reasons not to give early aspirin (e.g. contraindications) and those in receipt

of thrombolysis where aspirin may be delayed for clinical reasons. A small proportion of patients with query in-hospital wake-up strokes are also excluded.

2. The data included in Chart 3.4 were extracted from eSSCA on the 21st March 2019. Changes/ updates to the data following this date will therefore not feature in this analysis. The data relate to patients with final diagnosis of stroke and are for calendar years 2017 and 2018 (i.e. 1 January - 31 December).


4. During 2017 NHS Dumfries & Galloway opened the New Dumfries & Galloway Royal Infirmary.


12

Chart 3.5: Percentage of stroke patients with a swallow screen by number of hours to swallow screen, 2018 data (based on final diagnosis).

Vertical line reflects Scottish Stroke Care Standard (2016) of 100% of stroke patients to receive a swallow screen within 4 hours of admission.

Within 4 hoursWithin 12 hoursWithin 24 hoursStroke Standard (2016)

0 20 40 60 80 100

ScotlandBorders

Western IslesL&I

SJHDr Grays

IRHCrosshouse

VHKMonklands

WishawGilbert Bain

GRIRIE

GCHRAH

NinewellsHairmyres

QUEHDGRI

ARIRaigmoreCaithness

FVRHPRI

WGHBalfourBelford

Ayr

%

Notes regarding Chart 3.5:1. The data included in chart 3.5 were extracted from eSSCA on the 21st March 2019. Changes/ updates to the data following this date will

therefore not feature in this analysis. The data relate to patients with final diagnosis of stroke and are for calendar year 2018 (i.e. 1 January - 31 December).


3. There may be some slight differences in the numerators and denominators when comparing Chart 3.5 to Chart 3.3 because some records for in-hospital stroke patients may have been assigned to their year of admission rather than their year of onset. This principally affects records around the period of December of one year and January of the next year where the date of admission is in one year and the date of onset is in the next year.

4. Uist and Barra Hospital has been excluded from this chart due to very low patient numbers. 5. During 2017 NHS Dumfries & Galloway opened the New Dumfries & Galloway Royal Infirmary.6. Excludes a small proportion of in-hospital events where the date of onset is recorded but the time of onset is missing.


13

Chart 3.6: Percentage of stroke patients with a brain scan by number of hours to scan, 2018 data (based on final diagnosis).

Vertical line reflects Scottish Stroke Care Standard (2016) of 95% of stroke patients to receive a brain scan within 24 hours of admission.* The Scottish Stroke Care Standard for swallow screen within 4 hours was introduced from April 2016 and complete data are unavailable prior to this date because swallow screen time was only recorded from April 2016. Prior to April 2016 only swallow screen date was recorded.

Note that the Scotland column in the chart is coloured light green and dark green simply to differentiate it from the hospital columns and the colours are not indicative of performance. Light green corresponds to ‘Within 24 Hours’ and dark green corresponds to ‘Within 4 Hours’.

Within 12 hoursWithin 24 hoursStroke Standard (2016)

0 20 40 60 80 100

ScotlandBelford

WishawHairmyres

BordersGCH

Western IslesDGRI

QUEHVHKSJH

FVRHARIIRH

Dr GraysRaigmore

WGHMonklands

BalfourGRIRIE

CrosshouseCaithness

PRIGilbert Bain

RAHNinewells

AyrL&I

%




3. During 2017 NHS Dumfries & Galloway opened the New Dumfries & Galloway Royal Infirmary.4. Uist and Barra Hospital has been excluded from this chart due to very low patient numbers. 5. There may be some slight differences in the numerators and denominators when comparing Chart 3.6 to Chart 3.4 because some records for

in-hospital stroke patients may have been assigned to their year of admission rather than their year of onset. This principally affects records around the period of December of one year and January of the next year where the date of admission is in one year and the date of onset is in the next year.

6. Excludes a small proportion of in-hospital events where the date of onset is recorded but the time of onset is missing.


14

Chart 3.7: Percentage of acute ischaemic stroke patients given aspirin in hospital by number of days to receipt, 2018 data (based on final diagnosis).

Vertical line reflects Scottish Stroke Care Standard (2013) of 95% of acute ischaemic stroke patients to receive aspirin within 1 day of admission.Note that the Scotland column in the chart is coloured light green and dark green simply to differentiate it from the hospital columns and the colours are not indicative of performance. Light green corresponds to ‘Within 24 Hours’ and dark green corresponds to ‘Within 4 Hours’.

Same Day1 Day2 DaysStroke Standard (2013)

0 20 40 60 80 100

ScotlandWestern Isles

Gilbert BainGCH

WishawFVRH

BordersSJHIRH

MonklandsHairmyres

GRICaithness

QUEHARI

Dr GraysVHK

RaigmoreCrosshouse

BelfordNinewells

DGRIAyrPRI

RAHRIE

WGHL&I

Balfour

%




3. The denominator for the percentages excludes patients with valid contraindications to aspirin and those in receipt of thrombolysis where aspirin may be delayed for clinical reasons.

4. During 2017 NHS Dumfries & Galloway opened the New Dumfries & Galloway Royal Infirmary.5. Uist and Barra Hospital has been excluded from this chart due to very low patient numbers.6. There may be some slight differences in the numerators and denominators when comparing Chart 3.7 to Chart 3.5 because some records for

in-hospital stroke patients may have been assigned to their year of admission rather than their year of onset. This principally affects records around the period of December of one year and January of the next year where the date of admission is in one year and the date of onset is in the next year.

One group of patients in whom it is particularly challenging to meet the standards are the patients who have a stroke whilst an inpatient. Early recognition of the diagnosis is often difficult because patients may have the stroke whilst under anaesthetic, or during an intensive care admission, or on a background of complex co-morbidities. There are sometimes delays in referral to the stroke service. About 5% of strokes in Scotland occur whilst the patient is an inpatient but this varies between hospitals and probably reflects the services they provide.


15

Chart 3.8: Comparison of initial diagnosis of stroke versus final diagnosis of stroke, 2018 data).

Note that the Scotland column in the chart is coloured green and red simply to differentiate it from the hospital columns and the colours are not indicative of performance. Light green corresponds to ‘Final Only’, red corresponds to ‘Initial & Final’ and dark green corresponds to

‘Initial Only’.

Final OnlyInitial AND FinalInitial Only

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Sco

tland Ayr

Cro

ssho

use

Bor

ders

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RI

GC

H

VHK

FVR

H

AR

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Dr G

rays

GR

I

IRH

QEU

H

RA

H

Bel

ford

Cai

thne

ss L&I

Rai

gmor

e

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rmyr

es

Mon

klan

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Wis

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RIE

SJH

WG

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four

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t & B

arra

Wes

tern

Isle

s0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Sco

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VHK

FVR

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Dr G

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QEU

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Cai

thne

ss L&I

Rai

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arra

Wes

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s0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Sco

tland Ayr

Cro

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use

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RI

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VHK

FVR

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AR

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Dr G

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IRH

QEU

H

RA

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ford

Cai

thne

ss L&I

Rai

gmor

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Hai

rmyr

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Mon

klan

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RIE

SJH

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Nin

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PR

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Uis

t & B

arra

Wes

tern

Isle

s

Notes regarding Chart 3.8:1. Both initial diagnosis and final diagnosis may be recorded in the SSCA data relating, respectively, to whether a patient may be suspected of

having had a stroke and whether the stroke diagnosis is confirmed on investigation. Chart 3.8 presents information on three groups of patients, those with: - an initial diagnosis of stroke i.e. possible stroke patients who may turn out to have another diagnosis once investigations are complete; - a final diagnosis of stroke i.e. patients confirmed as having had strokes when their initial diagnosis may have been considered as something else; - an initial diagnosis and final diagnosis of stroke i.e. patients suspected of having had a stroke who have this diagnosis confirmed on investigation.




16

Table 3.1: Stroke Unit Information.

Hospital Name Number of acute strokes

discharged in 2018

Hyper Acute Stroke

Unit (HASU) beds

Acute Stroke

Unit (ASU) beds

Integrated Stroke

Unit (ISU) beds

Stroke Rehabilitation

Unit (SRU) beds on

acute site

Comments (e.g. Off-site Locations)

Ayr Hospital 37 0 0 0 24 24 stroke rehab beds within Station 16

Crosshouse Hospital, Kilmarnock

791 0 24 0 0 20 stroke rehab beds within 30 bed Redburn Rehabilitation ward, Ayrshire Central Hospital.

Borders General Hospital, Melrose

196 0 0 12 0

Dumfries & Galloway Royal Infirmary (DGRI)

202 0 0 14 0

Galloway Community Hospital (GCH)

47 0 0 0 0 20 bedded unit with mix of medical and sugical admissions. It includes hyperacute & acute stroke bed.

Victoria Hospital, Kirkcaldy (VHK)

786 0 0 24 0 QMH Ward 6 - 15 beds within a stroke and general rehabilitation ward.

Letham ward Cameron Hospital - 12 funded beds but currently operating 14 with increase to 15/16 beds as necessary (rehabilitation for over 65).

Sir George Sharp Unit (rehabilitation for under 65) 6 to 7 out of 12 beds.

Forth Valley Royal Hospital

509 0 0 30 0 Stirling Community Hospital - 26 beds in total - 10 stroke rehabilitation and 16 for patients with generic rehabilitation requirements

Aberdeen Royal Infirmary (ARI)

686 0 16 0 0 Currently operating as stroke unit with 4 additional beds. Woodend - SRU: 34beds. Fraserburgh - SRU: 6 beds

Dr Gray's Hospital, Elgin 160 0 0 8 0

Glasgow Royal Infirmary (GRI)

660 5 0 0 38 24 off-site rehab beds at Stobhill

Inverclyde Royal Hospital, Greenock (IRH)

216 0 0 17 0

Queen Elizabeth University Hospital (QEUH), Glasgow

1 075 26 0 60 0

Royal Alexandra Hospital, Paisley (RAH)

443 0 0 30 0 Off site stroke rehab at Vale of Leven, 6 beds

Belford Hospital, Fort William

24 0 0 0 0 Stroke beds within an acute medical ward

Caithness General Hospital, Wick

47 0 0 0 0 Stroke beds within an acute medical ward

Lorn & Islands Hospital, Oban

34 0 0 0 0 6 stroke beds within another ward

Raigmore Hospital, Inverness

334 0 0 22 0

Hairmyres Hospital, East Kilbride

320 0 0 18 0

Monklands Hospital, Airdrie

285 0 0 20 0

Wishaw General Hospital

408 0 0 25 0

Royal Infirmary of Edinburgh

981 0 0 44 0 Astley Ainslie Charles Bell Pavilion 40 beds and East Pavilion 6 beds = 46 All are neuro rehab beds (none are ring fenced for stroke).

St John's Hospital, Livingston (SJH)

277 0 0 22 0


17

Hospital Name Number of acute strokes

discharged in 2018

Hyper Acute Stroke

Unit (HASU) beds

Acute Stroke

Unit (ASU) beds

Integrated Stroke

Unit (ISU) beds

Stroke Rehabilitation

Unit (SRU) beds on

acute site

Comments (e.g. Off-site Locations)

Western General Hospital, Edinburgh (WGH)

235 0 0 24 0

Balfour Hospital, Orkney

34 0 0 0 0 No specific stroke beds but beds will be made available within acute ward as required.

Gilbert Bain Hospital, Shetland

33 0 0 0 0 Stroke beds within medical ward

Ninewells Hospital, Dundee

584 0 18 0 0 Stracathro Hospital has 10 stroke rehabilitation beds.

Perth Royal Infirmary (PRI)

188 0 0 22 0 Royal Victoria has 16 stroke beds, The Centre for Brain Injury has 16 beds for patients aged 16/65ys with either brain injury or stroke

Uist & Barra Hospital, Benbecula

2 0 0 0 0

Western Isles Hospital (WIH)

35 0 0 6 0

TOTALS 9 629 31 58 398

Note regarding Table 3.1:1. The column “Number of acute strokes discharged in 2018” is based on inpatients with a final diagnosis of stroke discharged during Jan-Dec

2018 and this cohort of patients differs slightly from the inpatient cohort reported upon elsewhere in this National Report. For inpatients, the report focuses principally on those patients with a final diagnosis of stroke admitted during Jan-Dec 2018. Some patients discharged in 2018 may have been admitted in 2017 or earlier. Some patients admitted in 2018 may have been discharged in 2019.


18

4 Outpatients

Summary and key findings relating to outpatient data

Key findings:

Performance in many areas is improving against the current standard. There is still considerable variability across Scotland, reflecting service structure and clinic availability. Most centres have improved on the time from event to completion of imaging studies, but some have slipped, for example Borders General Hospital.

Outpatient assessment is an important part of all Stroke Services. Early assessment and treatment is proven to reduce recurrent ischaemic events. While available evidence suggests the risk of recurrence is highest in the first 48 hours, the current standard recommends review within four days of referral. Across Scotland, 74% of patients with an ischaemic event are already on antiplatelets or anticoagulants by the time of first assessment (Table 4.1), suggesting a proactive primary care team who in some areas will have interacted with the stroke service using TIA hotlines.

In 2018 twenty five hospitals contributed TIA Clinic data to the SSCA. NHS Greater Glasgow & Clyde (NHS GGC) are now able to provide some data for the report, providing a more comprehensive picture of service delivery across Scotland. This data is included in Chart 4.3.

Data were collected on 3,910 outpatients in 2018, a smaller number than 2017.

Chart 4.1 shows the percentage of patients with a definite cerebrovascular diagnosis seen in specialist stroke/TIA clinics with referral to examination time within four days, and shows 2017 and 2018 data. While most hospitals are reaching the current standard of 80% reviewed within four days of referral, Perth Royal Infirmary, Ninewells hospital, WIH, QMH, BGH, FVRH, Raigmore and L&I are failing to achieve the standard. Two hospitals (Monklands and Raigmore) have had a statistically significant drop in performance since 2017, although Monklands is still achieving the standard. Raigmore and Western Isles Hospital have redesigned their pathways and should show an improvement in next year’s report.

Chart 4.2 shows the proportion of patients seen on the day of referral, the following day, and between days 2-4. There is considerable variation in performance, with Dr Gray’s hospital seeing 65% of patients on the same day as referral, while Western Isles Hospital does not manage to have any patients reviewed on day of referral. These differences will reflect variations in service structure and availability of staff, but give the opportunity to review how early review can best be facilitated.

Chart 4.3 shows the median wait from stroke event to points on the outpatient imaging timeline, indicating the variation between different hospitals in waiting times. Some hospitals are performing extremely well against the standard, such as Dr Gray’s Hospital, Crosshouse Hospital and the Western General Hospital. Others have a long delay to completion of imaging: these hospitals include Victoria Infirmary and Forth Valley Hospital.

The outpatient audit is under review due to a number of evidence-based changes in practice. The use of dual antiplatelet therapy for selected high risk TIA patients may result in a change in the standard with the aim of reviewing selected patients within a shorter time period after the initial event. The audit also does not reliably capture patients who may have been reviewed and investigated by the stroke team in emergency departments (particularly in GG&C). On going work will help to standardise data capture and refine the standards with the overall aim of improving outcomes for TIA patients in Scotland.


19

Chart 4.1: Percentage of patients with definite cerebrovascular diagnosis seen in specialist stroke/ TIA clinic with referral to examination time within 4 days, 2017 and 2018 data.

Horizontal line reflects Scottish Stroke Care Standard (2013) of 80% of TIA patients being seen in specialist stroke/TIA clinic within 4 days of receipt of referral.

2017 (%)





10

20

30

40

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80

90

100

Tot

al

WG

H

RIE

Ba

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irmyr

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Dr

Gra

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VH

K

SJH PR

I

Nin

ewel

ls

Wes

tern

Isl

es

QM

H

Bor

der

s

FVR

H

Ra

igm

ore

L&

I

%

Notes regarding Chart 4.1:1. Data presented are for hospitals using eSSCA where all relevant dates (last event, referral, referral-received, appointment and

examination) are present and ordered chronologically.2. The following hospitals either do not hold specialist stroke/TIA clinics or do not collect and submit data to SSCA – Caithness, QEUH, WIG,

GCH, Belford, GRI, IRH, VI Glasgow, RAH, Gilbert Bain and Uist & Barra. The omission of these data may affect the estimate of national performance based on those hospitals contributing to SSCA. Greater Glasgow & Clyde (GGC) started routine collection of outpatient data in eSSCA during 2018. GGC hospitals are omitted from Chart 4.1 because of the absence of a 2017 comparator.



20

Chart 4.2: Percentage of patients with definite cerebrovascular diagnosis seen in specialist stroke/ TIA clinic with referral to examination time (days): same day and within 1, 2, 3 & 4 days, 2018 data.

Horizontal line reflects Scottish Stroke Care Standard (2013) of 80% of TIA patients being seen in a specialist stroke/TIA clinic within 4 days of receipt of referral.

Note that the Scotland column in the chart is coloured green, amber, red and grey simply to differentiate it from the hospital columns and the colours are not indicative of performance. Dark green corresponds to ‘Same Day’, red corresponds to ‘1 Day’, amber corresponds to ‘2 Days’, light green corresponds to ‘3 Days’ and grey corresponds to ‘4 Days’. The chart columns are ranked, by hospital, on the percentage within 4 days.

Same Day1 Day2 Days3 Days4 DaysStroke Standard (2013)

0 10 20 30 40 50 60 70 80 90 100

TotalWGH

RIERAH

BalfourHairmyres

DGRIWishaw

CrosshouseMonklands

ARIDr Grays

StobhillVHKSJHPRIGRI

NinewellsQUEH

Western IslesQMH

BordersFVRH

RaigmoreL&I

QUEH

%

Notes regarding Chart 4.2:1. In some instances, data entered into eSSCA are assigned to admitting hospitals other than the main acute hospitals participating in the

Scottish Stroke Care Audit. Data for these hospitals are combined with data for their respective main acute hospitals.2. The following hospitals either do not hold specialist stroke/TIA clinics or do not collect and submit data to SSCA – Caithness, GCH, Belford,

Gilbert Bain and Uist & Barra. The omission of these data may affect the estimate of national performance based on those hospitals contributing to SSCA. Greater Glasgow & Clyde (GGC) started routine collection of outpatient data in eSSCA during 2018.

3. During 2017 NHS Dumfries & Galloway opened the new Dumfries & Galloway Royal Infirmary.


21

Chart 4.3: Median waits since stroke event to points on the outpatient imaging timeline, 2017 and 2018 data.

There are instances where elements of the outpatient timeline share the same or similar data point and might not be visible. In these instances the most recent part of the timeline sits on top indicating that the elements have been delivered closely together.

Notes regarding Chart 4.3:1. In some instances, data entered into eSSCA are assigned to admitting hospitals other than the main acute hospitals participating in the

Scottish Stroke Care Audit. Data for these hospitals are combined with data for their respective main acute hospitals.2. The following hospitals either do not hold specialist stroke/TIA clinics or do not collect and submit data to SSCA – Belford, Gilbert Bain and

Uist & Barra. The omission of these data may affect the estimate of national performance based on those hospitals contributing to SSCA.3. The chart only includes events where all relevant dates (last event, event to referral, referral received, appointment, attendance and imaging)

are present and ordered chronologically.4. Cameron Hospital had only one event and Mid Argyll Hospital had only two events in 2017 and these have not been included in the chart.

However, these events are included in calculating the median waits for Scotland.5. During 2017 NHS Dumfries & Galloway opened the new Dumfries & Galloway Royal Infirmary.


22

Table 4.1 Patients with ischaemic diagnosis seen in specialist stroke/ TIA clinics and on anticoagulation at onset of current cerebrovascular event or on aspirin or another antiplatelet at first assessment, 2018 data.

Note that some percentages are based on very small numbers of records.

Denominator Patients with ischaemic diagnosis seen in specialist stroke/TIA clinics during 2018

Hospital (in order of NHS board

of treatment)

Number with ischaemic diagnosis

Number on anticoagulation at onset of current cerebrovascular

event or on aspirin or another antiplatelet at first assessment

Percentage on anticoagulation at onset of current cerebrovascular

event or on aspirin or another antiplatelet at first assessment

Crosshouse Hospital 341 153 45

Borders General Hospital 151 108 72

Dumfries & Galloway Royal Infirmary 132 103 78

Queen Margaret Hospital 152 119 78

Victoria Hospital Kirkcaldy 218 156 72

Forth Valley Royal Hospital 229 174 76

Aberdeen Royal Infirmary 527 392 74

Dr Gray's Hospital 21 12 57

Lorn & Islands Hospital 63 36 57

Raigmore Hospital 249 197 79

Hairmyres Hospital 154 119 77

Monklands Hospital 139 121 87

Wishaw General Hospital 121 93 77

Royal Infirmary of Edinburgh 234 194 83

St John's Hospital 74 51 69

Western General Hospital 435 330 76

Balfour Hospital 14 10 71

Ninewells Hospital 218 181 83

Perth Royal Infirmary 117 90 77

Western Isles Hospital 15 12 80

Total 3 604 2 651 74

Notes regarding Table 4.1: 1. The source database, eSSCA, captures information about stroke type for outpatients via a question on stroke pathology but also includes

additional variables to indicate Transient Ischaemic Attack (TIA), transient monocular blindness (TMB) and retinal artery occlusion (RAO). The cohort of patients for Table 4.1 is based on outpatients with an ischaemic stroke, TIA, TMB or RAO. This group differs slightly from the outpatient cohort used elsewhere in this National Report because of its restriction to stroke patients with ischaemic events rather than patients with any type of cerebrovascular diagnosis.


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5 Atrial FibrillationAtrial Fibrillation (AF) is a common cardiac rhythm problem and one which becomes commoner with advancing age. Over the age of 60 it affects 4% of the population but by the age of 80 or more this figure is 10%. It is a concern because it increases the risk of ischaemic stroke. Unfortunately because AF does not usually cause symptoms, the first time it is detected is often when a person has a stroke or TIA. In addition, strokes which occur in people with AF tend to be more severe than other types of stroke, with more chance of them leading to death or long-term disability.

In some stroke patients AF is continuous and, therefore, fairly easy to identify by checking for an irregular pulse or doing an ECG. In other patients, AF can be intermittent and much more difficult to identify without putting on a cardiac monitoring device, which may need to be worn for many days. It is important to identify continuous or intermittent AF in ischaemic stroke because patients with these conditions are at a very high risk of further ischaemic strokes.

When AF is identified, patients would usually be commenced on anticoagulant (blood thinning) therapy unless there was a very good reason not to. This medication reduces the risk of further stroke. Traditionally this anticoagulant was Warfarin. In the last few years a group of drugs called Direct Oral Anticoagulants (DOACs) have become available. Examples include Apixaban, Dagibatran, Edoxaban and Rivaroxaban. DOACs are as effective as Warfarin in preventing strokes, generally have fewer side effects and are more convenient and less complicated to take than Warfarin. This should mean that fewer patients have a reason not to be anticoagulated and that more strokes can, therefore, be prevented.

Chart 5.1: Ischaemic stroke/ TIA patients with current atrial fibrillation (AF) and on anticoagulation at onset of the current cerebrovascular event or prescribed/ recommended anticoagulation at discharge, Scotland, 2013 - 2018 data (final diagnosis).

0

10

20

30

40

50

60

70

80

90

100

2013 2014 2015 2016 2017 2018

%

% in AF with anticoagulation on admission % in AF with anticoagulation on discharge

Notes regarding Chart 5.1:1. The source database, eSSCA, captures information about stroke type for inpatients via a question on stroke pathology but also includes an

additional variable to indicate a final diagnosis of Transient Ischaemic Attack (TIA). The cohort of patients for Chart 5.1 is based on inpatients with a final diagnosis of either ischaemic stroke or TIA. This group differs from the inpatient cohort used elsewhere in this National Report. The inpatient section of the National Report focuses on patients with any type of stroke (e.g. ischaemic, haemorrhagic), apart from the charts concerning aspirin which relate to ischaemic stroke only, excluding TIA.

Chart 5.1 shows that year on year there has been an increase in the percentage of admitted Stroke/TIA patients with current AF who are on anticoagulation at presentation (blue boxes). Between 2013 and 2018 the figure has increased from 26% to 38%. This may reflect an increase in anticoagulant prescribing in Primary Care and could suggest that, in addition, more strokes are being prevented; with such patients never appearing in the SSCA data.


24

Separately, Chart 5.1 shows the percentage of patients with TIA/Ischaemic Stroke who have AF on admission and who are discharged on anticoagulants. Here the numbers have increased more impressively from 53% to 74%. This suggests increased/more consistent use of anticoagulants in patients post-stroke and will mean that fewer patients have recurrent stroke.

Overall the percentage patients on anticoagulation on admission has shown considerable variation between hospitals and was generally low. This suggests variable detection of AF before a stroke event. However, the results for anticoagulation after assessment were much better and more consistent between hospitals. This suggests that once identified most AF patients are being recommended anticoagulants

Efforts are currently underway to find ways to identify AF in high risk groups of the population so that strokes can be avoided. Last year’s report set out new standards to better identify patients with intermittent AF after an ischaemic stroke, so that recurrent strokes can be avoided. The Scottish Stroke Improvement Plan section of this year’s report shows where the various NHS boards are with this standard. The Scottish Parliament’s Cross Party Group on Heart Disease and Stroke has also recently highlighted the importance of improving detection and treatment of AF.


25

6 Thrombolysis and Thrombectomy

Emergency treatments to unblock arteries causing ischaemic stroke

In 2018, 9,641 patients were admitted to hospital with a final diagnosis of stroke. Of these 8.354 (86.7%) had an ischaemic stroke. Early treatment with intravenous thrombolysis (alteplase), and/or mechanical thrombectomy (‘clot retrieval’) has been shown in large randomised studies to greatly improve the outcomes for such patients.

Key findings:In 2018, the number of patients receiving thrombolysis was 1033, very similar to the number in 2017.

This is equivalent to 190/million population, very similar to rest of UK, but higher than the average across Europe (Mean 142/million (Range 0 to 412 (Estonia)).

In 2018, 60% of patients were thrombolysed within one hour of arrival at hospital (door to needle (DTN) time 59% in 2017), a very similar to the rate in the rest of UK (61%).

Mean DTN times vary between hospitals. Larger hospitals, and those with nurses or doctors who can attend the emergency dept to support the process, achieve shorter DTN times

Transfers between hospitals to deliver thrombolysis result in very long delays, and reduced effectiveness of treatment

Pre-alerts by the Scottish Ambulance Service, centralisation of stroke admissions within a geographic area, or telemedicine networks with dedicated stroke staff within the spoke hospitals can greatly reduce DTN times.

Mechanical thrombectomies are not currently performed in Scotland. Directors of Planning Thrombectomy Advisory Group are developing a national planning framework which will provide the basis for developing a thrombectomy service in Scotland.

Improvements in the speed of delivery of thrombolysis will, once a service is established, increase the proportion of patients eligible for thrombectomy, reduce delays to thrombectomy and improve the outcomes of patients.

Thrombolysis

The studies demonstrating the effectiveness of thrombolysis given within 4.5 hours of a known onset time were completed by 2012, and since then the numbers treated in Scotland have increased from 130 to 190/million population in 2018. In 2018, 1033 (12.4%) patients with ischaemic stroke received thrombolysis; a rate which compares favourably with the rest of the UK and other European countries. The observed increase reflects increasing public awareness, enhanced ambulance protocols and improved delivery in acute hospitals.

Recently published studies now indicate that some patients in whom an onset time is unclear, usually because the patient woke from sleep with new stroke symptoms, can also benefit from intravenous thrombolysis. Selection of such patients is based on more complex imaging, which will inevitably mean that implementation of the results will be challenging.

The earlier the artery is unblocked, the more effective the treatment and the better the patients outcomes. Therefore our national standard encourages attempts to treat as early as possible by reducing the so


26

called door to needle (DTN) time. The standards we are working towards are that 80% of patients treated should receive thrombolysis within 60 minutes of arrival at hospital, and 50% within 30 minutes. Across Scotland in 2018, 60% of patients received thrombolysis within 60 minutes, a small increase from 59% in 2017, and almost identical to the average performance of hospitals in the rest of the UK. The proportion across Scotland receiving thrombolysis within 30 minutes of arrival has risen slightly from 11% in 2017, to 14% in 2018.

There is marked variation between hospitals. We measure the delay from arrival at the first hospital they are taken to, to the time of their injection of alteplase. Whilst some hospitals (e.g. QEUH, Glasgow) are among the fastest to give thrombolysis when the patient arrives (see chart 6.1 and chart 6.2), the overall figures for the DTN for the QEUH (see chart 6.3), are greatly inflated because of the delays incurred by transferring patients from another hospital which was unable to deliver thrombolysis.

Delays are reduced by SAS pre alerts, having dedicated stroke service staff at the front door, and by treating the patients at the first hospital they arrive at, to avoid any inter hospital transfers. This can be achieved by either centralising acute stroke admissions, or by supporting hospitals, especially out of hours, with a telestroke service. There is plenty of work to be done to reduce DTN time across Scottish hospitals, which whilst they are similar to those in rest of UK, are much slower than the best performing services in Europe– important work which would be associated with better recovery for patents.

Table 6.1: Thrombolysis - numbers thrombolysed by NHS Board in 2018. Also give rate per million population, and percentage of all strokes, and ischaemic strokes treated.

Hospital Number of patients receiving thrombolysis in 2017r

Number of patients receiving thrombolysis in 2018

Scotland 1 056 1 033

Ayrshire & Arran 83 73

Ayr Hospital 1 2

Crosshouse Hospital, Kilmarnock 82 71

Borders 16 21

Borders General Hospital, Melrose 16 21

Dumfries & Galloway 23 38

Dumfries & Galloway Royal Infirmary (DGRI) 17 31

Galloway Community Hospital (GCH) 6 7

Fife 63 80

Victoria Hospital, Kirkcaldy (VHK) 63 80

Forth Valley 46 42

Forth Valley Royal Hospital, Larbert (FVRH) 46 42

Grampian 153 147

Aberdeen Royal Infirmary (ARI) 127 132

Dr Gray's Hospital, Elgin 26 15

Greater Glasgow & Clyde 222 228

Glasgow Royal Infirmary (GRI) 22 18

Queen Elizabeth University Hospital, Glasgow (QEUH) 199 210

Royal Alexandra Hospital, Paisley (RAH) 1 0

Highland 50 46

Belford Hospital, Fort William 6 7

Caithness General Hospital, Wick 14 5

Lorn & Islands Hospital, Oban 5 2

Raigmore Hospital, Inverness 25 32

Lanarkshire 125 117

Hairmyres Hospital, East Kilbride 34 32

Monklands Hospital, Airdrie 40 47

Wishaw General Hospital 51 38


27

Hospital Number of patients receiving thrombolysis in 2017r

Number of patients receiving thrombolysis in 2018

Lothian 162 148

Royal Infirmary of Edinburgh at Little France (RIE) 125 121

St John's Hospital, Livingston (SJH) 34 24

Western General Hospital, Edinburgh (WGH) 3 3

Orkney 0 7

Balfour Hospital, Orkney 0 7

Shetland 1 5

Gilbert Bain Hospital, Shetland 1 5

Tayside 99 70

Ninewells Hospital, Dundee 63 51

Perth Royal Infirmary (PRI) 36 19

Western Isles 13 11

Western Isles Hospital (WIH) 13 11

Note regarding Table 6.1:1. Note that this table is not directly comparable with Table 6.3 because it is based on hospital/ NHS board of treatment rather than Health

Board of residence, upon which Table 6.3 is based. Health Boards may treat patients from outside their board area or may treat non-Scottish residents.

2. Records are included if a thrombolysis date is present; a small proportion of these records will not have an associated thrombolysis time recorded. This table also includes a small proportion of patients who were thrombolysed for a non-index event. This differs slightly from Charts 6.3 where measurement of the 30 & 60 minute thrombolysis door-to-needle time standards focuses on patients thrombolysed for index events only.

3. Data for this table are derived from the ‘admission hospital’ field (inpatient dataset).Revised since publication in 2018 Scottish Stroke Improvement Programme annual report.

r Revised since publication in 2018 Scottish Stroke Improvement Programme annual report.


28

Chart 6.1: Funnel plots showing Mean door-to-needle time by first hospital (Mon – Fri 9-5).

ARI

Ayr Balfour

BGH

Caithness

Cowal

XH

Dr Gray's

DGRI

FVRH

GCH

GB

GRI

Hairmyres

IRH

Monklands

NVH

Ninewells

PRIQEUH

Raigmore

RAH

RIE

St John's

VH

WGHWI

Wishaw

20

30

40

50

60

70

80

90

100

110

120

130

140

150

160

170

180

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80

Geo

met

ric M

ean

DTN

tim

e (m

inut

es)

Number of cases

99.8% Limits95% LimitsGeometric Mean

Notes regarding chart 6.1 and 6.2 Geometric Mean Door to Needle Time by First Hospital:1. Only cases entered into the Scottish Stroke Care Audit (SSCA) with a final diagnosis of stroke where the thrombolysis was for the index event

are included in the analysis.2. The door to needle (DTN) time is measured from arrival at first hospital unless the stroke occurred in hospital in which case the DTN time is

measured from the time of onset.

Chart 6.2: Funnel plots showing Mean door-to-needle time by first hospital (Not Mon-Fri 9-5).

99.8% Limits95% LimitsGeometric Mean

ARI

AWMH

Ayr

Balfour

Belford

BGH

Caithness

Cowal

XH

Dr Gray's

DGRI FVRH

GCH

GBGRI

Hairmyres

IRH

L&I

Monklands

Ninewells

PRI

QEUH

RaigmoreRAH

RIESt John's

VoL

VH

WGH

WI

Wishaw

20

30

40

50

60

70

80

90

100

110

120

130

140

150

160

170

180

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80

Geo

met

ric M

ean

DTN

tim

e (m

inut

es)

Number of cases


29

Chart 6.3: Percentage of patients receiving thrombolysis within 30, 60 & 75 minutes of arrival at first hospital, 2018 data.

Note that the Scotland column in the chart is coloured green and red simply to differentiate it from the hospital columns and the colours are not indicative of performance. Light green corresponds to ‘>60<=75 mins’, red corresponds to ‘>30<=60 mins’ and dark green corresponds to ‘Within 30 mins’.

0

10

20

30

40

50

60

70

80

90

100

Sc

otla

nd (n

=10

08)

Mon

klan

ds

(n=4

7)

Hai

rmyr

es (n

=31

)

RIE

(n=

121)

Wis

haw

(n=3

8)

Cro

ssh

ouse

(n=6

9)

FV

RH

(n=

41)

Nin

ewel

ls (n

=49

)

AR

I (n=

127)

VH

K (n

=75

)

DG

RI (

n=30

)

PR

I (n=

19)

SJH

(n=2

4)

GR

I (n=

18)

Bor

der

s (n

=20)

GC

H (n

=7)

QU

EH

(n=2

07)

Wes

tern

Isle

s (n

=9)

L&I

(n=2

)

WG

H (n

=2)

Rai

gmor

e (n

=32

)

Dr G

rays

(n=

15)

Bal

four

(n=

6)

Cai

thne

ss (n

=5)

Gilb

ert B

ain

(n=5

)

Ayr

(n=2

)

Bel

ford

(n=

7)

%

>60<=75 mins

>30<=60 mins

Within 30 mins

Stroke Standard (2016) (80% within 1 hour)

Stroke Standard (2016) (50% within 30 mins)

Notes regarding chart 6.3:1. Hospitals shown are those that provide a thrombolysis service. See Table 3.2 for further details. Records included must have date and time of

arrival at first hospital and date and time of thrombolysis to permit the calculation of time to thrombolysis and a small proportion of records are missing these data items.

2. Some percentages are based on very small numbers (see numbers in brackets on axis) and should be interpreted with caution. 3. Some hospitals (e.g. QEUHG) receive a small number of patients transferred from neighbouring Health Boards which may affect their onset-to-

needle time performance. 4. In some instances, data entered into eSSCA are assigned to admitting hospitals other than the main acute hospitals participating in the

Scottish Stroke Care Audit. Data for these hospitals are combined with data for their respective main acute hospitals. 5. Some hospitals admitted ischaemic stroke patients for thrombolysis but did not thrombolyse any patients within the time spans included in this

chart. These hospitals are included in the chart denominator but show as zero percent with regard to the time spans analysed 6. A small proportion of records have thrombolysis date recorded but no thrombolysis time. These records are included in the denominator

because the presence of a date indicates thrombolysis occurred. The absence of a thrombolysis time, however, prevents the calculation of door-to-needle time so these cases cannot be measured against the 30 or 60 minute standards and cannot be confirmed as having achieved it and are assumed not to have done so.

7. A small proportion of records may involve admission dates at the end of one year and thrombolysis dates at the beginning of the next year. 8. The thrombolysis figures may include a small number of thrombectomy cases, involving the physical removal of the clot from the blood vessel,

because the data collection system, eSSCA, cannot always capture the complexity of the patient pathway for this intervention.9. During 2017 NHS Dumfries & Galloway opened the New Dumfries & Galloway Royal Infirmary.


30

Thrombectomy

In 2015 some large studies showed that a procedure, mechanical thrombectomy, could greatly improve the chances of a patient with a severe ischaemic stroke making a good recovery, usually in combination with thrombolysis. Thrombectomy, which is carried out in a special operating theatre (a biplanar angio suite), sometimes under a general anaesthetic, physically removes the clot to open up the artery. This involves inserting a thin flexible tube into an artery in the top of the leg, passing it through the arteries to the blockage in the brain and using a wire net (stent retriever), or suction, to remove the clot – a bit like

“Dyno-RodTM” for the brain. However, thrombectomy is only possible if the blocked artery is large and visible on a brain scan.

Thrombectomy, like thrombolysis, is most effective if carried out within the first few hours but can help selected patients even if performed later within the first day. Thrombolysis and thrombectomy can be given alone or together. Thrombectomy in combination with thrombolysis is much more effective than thrombolysis alone.

Both thrombolysis and thrombectomy require care in a hospital with special facilities. Thrombolysis can be given in any hospital with an acute stroke unit and brain scanner. Thrombectomy can only be given in a hospital with doctors who can perform the procedure. It will therefore usually be necessary to rapidly transfer a patient from their local hospital to a more specialist hospital, unless the patient lives fairly close to a specialist hospital.

Currently no hospitals in Scotland can offer thrombectomy although we estimate that 600-800 patients each year could benefit from this treatment. If we could treat these patients, about 300 would have reduced disability and over 100 would avoid dependency on others and the need to live in a nursing home.

The Directors of Planning have established a Thrombectomy Advisory Group who are designing a framework for developing a thrombectomy service in Scotland which is clinically safe and provides high quality interventions to patients. This group are using data from the Scottish Stroke Care Audit to help plan a service. The audit will also monitor thrombectomy rates and times, as it currently does for thrombolysis, to help drive forward improvements in service delivery and patient care.

As part of the Stroke Improvement plan we are starting to train healthcare staff to select and treat patients with thrombectomy in preparation for the introduction of this service. Inevitably, it will take several years before patients in all parts of Scotland can be treated with thrombectomy.


31

7 Carotid InterventionIn a small group of patients with TIA or ischaemic stroke, the event has been caused by narrowing of the carotid artery. In these patients the risk of further stroke can be reduced by performing an operation to fix this narrowing. This operation, carotid endarterectomy, is effective in reducing stroke risk, but the operation is only usually beneficial if done very soon after the stroke or TIA. For this reason the Scottish Stroke Care Standard is that 80% of patients undergoing a carotid intervention should do so within 14 days of the event that led to them first seeking medical attention.

For stroke services, there are some parts of this 14 days that are very difficult to influence, such as if the patient did not present to stroke services until a week after the TIA/stroke event. For this reason, we also report data on the percentage of patients receiving carotid endarterectomy within 14 days of either the hospital admission date, or the date of being referred to the stroke service. This measure is felt to reflect the parts of the pathway that stroke and vascular services have more direct control over. This measure is referred to as being within 14 days of the “pathway entry date”.

After several years of falling numbers of carotid endarterectomies being performed in Scotland (which mirrors a similar pattern in the rest of the United Kingdom) the numbers of procedures performed increased from 342 in 2017 to 385 in 2018. Whether this is a real change or just a blip will become clear over coming years.

In 2018 there was a slight deterioration in performance from 56% to 53% in the percentage of patients undergoing a carotid intervention within 14 days of the event that led to them first seeking medical attention. This falls well short of the 80% Scottish Stroke Care Standard. Aberdeen Royal Infirmary was again the best performing centre in Scotland but even there the Standard was not achieved, showing just how challenging this time frame can be. Greater efforts are needed to move this patient group through the pathway to treatment as swiftly as possible to achieve the best outcomes.

The percentage of patients receiving carotid endarterectomy within 14 days of the pathway entry date was 84% in 2018 with 6 services achieving this measure (compared to 7 in 2017). This emphasises the need to improve public awareness around stroke and TIA so that medical attention is sought early. Emergency Department, Medical, Ophthalmology and Primary Care teams also need to be educated on the importance of getting appropriate patients into the pathway as soon as possible.


32

Table 7.1: Carotid Endarterectomy - number of patients receiving a carotid endarterectomy in acute hospitals in Scotland during 2018.

NHS board of hospital Hospital providing carotid intervention service

Total Residents Rate per 100,000 residents

Non-residents Non-resident NHS boards

(ranked on number of events, high-to-low)

Ayrshire & Arran Ayr Hospital 52 52 14.1 0

Dumfries & Galloway Dumfries & Galloway Royal Infirmary

21 21 14.1 0

Fife Victoria Hospital, Kirkcaldy 1 0 1 Greater Glasgow & Clyde

Forth Valley Forth Valley Royal Hospital (Larbert)

18 18 5.9 0

Grampian Aberdeen Royal Infirmary 23 19 3.3 4 Highland/ Orkney

Greater Glasgow & Clyde

Queen Elizabeth University Hospital, Glasgow

112 92 7.8 20 Forth Valley/ Highland/ Lanarkshire/ Lothian/ Outside Scotland/ Not Known/ Other

Highland Raigmore Hospital, Inverness

30 27 8.4 3 Western Isles/ Outside Scotland/ Not Known/ Other

Lanarkshire Hairmyres Hospital, East Kilbride

48 47 7.1 1 Outside Scotland/ Not Known/ Other

Lothian Royal Infirmary of Edinburgh at Little France

50 35 3.9 15 Borders/ Fife/ Outside Scotland/ Not Known/ Other

Tayside Ninewells Hospital, Dundee

26 15 3.6 11 Fife/ Grampian/ Outside Scotland/ Not Known/ Other

Scotland Scotland 381 326 6.2 55

Notes regarding Table 7.1:1. Hospitals shown are those that provide a carotid intervention service and have submitted data to eSSCA for 2018.2. A small proportion of records could not be assigned to a Health Board of residence because they were either for non-Scottish residents or

there was insufficient information to allow their assignment to a Health Board (e.g. partial or incorrect postcode).3. Health Board boundary changes occurred from April 2018. SSCA data use the revised Health Board boundaries. The issue primarily affects

NHS Greater Glasgow & Clyde and NHS Lanarkshire.4. The Scotland rate is based on the combined mid-year population estimates for the NHS boards shown in the table.


33

Chart 7.1: Percentage of patients undergoing a carotid intervention within 14 days of the event that led the patient to first seek medical assistance, 2017 and 2018 data.

Vertical line reflects Scottish Stroke Care Standard (2016) of 80% of patients undergoing carotid endarterectomy for symptomatic carotid stenosis have the operation within 14 days of the stroke event.

Note that the Scotland columns in the chart are coloured light green and dark green simply to differentiate them from the hospital columns and the colours are not indicative of performance. Light green corresponds to ‘2017’ and dark green corresponds to ‘2018’.

0 10 20 30 40 50 60 70 80 90 100

Scotland (n=385)

ARI (n=23)

RIE (n=50)

FVRH (n=18)

Ayr (n=52)

Hairmyres (n=48)

QUEH (n=116)

Ninewells (n=26)

Raigmore (n=30)

DGRI (n=21)

VHK (n=1)

%

2017 <=14 days2018 <=14 daysStroke Care Standard

Notes regarding Chart 7.1:Bracketed number on chart x-axis indicates number of patients in denominator for 2018.1. Hospitals shown are those that provide a carotid intervention service and have submitted data to eSSCA for 2018. 2. Patients in Borders, Orkney, Shetland & Western Isles are treated in other Health Boards as part of their respective carotid intervention

pathways.3. A small proportion of records have a carotid intervention date but no date recorded for the event that led to the first medical assessment.

These records are included in the denominator because the presence of an intervention date indicates that a carotid intervention was performed. The absence of a date for the event that led to the first medical assessment, however, prevents the calculation of days to carotid intervention so these cases cannot be measured against the 14 day standard and cannot be confirmed as having achieved it and are assumed not to have done so. This is a slightly different approach from the carotid timeline chart (see associated Excel files on SSCA web site at http://www.strokeaudit.scot.nhs.uk/Reports/Reports.html) where inclusion in the chart requires both a carotid intervention date and date recorded for the event that led to the first medical assessment. As a result, the Chart 7.1 denominators, for individual hospitals, may be slightly higher than those in the carotid timeline Charts 7.3 and 7.4.

http://www.strokeaudit.scot.nhs.uk/Reports/Reports.html


34

Chart 7.2 (referral) Percentage of patients undergoing a carotid intervention within 14 days of the carotid pathway entry date*, 2017 and 2018 data.

* In this analysis we try to reflect the performance of the hospital based services with respect to getting a carotid endarterectomy performed as quickly as possible. For patients receiving their carotid intervention via an inpatient stroke service the interval from the date of inpatient admission to surgery was used. For patients receiving their carotid intervention via an outpatient TIA/stroke clinic service the interval from the date of receipt of referral to the TIA clinic to surgery was used. For other outpatients, the delay from first outpatient assessment to surgery was used. If there was no preceding outpatient or inpatient admission then the date the patient was first seen by surgeons was taken.

Vertical line reflects Scottish Stroke Care Standard (2013) of 80% of patients undergoing carotid endarterectomy for symptomatic carotid stenosis have the operation within 14 days of the stroke event.

Note that the Scotland columns in the chart are coloured light green and dark green simply to differentiate them from the hospital columns and the colours are not indicative of performance. Light green corresponds to ‘2017’ and dark green corresponds to ‘2018’.

The chart columns are ranked, by hospital, on the percentage receiving their intervention within 14 days of referral.

0 10 20 30 40 50 60 70 80 90 100

Scotland (n=385)

FVRH (n=18)

ARI (n=23)

RIE (n=50)

QUEH (n=116)

Hairmyres (n=48)

Ayr (n=52)

Ninewells (n=26)

Raigmore (n=30)

DGRI (n=21)

VHK (n=1)

%

2017 <=14 days2018 <=14 daysStroke Care Standard

Notes regarding chart 7.2:Bracketed number on chart x-axis indicates number of patients in denominator for 2018.1. Hospitals shown are those that provide a carotid intervention service and have submitted data to eSSCA for 2018. 2. Patients in Borders, Orkney, Shetland & Western Isles are treated in other Health Boards as part of their respective carotid intervention

pathways.3. A small proportion of records have a carotid intervention date but no date recorded for the event that led to the first medical assessment.

These records are included in the denominator because the presence of an intervention date indicates that a carotid intervention was performed. The absence of a date for the event that led to the first medical assessment, however, prevents the calculation of days to carotid intervention so these cases cannot be measured against the 14 day standard and cannot be confirmed as having achieved it and are assumed not to have done so. This is a slightly different approach from the carotid timeline chart (see associated Excel files on SSCA web site at http://www.strokeaudit.scot.nhs.uk/Reports/Reports.html) where inclusion in the chart requires both a carotid intervention date and date recorded for the event that led to the first medical assessment. As a result, the Chart 7.1 denominators, for individual hospitals, may be slightly higher than those in the carotid timeline chart.



35

8 RehabilitationEnsuring the delivery of appropriate rehabilitation for stroke survivors is a key priority within the Scottish Stroke Improvement Programme (SIP). This means having specialist stroke rehabilitation available for everyone who needs it, delivered intensively enough to be effective. When patients need to be in hospital for their early post stroke rehabilitation, this should be delivered in a stroke unit with a specialist multidisciplinary team and adequate staffing levels. Over the past few years there has been a shift towards increasing amounts of rehabilitation taking place in the patient’s own home. The Health and Social Care Integration agenda is a key driver for a multi agency approach to rehabilitation in our communities: we must ensure that consistent access to stroke rehabilitation is available across Scotland allowing patients to maximise their recovery and reach their goals.

The Scottish stroke rehabilitation audit has had additional funding from the Scottish government and is an on-going part of the Stroke Improvement Programme, with scoping and consultation work to gather intelligence from relevant audits and studies in similar demographic areas such as the Greater Manchester Stroke Operational Delivery Network (GMSODN), the SSNAP Post Acute Stroke Audit, community stroke service scoping work commissioned by Chest Heart & Stroke Scotland and the Scottish Government Chief Health Professions Office stroke unit staffing calculator outputs in relation to the SSCA Organisational Audit reported staffing levels.

The SIP stroke rehabilitation workshop in November 2018 had representation from a variety of disciplines from all Scottish NHS boards, including both hospital and community services. We explored issues around measuring case-mix, intensity and frequency of intervention, specialist vs. generic service provision, exercise after stroke, education and data - currently collected and required in the future.

The revised organisational audit went out to MCNs in January 2019. It now contains elements of the previous sprint rehabilitation audit and more explicit information about community provision of rehabilitation services, including staffing levels, and includes community teams within the education template. We have asked Boards about referral pathways to community rehabilitation services and exercise after stroke services.

We have updated the SIP performance targets to reflect access to rehabilitation in inpatient settings, intensity of provision in stroke units and access to stroke specialist Early Supported Discharge and community teams. There are now 4 criteria: 7.1 Access to Acute Therapy Assessment (as per the sprint audit); 7.2 Access to Inpatient Stroke Therapy (reflecting intensity), 7.3 Access to Community Stroke Therapy (reflecting availability of specialist vs. generic services) and 7.4 Availability by days per week of community therapy input (again reflecting intensity). We plan to change the criteria to a more quantifiable approach, including reporting of actual numbers of patients receiving these interventions. This will go out for wider comment before finalised. We used the previously described and tested clinical stroke inpatient case-mix categorisation tool to specify the patients most eligible for appropriately intensive and specialist stroke rehabilitation in hospital and community settings. We will ultimately use Clinical Knowledge Publisher, the online pathway tool supported by NES, to roll this out across Scotland.

We are working on the use of a patient reported outcome measure – pilots are currently underway in NHS Lanarkshire and NHS Lothian.


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9 Outcomes after admission with strokeThe SSIP aim to optimise the delivery of effective stroke services across Scotland and thus to optimise the outcomes for patients suffering a stroke or TIA. Large trials tell us that if we give certain stroke interventions, such as thrombolysis, thrombectomy, antiplatelet agents (aspirin and/or clopidogrel), anticoagulation, intermittent pneumatic compression (IPC), carotid endarterectomy and stroke unit care to appropriate patients, the patients have a better chance of a good outcome – this might be survival (for IPC), function (for thrombolysis and thrombectomy) or lower risks of recurrence (for antiplatelet agents, statins, anticoagulation and carotid endarterectomy).

It would be attractive if we could use patient outcomes to determine the quality of stroke care in Scotland but research has shown that differences in the outcomes of patients between services, and changes over time, do not reliably reflect the quality of those services. Even in SSCA which includes all admitted stroke patients in Scotland, the numbers of patients overall in any given year, are modest and in any specific hospital or NHS board are too small to provide really precise estimates of outcome.

Whilst the quality of care is likely to influence outcomes, other factors which will lead to variation in outcomes include changes in the types of people having strokes, receiving treatments, stroke severity and changes in the tests used to diagnose strokes and TIA. These factors will often swamp any effects of treatment. Also, whilst it is fairly easy to measure the treatment delivered to patients in hospital, it is much more difficult to measure their outcomes after they have left hospital. For these reasons the SSCA previously only measured the delivery of stroke interventions to infer the quality of stroke care rather than patient outcomes.

We can reliably measure using routinely available data whether patients have survived or not, but survival with major disability is not an outcome which many patients value. Also, even if we identify that a larger proportion of patients treated by one hospital die, compared with others, this information does not tell us why, or even what might be going wrong. The SSCA now reports annually on both mortality and also

“home-time” (see below) corrected for important external factors.


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Chart 9.1: 90-day mortality for 2018 admissions by NHS board.

A&A

Borders

D&G

Fife

FV Grampian

GG&CHighland Lanarkshire

Lothian

Orkney

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TaysideWI

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25%

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0 200 400 600 800 1000 1200 1400 1600 1800 2000 2200 2400

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ay m

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Number of inpatient cases

99.8% Limits95% LimitsMean

Note for Chart 9.1:1. The models used for the case-mix adjustment were fitted on the 2018 admissions data and include the variables, age on admission, sex,

stroke type. Independent in ADL prior to event; patient lived alone at normal place of residence; talking at first assessment; oriented to time, place and person at first assessment; lift both arms at first assessment; walking without help from another person.

Chart 9.1 shows the 90 days case fatality amongst those patients admitted to hospital in 2018. These figures have been adjusted for age, stroke severity and other factors which affect survival and might vary between NHS boards. There are no differences between NHS boards which cannot be explained by chance alone. Chart 9.2 shows these data in a different way. The w score with 95% confidence interval (broken line) and 99.8% confidence intervals (solid line), again adjusted, for patients admitted to hospitals in each NHS board area. The w score is the number of ‘excess’ deaths per 100 cases where the expected mortality is the average across Scotland. Whilst the point estimates for NHS Lothian indicate a higher mortality than expected, and the case fatality in Tayside is lower, the fact they do not exceed the 99.8% confidence interval indicates that this might be explained by chance alone. So, the conclusion is that no NHS board has a definitively higher or lower than expected 90 days case fatality after stroke.


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Chart 9.2: 90-day mortality W-score for 2018 admissions by NHS board.

A&A

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D&GFife

FV GrampianGG&CHighland Lanarkshire

Lothian

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Note for Chart 9.2:1. The models used for the case-mix adjustment were fitted on the 2018 admissions data and include the variables: age on admission; sex;

stroke type; independent in ADL prior to event;patient; lived alone at normal place of residence; talking at first assessment; oriented to time, place and person at first assessment; lift both arms at first assessment; walking without help from another person.

2. See reference 15 for more detail on the W-score.

Home days, or home time, measures the number of days patients are at home in the first 90 days after their stroke. We believe that more home days would generally be valued by the patients. Patients who rapidly recover, who are able to go home within the first few days, and who do not require readmission, or admission to a care home, would accrue lots of home days, whereas patients who do not survive to be discharged home, who are discharged to a nursing home, who have a prolonged length of stay in hospital, or who are readmitted having gone home will have fewer or even no home days. Research has shown that home days reflect how well the patients are functioning at 3 months after a stroke.


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Chart 9.3: Mean 90-day home-time for 2018 admissions by NHS board.

A&A

Borders

D&G

Fife

FV

Grampian

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Highland

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Lothian

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Note for Chart 9.3:1. The models used for the case-mix adjustment were fitted on the 2018 admissions data and include the variables: age on admission; sex;

stroke type; independent in ADL prior to event;patient; lived alone at normal place of residence; talking at first assessment; oriented to time, place and person at first assessment; lift both arms at first assessment; walking without help from another person.

Chart 9.3 shows the average number of home days experienced by patients admitted to different NHS boards in Scotland. These data have also been adjusted to take account of age, stroke severity and other prognostic factors. Interestingly patients in NHS Lanarkshire experience more home days than elsewhere. Where in 2017 patients in NHS Grampian experienced less home-time than other services in Scotland, this is not the case in 2018.

Interventions such as thrombectomy (in the future) and early supported discharge services might increase home days whilst delays in accessing community care and aids and adaptations are likely to reduce home days. Home-time will be a method to measure the impact of such service changes in the future.


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10 Using SSCA data for researchThere are a number of ongoing or planned projects utilising the rich information available within the SSCA dataset. Appropriate ethical and PBPP approvals are in place.

Work funded by Chest Heart and Stroke Scotland is looking at how prescribing of specific medications affects stroke outcomes. To date this has focussed on analysing the prescribing patterns of anti-thrombotics (drugs like aspirin, clopidogrel and warfarin) prior to stroke onset, and looking at the effects of each on outcomes after stroke. Not surprisingly, haemorrhage is commoner in people taking anticoagulants, while ischaemic stroke is less likely when compared to stroke patients not on prior anticoagulation. Patients taking anti-platelets (e.g. aspirin, clopidogrel) at the time of stroke have higher mortality rates than those not taking these medicines, but this probably reflects that they have other conditions that make them more susceptible to a poor outcome. We are now exploring these finding further.

Ongoing work by Dr Melanie Turner funded by The Stroke Association is assessing the effects of comorbidities on stroke management, secondary prevention and outcomes (including recurrent events and hospital readmission). Patients with a high comorbidity index are more likely to have blood pressure, antithrombotic and lipid lowering medicines prescribed within the six months prior to their stroke. The more comorbidities, the less likely patients are to achieve the care bundle, with particular conditions such as heart disease or cancer having more influence on this. Increasing numbers of comorbidities also make survival to 30 days less likely, and reduce the time spent at home within the 90 days after stroke onset.

7.5% and 11.7% of patients have been readmitted to hospital 30 and 90 days after a stroke. By one year this figure has risen to 20.3%. An increasing number of comorbid conditions increases the likelihood of readmission at 30 and 90 days after a stroke, and also increases the risk of recurrent stroke within one year. Further work will explore how comorbidities and medicine history can be used to help predict outcome after stroke, with the aim of eventually helping patients, relatives and care teams make decisions about management after stroke.

Some of these findings were presented at the European Stroke Organisation Conference in Milan in May and when published will be available on the SSCA website. Further information on any of this research can be obtained from [email protected] or [email protected]

Other work includes a paper recently published in Stroke (lead author Dr T Quinn, University of Glasgow with analysis done by Iain McDermid, ISD), showing that home time is a feasible outcome measure in national datasets. A link to this paper is available on the SSCA website (https://www.ahajournals.org/doi/pdf/10.1161/STROKEAHA.118.023916).

A list of further funded and approved projects and related publications is available on the SSCA website.



https://www.ahajournals.org/doi/pdf/10.1161/STROKEAHA.118.023916

https://www.ahajournals.org/doi/pdf/10.1161/STROKEAHA.118.023916


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11 Where Next?The SSCA is continually reviewing our standards, and at the start of 2019 we reviewed the standard for brain imaging. The standard we have reported on in 2019 is that 95% of patients have CT/ MRI imaging within 24 hours of admission. The standard measured in 2020’s report will be 90% of patients will be scanned within 12 hours of arrival at first hospital.

Whilst the SSCA Steering Group and the National Advisory Committee for Stroke recognise that this new standard is not as challenging as the NHS England standard of 4 hours, we feel that there is not robust evidence to support the English standard. The enhanced standard of 12 hours will be testing for NHS boards but it is in line with the available evidence around antiplatelet prescribing in recently published trials.

NHS boards are already receiving management reports on how well they are performing against the new standard, and in this year’s report we can see that 79% of eligible patients in 2018 received brain imaging within 12 hours (Chart (3.6)).

With the changes to the standards and to ensure that NHS boards are continuing to monitor the performance against the SSCA Standards the SSIP, along with the other Scottish Healthcare Audits have adopted a robust governance process to ensure there is a thorough investigation into any outliers or NHS boards which fail consistently to meet the SSCA standards, and an improvement plan is put in place. NHS boards have the opportunity to describe their actions in Appendix A.

The SSCA will provide audit data for the new thrombectomy service throughout Scotland, with a dataset agreed by the steering group and the addition of another component scheduled for September 2019.

In addition, and as has been highlighted in section 4 (Outpatients) and section 8 (Rehabilitation), the SSCA is looking at how we can measure all aspects of the patient’s journey. Whilst there will be significant developments in a thrombectomy service in the coming years, we must ensure that we can evidence the care that stroke patients receive from all areas of the stroke service, be they in acute, community or third sector.

Finally to assure patients, carers and healthcare professionals across Scotland that the data we use is robust and accurate, the core team have completed a case note validation across all the contributing centres in Scotland. This quality assurance exercise found the data entered to be in line with the agreed definitions in almost all cases. Where there were areas of concern additional support was given and these areas are now entering the data according to the agreed definitions. This process will be repeated in Spring next year.


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List of References1. The Scottish Government, The Healthcare Quality Strategy. Edinburgh, Scotland: May 2010. http://

www.gov.scot/Topics/Health/Policy/Quality-Strategy

2. The Scottish Government, 2020 Vision. Edinburgh, Scotland: 2011. http://www.gov.scot/Topics/Health/Policy/2020-Vision

3. The Scottish Government, Stroke Improvement Plan. Edinburgh, Scotland: August 2014. http://www.gov.scot/Publications/2014/08/9114

4. CLOTS (Clots in Legs Or sTockings after Stroke) Trials Collaboration. Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS 3): a multicentre randomised controlled trial. The Lancet 2013; 382:516 – 524.

5. CLOTS (Clots in Legs Or sTockings after Stroke) Trials Collaboration. Effect of intermittent pneumatic compression on disability, living circumstances, quality of life, and hospital costs after stroke: secondary analyses from CLOTS 3, a randomised trial. Lancet Neurology 2014. published online Oct 31. http://dx.doi.org/10.1016/S1474-4422(14)70258-3

6. Langhorne (2013), Cochrane Database Syst Rev. 2013 Sep 11;9:CD000197. doi: 10.1002/14651858.CD000197.pub3.

7. Te Ao BJ, Brown PM, Feigin VL, et al. (2012) Are stroke units cost effective? Evidence from a New Zealand stroke incidence and population-based study. Int J Stroke 2012; 7:623–30.

8. Saunders DH, Sanderson M, Hayes S, Kilrane M, Greig CA, Brazzelli M, Mead GE. Physical fitness training for stroke patients. Cochrane Database of Systematic Reviews 2016, Issue 3. Art. No.: CD003316. DOI: 10.1002/14651858.CD003316.pub6

9. Saka O, McGuire A and Wolfe C. Cost of stroke in the United Kingdom. Age and Ageing 2009; 38: 27–32

10. Turner M, Barber M, Dodds H, Murphy D, Dennis M, Langhorne P and Macleod MJ on behalf of the Scottish Stroke Care Audit. Implementing a simple care bundle is associated with improved outcomes in a national cohort of ischemic stroke patients. Stroke 2015; 46:1065-1070. DOI: 10.1161/ STROKEAHA.114.007608.

11. Turner M, Barber M, Dodds H, Martin D, Langhorne P, Macleod M (2015). Agreement between routine electronic hospital discharge and Scottish Stroke Care Audit (SSCA) data in identifying stroke in the Scottish population. BMC Health Services Research, vol 15, 583.

12. Turner M, Barber M, Dodds H, Dennis M, Langhorne P, Macleod M-J on behalf of the Scottish Stroke Care Audit (2016). Stroke patients admitted within normal working hours are more likely to achieve process standards and to have better outcomes. Journal of Neurology, Neurosurgery & Psychiatry, vol 87, no 2, pp.138-143.

13. O’Donnell MJ, Xavier D, Liu L. et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet 2010; 376:112-123.

14. Benjamin D Bray, Craig J Smith, Geoffrey C Cloud, Pam Enderby, Martin James, Lizz Paley, Pippa J Tyrrell, Charles D A Wolfe, Anthony G Rudd (2016) The association between delays in screening for and assessing dysphagia after acute stroke, and the risk of stroke-associated pneumonia J Neurol Neurosurg Psychiatry 2016;0:1–6. doi:10.1136/jnnp-2016-313356.

15. Parry, Gould, McCabe and Tarnow-Mordi Annual league tables of mortality in neonatal intensive care units: longitudinal study’, BMJ, 1998.

http://www.gov.scot/Topics/Health/Policy/Quality-Strategy

http://www.gov.scot/Topics/Health/Policy/Quality-Strategy

http://www.gov.scot/Topics/Health/Policy/2020-Vision

http://www.gov.scot/Topics/Health/Policy/2020-Vision

http://www.gov.scot/Publications/2014/08/9114

http://www.gov.scot/Publications/2014/08/9114

http://dx.doi.org/10.1016/S1474-4422(14)70258-3


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Appendix A: Responses from Chief ExecutivesDuring the preparation of this report the NHS board Chief Executives were asked to provide some feedback on their performance against specific Scottish Stroke Care Standards or Improvement Priorities where there had been an improvement or decline in performance, or actions are required to improve access to services.

The Chief Executives responses are noted (by NHS board) below:

NHS Ayrshire & Arran

NHS Ayrshire & Arran’s performance against the Stroke Care Bundle continues to improve and compares favourably with the overall performance for Scotland, reflecting progress made in relation to the admission, swallow screen and aspirin Scottish Stroke Care Standards. There was a reduction in our performance against the brain scan standard at University Hospital Crosshouse.

During April 2018, a new Acute Stroke Unit (ASU) Band 6 practitioner nurse role was introduced. The role has a focus on improving compliance with the Scottish Stroke Care Standards, providing evidence based person centred care and staff education.

Swallow screenWe were one of the best performing NHS Boards in Scotland for this standard during 2018 and the local stroke team has worked hard to achieve this. For example, nursing staff attend the Emergency Department (ED) and Combined Assessment Unit (CAU) to carry out swallow screens.

Brain scanThe brain scan standard remains a challenge despite a number of initiatives. For example, nursing staff phone the radiology department at 8 am every day to identify the time window for brain imaging and an aide memoir is in place for junior doctors to facilitate brain imaging requests. The ASU team works closely with radiology colleagues to continually identify new solutions to improve performance.

In addition to the above there are daily ASU Band 6 and band 7 nurse afternoon ward rounds to ensure that all aspects of the Stroke Care Bundle are in place.

ThrombolysisWhile our performance against the thrombolysis within one hour standard has declined to 68% during 2018, this is higher than the overall percentage for Scotland (60%). The 30 minute standard continues to be a challenge. We have a robust thrombolysis pathway and process in place and all delays are discussed at Thrombolysis Governance meetings.

To assist in improving our door to needle time, during 2018, a new role was introduced for Band 3 practitioners to assist with thrombolysis assessment in the ED and transfer to imaging and the ASU and thrombolysis assessment documentation was reviewed and updated.

The ASU continues to work collaboratively with the ED and radiology to identify potential delays in the thrombolysis pathway and opportunities to improve performance against the thrombolysis standards.

Carotid intervention We continue to meet the carotid standard from referral to intervention (80% of all patients referred will receive intervention within 14 days). Unfortunately, the standard intervention within 14 days of event (80%) was not achieved. A robust pathway is in place which is evidenced by the achievement of the referral to intervention standard. The standard measuring event to intervention is more difficult to achieve as often there can be a time lag between event and referral. The vascular team despite having


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workforce challenges at the present time with only two substantive consultants in post continue to offer intervention within 14 days of referral for the majority of patients.

Specialist Stroke/TIA ClinicsNHS Ayrshire & Arran continues to perform well against this standard.

NHS Borders

The NHS Borders Stroke Team has continued to work towards improving our performance against the National Stroke Standards. The Stroke Team is not just the staff within the Borders Stroke Unit but includes the clinical and managerial teams in Emergency Department, Medicine, Radiology and Community and Social Work services, as well as colleagues in tertiary referral services in NHS Lothian.

Key achievementsNHS Borders continues to exceed the standard for CT scanning, achieving 98%. We continue education about early requesting. We have reviewed out of hours scanning protocols and continue to have excellent support from our radiology colleagues.

The Aspirin Administration standard of 95% has been achieved. This is facilitated by prompt scanning, reporting and prescribing education.

The Swallow Assessment standard has not achieved but we continue to improve from 85% to 87%. We use exception reporting – issues identified have been unusual presentations, such as posterior circulation strokes, haemorrhagic strokes and patients who are improving but not resolved. Education and training continue and encourage accurate data recording.

We have not achieved the Admission to Stroke Unit target but remain stable at 75%. We feed back weekly exception reports to the Hospital Safety Brief meeting to raise awareness. This winter a number of improvements to community rehabilitation were established, including Hospital to Home.

For the first time we have achieved a Thrombolysis door to needle time of less than 30 minutes (15% of patients). We have also increased thrombolysis within 1 hour from 38% to 55%. We have continued to focus on STAT and simulation training for the new intake of staff each year. During daytime the service is NHS Borders consultant led but when not available we have had support from the South East Scotland Thrombolysis service. Consistent consultant practice, training and radiology engagement has allowed us to reduce unnecessary delays.

NHS Dumfries & Galloway

Following our performance in 2017 the Stroke MCN embarked on a number of improvement strategies for 2018. This has resulted in a much improved performance against a number of the stroke standards across Dumfries & Galloway.

Admitting stroke patients promptly to the acute stroke ward at DGRI remains a priority and following the move to the new hospital in December 2017 there were significant challenges. Early 2018 saw little improvement due to winter pressures on our bed capacity but overall our performance has improved from 68% to 78%.

Our main action has been to improve communication between the combined assessment unit (CAU) and acute stroke unit (ASU) with the aim to highlight individuals as soon as possible after admission. As part of that process the capacity managers are able to prioritise beds in the ASU. The stroke team continue to have a daily presence Monday to Friday within CAU to facilitate stroke patient care and management. For 2019 the staffs working in the stroke unit are looking at a weekend in-reach service to CAU. The stroke liaison nursing team are also looking at providing rapid assessment to CAU and the Emergency


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Department (ED) during the working week to facilitate appropriate management of possible stroke and TIA admissions.

In 2017 only 57% of patients had swallowing screening assessment within 4 hours. In 2018 we saw an increase of compliance in swallow screening to 69%.

As part of the Scottish Improvement Skills programme the stroke nursing team undertook a project which specifically looked at the swallow screen process. They reviewed current practise which highlighted the need for further training and education of staff in CAU. They also introduced swallow packs for easy access to undertake the screening. The swallow label which had been used became embedded into the existing paperwork both in CAU and ED.

The thrombolysis door to needle times also remain an issue for Dumfries and Galloway but we have seen an increase with our overall 1 hour performance in DGRI go from 38% to 53% and GCH from 17% to 43%. This in part was due to a review of the thrombolysis pathway and the engagement with our ED colleagues. Following this review we now have agreement that ED staff will oversee thrombolysis in the out of hour period. There is also continued support from the Lothian hub. The paperwork was also reviewed.

Although the aspirin standard is still not met this has improved from 84% to 91%.

Across Dumfries & Galloway for patients with a final diagnosis of stroke receiving all aspects of the stroke care bundle our performance has improved from 43% to 56%.

In respect of the other standards, CT imaging within 24 hours of admission and Neurovascular clinic target were met in 2018.

The Stroke MCN wishes to acknowledge the wider support received from medical, surgical, emergency and radiology teams as well as the Lothian Hub.

NHS Fife

The continued improvement in Scottish Stroke Care Standards (2016) remains a priority for the Stroke MCN and NHS Fife. Please note the following on behalf of NHS Fife.

Percentage admitted to a stroke unit within 1 day of admission Victoria Hospital (VHK) (standard 90%): Performance in this area has been challenging in 2018. With a rise in the number of acute stroke patients admitted by 200 on previous year, alongside a reduction in acute stroke beds from 24 to 21 (September 2018) as part of site optimisation, this has seen length of stay within our acute area increase. The Health & Social Care Partnership (H&SCP) are currently completing a joined up care review which aims to increase the number of community stroke rehabilitation beds available from 29 to 34. This will support increased demand and flow from acute to community care. The Stroke Managed Clinical Network (MCN) continues to strive towards improving performance against this standard through collaboration with key stakeholders. Restructuring the way standards exception reporting is carried out, as weekly exception reporting, implemented 2013, has yielded little feedback. Therefore, from January 2019 onwards the MCN adopted an NHS Lothian reporting model.

Percentage seen at specialist stroke/TIA clinic within 4 days of receipt of referral Queen Margaret Hospital (QMH) (standard 80%): Performance in this area remains challenging. Standard for Queen Margaret Hospital (QMH) significantly impacts our ability to achieve this target overall. Discrepancies between sites are thought to be due to days of the week clinics run.


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In 2018 QMH clinic slots were increased alongside a new Friday Clinic at Victoria Hospital (VHK). As these changes were being implemented, Stroke Services lost a senior member of the medical team and was then working with reduced staff. Further improvement work continues in 2019 to restructure clinics at QMH. This includes, in collaboration with the Radiology Department, moving Tuesday morning clinics to the afternoon. This should help stroke patients & carers who struggle to attend morning appointments. Monitoring the impact of these changes is ongoing and further steps to improve access will be implemented if necessary. It should be noted that NHS Fife offers a One Stop Rapid Access TIA Clinic. This is based on first available appointment, serviced by the same Stroke Team, regardless of location. Measuring performance against Fife overall, at present we do meet the standards but work continues on meeting targets consistently across both sites.

Percentage receiving thrombolysis bolus within 1 hour of arrival at hospital (standard 80%): The 1 hour thrombolysis performance is improving but varies considerably between in hours and out of hours services. Since January 2019 in hours performance, when the Stroke Team was on site, met the standard for both door to needle time (DTN) targets. However DTN out of hours remains challenging. The Stroke MCN continuously work on improving targets including regular thrombolysis governance review meetings with Accident and Emergency staff.

Extended day time working hours for Stroke Specialist Nurses has been implemented already but further collaborative work with Services Managers is underway to look at ways of improving out of hours performance.

The Stroke MCN remains committed to improving and sustaining performance across all Stroke Standards.

NHS Forth Valley

Access to Stroke Unit Timely admission to the Stroke Unit remains a challenge in a system where overall hospital capacity and patient flow is significantly challenged which impacts on many services and other government targets. The Stroke Unit is also used for Ageing & Health patients when beds are available. Flow to the Stroke Unit is part of work relating to unscheduled care and protecting a bed within the Stroke Unit until 10pm when possible has started since April 2019.

Swallow Screening There has been no significant change in relation to this standard and efforts are ongoing to improve screening and recording of screening in front-door acute services.

Brain Imaging The target for brain imaging within 24 hours was achieved in 2018, but with the change in standard for 2019, reorganisation of out-of-hours imaging has been implemented.

Outpatient Clinics As reported in the 2017 report, consultant vacancies had a very significant impact on the delivery of frequent outpatient clinics to achieve a 4-day target. Since the appointment of a new consultant, the backlog of patients was cleared and Forth Valley is again achieving this standard. For clinics January to May 2019, 85% of patients with a vascular diagnosis were on target. There remains a vulnerability to the service during periods of leave and cancellations due to acute general medical on-call commitments.


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Thrombolysis Mean door-to-needle times have fallen to 53 minutes (95% confidence interval 44 to 62 minutes) but numbers receiving treatment within 30 and 60 minutes, whilst improved, remain below the national targets. Treatment timelines are reviewed at regular governance meetings with the Emergency Department to understand and address delays in therapy. STAT training courses were held and delivered to 23 ED nurses since October 2018 to date. Further training is in place this year and will be delivered on an ongoing basis. A Scottish Ambulance Service information event took place in April 2019.

Carotid Intervention Systems in place have seen improvement in the proportion of patients having surgery within 14 days of vascular event, and all but one patient in 2017 and 2018 receiving surgery within 14 days of entering the carotid pathway. Re-organisation of services in early 2019 means that patients are now being transferred to the Queen Elizabeth University Hospital for surgery rather than being done locally.

Community Stroke Services These services relating to the Scottish Stroke Improvement Programme priorities 7 and 8 remain difficult to deliver and co-working with the Integrated Joint Boards who manage the community teams is necessary.

Public Awareness / FAST events since October 2018 A FAST information event has been held in FVRH, plus an information event combined with a bake sale/fundraiser for the Stroke Association. A further FAST event was delivered to a local secondary school with two further schools planned. FAST events are also organised for two local shopping centres, and

“Know Your Blood Pressure” events are planned in summer and autumn.

NHS Grampian

The 2018 Scottish Stroke care audit National report highlights many areas where we are continuing to improve, and some areas with slight decline. We admit about 800-840 patients per year with stroke at Aberdeen Royal Infirmary (ARI, 82%) and Dr Gray’s Hospital (DGH, 18%). In terms of the main standards;

1) 90% admission to the stroke unit within 24 hours; this standard was achieved for the first time at ARI in 2018 and in the last 12 months, and improved at DGH from 70 to 79% (82% in the last 12 months).

2) >90% Swallow screening within 4 hours of admission has significantly improved with both centres achieving the standard in 2018.

3) The new CT standard of being scanned within 12 hours of admission in >90% of cases is being achieved of the time in both ARI and DGH in 2018.

4) 95% patients receiving aspirin within 24 hours is just below the standard at 94.2%. This is likely due to delayed diagnosis in some cases, but we continue to do weekly exception reporting to understand the reasons for this.

These 4 standards together are the ‘stroke bundle’, which is being achieved >80% of the time for the first time in ARI in 2018, and improved from 60.7 to 66.9% at DGH.

5) Thrombolysis numbers at ARI are high with ~22% of patients with ischaemic stroke receiving this treatment, with door to needle times close to the Scottish average (60% in 60 minutes, and 14% within 30 minutes). In DGH the proportion of patients being thrombolysed has dropped from ~20% to 11%, and the door to needle times are much longer than average. The reasons for this are being explored by the clinicians and staff at Dr Grays. It is hoped a new appointment of a stroke consultant at DGH will help address this issue.


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6) The standard of 80% of patients being seen at clinic within 4 days of referral is achieved for the first year at ARI in 2018, and continues to be achieved at DGH in 2017-18. In terms of carotid endarterectomy (CEA) we have the quickest service in Scotland, with just under 80% being treated within 2 weeks. The proportion of patients receiving CEA is similar to Lothian and Tayside.

At ARI we have weekly exception report meetings and monthly Emergency department meetings where we examine cases that have failed these standards and try and improve systems and practice. We benefit from extra stroke beds and nursing provision at pressure times of the year. We have a very dedicated team of nurses and therapists. Better clinic timing produces more consistent timely out-patient review. These areas will be examined at Dr Gray’s, helped if a stroke specific clinician can be recruited.

NHS Greater Glasgow & Clyde

Thank you for asking me to comment on the NHS Greater Glasgow and Clyde (NHSGGC) performance in the Scottish Stroke Care Standards and one Scottish Stroke Improvement Plan priority area.

For the Scottish Stroke Care Standards, you asked for comments about a significant decrease in performance in the proportion of patients receiving aspirin at the Royal Alexandra Hospital (RAH) and the significant increase in performance in rates of swallow screening at Glasgow Royal Infirmary (GRI).

The Board has been actively addressing patient flow in the RAH and its impact across all 4 measures in the stroke bundle. The Senior Management Team in the Clyde Sector is strongly focussed on this issue. This has improved speed of prescribing of aspirin and within the RAH, performance is 93% for the first quarter of 2019. We are confident that the improved processes will lead to sustained improvement.

In GRI the Stroke Clinicians have worked closely with colleagues in the Emergency Department in raising awareness of the importance of swallow screening and the Emergency Department nursing team have been very supportive of this. A senior nurse in the department has responsibility for ‘championing’ this standard and she follows up all instances where the standard is not met to look for remediable reasons. Swallow screening rates have continued to improve and on several occasions recently the weekly performance report I receive has shown 100% achievement of the standard.

For the Stroke Improvement Plan - Priority 2, Action 3 relating to the thrombolysis process and pathway: we are aware there are problems posed by the number of patients who originate at a hospital other than the Queen Elizabeth University Hospital (QEUH) but travel to the QEUH for thrombolysis. At present in NHSGGC the QEUH is the only hospital providing 24 hour stroke thrombolysis; GRI has a weekday daytime service only.

Patients potentially eligible for stroke thrombolysis who arrive “out of hours” at GRI, or at any time of day at Inverclyde Royal Hospital or the RAH, are transferred to the QEUH for treatment thus building in a delay while the patient is transferred. The ‘door to needle’ times for patients who arrive at the QEUH as their first hospital are substantially better than for those who originate elsewhere. We are actively working to find a solution to this disparity via the NHSGGC Stroke Improvement Programme.

NHS Highland

A Stroke Action Plan Working Group, led by Jane Buckley, Divisional Manager and Moranne MacGillivray, Service Manager has been established. This group has excellent clinical and full MDT engagement and meets and reports out fortnightly on progress on all actions in the Raigmore Stroke Action Plan.

Admission to Stroke Unit (% admitted to a stroke unit within one day of admission): Performance against this target continues to be a challenge to NHS Highland in part due to small numbers which influence percentages at RGH’s . However at Raigmore enhancements in this pathway have been implemented and are already leading to improvement. In the last two months there has been an


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improved performance against the standard (89% & 92% respectively). The new process ensures that the stroke team, flow coordinators, bed manager and Service/Duty Manager can identify who is waiting for access to the Stroke Unit and can create the capacity required. At Belford, Caithness General and Lorn & Islands hospitals improvement work which focuses on “flow” through the hospital is being used to support achievement of the standard.

Outpatients: (% seen at specialist stroke/TIA clinic within 4 days of receipt of referral). The data contained within the report refers to the clinics routinely held at Raigmore and the Lorn & Islands. At Raigmore the pathway has been reviewed and as a result a redesign of the clinic and Ultrasound Scanning pathway has taken place. We are confident that this will improve performance against the standard. This will be monitored fortnightly at the Stroke Action Plan Working Group report out.

Thrombolysis (% receiving thrombolysis bolus within one hour of arrival at hospital): At Raigmore the management of patients presenting with acute stroke to the Emergency Department(ED) has been changed to improve the “door to needle” time for patients who meet the criteria for thrombolysis. Any patient who has been pre-alerted or presents to the ED with a suspected stroke (FAST positive) will be immediately triaged by an ED nurse using a Stroke Thrombolysis Screening Tool. If criteria are met for potential thrombolysis, the nurse will put out a 2222 call specifically for stroke thrombolysis response team. This team based approach has clearly designated roles and a robust triage system enabling the process of assessing and treating patients with acute stroke to become easier and more efficient.

Carotid Intervention (% intervention 14 days after event): The pathway to surgery for northern NHS Highland is to Raigmore and is currently under review. Plans include set operating days and changes to the processes and pathways around recovery.

General Comments: Small numbers can and do significantly impact in relation to percentages. As indicated improvement work in line with the HQA is ongoing in all the highland hospitals. For example changes have been made to the process for recording of Swallow Screen at the Belford and at Lorn & Islands where the ED has led on this work.

NHS Lanarkshire

Overall, NHS Lanarkshire is satisfied with performance against the Scottish Stroke Care Standards and Scottish Stroke Improvement Action Plan over the past 12 months, although some areas remain challenging to improve.

For the Inpatient Standards, access to stroke unit care at University Hospital Wishaw remains difficult and this to some extent reflects other challenges with flow in the hospital. Regular meetings with the management team continue, in the hope of prioritising stroke flows. Achieving the swallow screen Standard is difficult and we recognise that this is not a unique problem in NHS Lanarkshire. We work


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closely with the Emergency Departments to increase awareness of this issue and it is pleasing to see such an improvement in performance at University Hospital Monklands in this year’s report. Maintaining this improvement will require ongoing work.

Although we do not meet the Standard for Carotid Endarterectomy within 14 days of event, we do achieve the target of carotid surgery within 14 days of pathway entry date, suggesting that our model of having a specialist Carotid Endarterectomy pathway nurse does help flow through the parts of the pathway that we have control over.

NHS Lanarkshire is particularly pleased with the improvements in performance against the 60 minute thrombolysis standard. It is good to be an outlier in a positive way! These improvements have been made as part of our ongoing thrombolysis governance model, which includes multidisciplinary representatives from Emergency Departments and Radiology and also depends on support from colleagues in Ayrshire and Arran as part of our shared telestroke network. In preparation for the development of a thrombectomy service in Scotland, we plan to pilot models of thrombolysis (still supported by our telestroke system) closer to the front door. This should lead to further reductions in door to needle times as well as leading to shorter ‘door in, door out’ times in the future for thrombectomy cases.

NHS Lothian

NHS Lothian has made considerable progress in improvements across some of the national stroke standards. This is partly due to the board’s focus on quality improvement (QI) in stroke; the transformation of the MCN into the Stroke Services Quality Improvement Board (SSQIB); and an active QI programme to promote continuous improvement. Whilst acknowledging that we still struggle with adequate access to early stroke unit care, we believe that almost all patients who require this access get it for the majority of their admission. There can be some delays in identifying stroke patients when cases are complex, and this adds to the time to deliver stroke care. Across front door areas on all sites there is ongoing training in stroke recognition and immediate treatment. Additional consultant sessions at St John’s Hospital (SJH) since October 2018 and the increase in stroke liaison nurses at Royal Infirmary of Edinburgh (RIE) have enabled these teams to engage with a number of QI initiatives to improve appropriate access to the stroke units.

The senior stroke nursing teams on all the sites have identified robust systems to proactively identify stroke patients at the front doors to enable early treatment and ensure the swallow screen is carried out and recorded. Swallow screen performance is improving; from 74.4% in 2017 to 79.7% in 2018. ED nursing teams have been trained to perform these screens, and it’s consistently carried out at the triage stage at SJH. There remain issues when patients are admitted directly to the medical assessment units and this is the focus of improvement plans.

The majority of patients receiving thrombolysis are admitted to the RIE. Their door to needle times are reliably short for admissions in hours, and QI projects are ongoing for further improvements to be made. The other sites struggle with prompt treatment within hours, and all three sites are under strain during out of hours when there is no dedicated stroke member of staff to support the ED teams.

As part of our preparation to deliver thrombectomy treatment, we will aim to increase the current support to front door from the stroke teams to a 24/7 service. In particular this will include enhanced roles for the stroke outreach nurses and this will fit into the national plan. We have an active local thrombectomy planning group which is working with the national group to ensure this treatment will be available as soon as practicable. The team at RIE is also working towards developing a hyperacute stroke unit (HASU).

Our future plans for improving stroke care locally, as per the Stroke Improvement Plan include:

Opening a Life After Stroke clinic at the RIE, to offer better access to stroke specialists for discharged patients with a post-stroke problem. We anticipate this will also improve patient’s access to visual and psychological assessments.


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Taking ownership of 15 devices for ambulatory monitoring of patients with suspected Atrial Fibrillation (AF). These will be used across Lothian to improve secondary prevention of stroke.

NHS Orkney

Thank you for the letter dated 31 May 2019 regarding the Scottish Stroke Care Audit and NHS Orkney failing to meet the following stroke standards:

● Percentage with swallow screen within 4 hours of arrival at hospital

● Percentage of ischaemic stroke patients given aspirin within 1 day of admission

● Percentage receiving thrombolysis bolus within one hour of arrival at hospital

Since we became aware of the breaches, we have done the following to improve care for our patients, and would also improve our compliance with the standards.

● The report, and the failed standards, was discussed at a hospital-wide Mortality and Morbidity meeting, where the underlying causes for the breaches were discussed. We focused on the reasons for the delays in getting the patient to needle, and why the other standards were not reached. This discussion raised staff member’s awareness, and it was also decided that the stroke pathway should be reviewed to clarify the actions taken, to reduce unnecessary delays.

● A new Swallow Assessment form is being developed, and training for the use of this form will be taking place shortly. This will improve the uptake and documentation of swallow assessments.

● A step by step pathway focusing on the expediency of the steps required (e.g. where does the patient go directly after the CT scan to get to the point of starting a thrombolytic injection is currently being developed, with the help of Prof John Webster, previously of the Stroke Unit in Aberdeen. We hope that this will assist in a more streamlined pathway for patients with improvement in the door to needle time, and also remind staff to continue with the pathway after thrombolysis. This pathway is in the early phases of development, but we will hopefully be able to implement this in the near future.

I hope this assures you that we have taken the report, and the breaches it highlighted, seriously, and that we are progressing steps to improve the care for our patients.

NHS Shetland

We continue to perform well against the Aspirin target and the target for patients being admitted to a Stroke Unit. The General Medical ward is counted as a stroke unit for the purposes of the audit, as staff receive training in stroke care, patients are seen daily on a ward round, and there is a weekly Multidisciplinary team meeting.

The NHS Shetland Stroke Thrombolysis Pathway is updated yearly, or more often if required, with all stakeholders being included in the process. The main challenges we face with regard to thromobolysis are, not knowing the time of onset of symptoms and late presentation. In order to address the late presentation problem NHS Shetland, in conjunction with the Shetland Stroke Support Group, organise a FAST campaign each year to raise public awareness of getting help FAST for a suspected stroke.

Formal staff training sessions, using the STAT materials are provided each year, as well as informal training sessions provided by the Stroke Specialist Nurse, to raise awareness of rapid assessment of stroke patients for thromobolysis, utilising the NHS Shetland Stroke Pathway.

Debriefing sessions are organised by the Senior Nurse after each stroke thromobolysis and all staff involved in the process are invited to attend, to encourage learning and improve the service provided to patients.


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Stroke patients require a swallow screen before having anything to eat and drink and this is now carried out routinely, however staff are not always good at documenting the time that this has taken place, so this means we sometimes fail the 4 hour window. Documentation is being updated to include time as well as date for swallow screening when next printed.

NHS Tayside

The response highlights the improvements NHS Tayside and partners across the Managed Clinical Network have made and also where future service models are being transformed to continue to improve stroke care for the population of Tayside and North Fife.

Changes to the stroke admission pathway to Ninewells were implemented in February 2018, resulting in significant improvement in stroke unit admission from 83% to 95%. This target has also been consistently met in PRI since August 2018. There continue to be challenges in ensuring all patients have a timely swallow screen, recognising the need to undertake screening in our Emergency Department (ED) and in response to this, training and support for ED nurses is being led by a Senior Nurse from the Acute Stroke Ward. Some patients are still admitted via Acute Medical Unit, where we are working to include swallow screening in the initial “60 minute bundle” of care. Changes to the requesting and appointing process for brain imaging and increased ability of radiology staff to do scans after 5pm has so far led to incremental month on month improvements in meeting the new 12 hour target from a baseline of 56% in January 2019 to 83% in April 2019. Further changes, including nurse requesting and earlier processing of requests early in the morning are being tested to ensure timely scans for those people who present in the late evening and at weekends (we have identified this as a group who frequently fail the standard). Issues with the aspirin target have been identified as a combination of documentation gaps for same day discharge patients who present with minor stroke and the lack of a stroke specific weekend service. The documentation issue is being addressed and there are plans to deliver a stroke specialist weekend service later in 2019.

Tayside door to needle time for those receiving thrombolysis is lower than the national average, however there remains variation between individual patients and across sites. We are about to start testing changes to the thrombolysis pathway including better use of prealert information, stroke team working alongside ED team to help ‘pull’ the patient through the pathway and establishing an on call stroke service so that decisions can be made involving stroke experts at all times. Plans are at an advanced stage to centralise hyperacute stroke care across Tayside to facilitate access to stroke specialists in the vital first few hours and days following a stroke, building on the improvements outlined above.

For TIA clinics there have been staffing challenges on both PRI and Ninewells sites meaning that clinics are reduced during times of leave. From January 2019 the urgent TIA service has been run as a Tayside wide service with all staff supporting clinics in both hospitals and patients being offered the next available clinic on either site to optimise access. This has led to an improvement, work is ongoing to ensure that timing and location of clinics best meets demand. There is work required to improve the time from admission to carotid intervention. The drivers for this are limited access (only once a week) to carotid scanning in PRI and delays to being seen in TIA clinic. The improvement work to TIA clinics and proposed centralisation of hyperacute stroke should address this.

NHS Western Isles

NHS Western Isles has made significant progress in its stroke care pathways following the 2017 Stroke audit review. In particular we have focused on the following areas:

● Inpatient Standards: through education and awareness raising in A+E and the stroke unit, as well as general education of staff involved in the admission of patients throughout the hospital, we have managed to improve in all areas of this group of standards. This approach, co-ordinated by leads from the Stroke Unit, A+E and the Stroke Liaison nurses has seen improvement in each of


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the four areas. We aim to improve further in raising awareness of recording a swallow screen as this remains an area in which there is some misunderstanding of what is required to complete this standard within the timeframe allowed.

● Outpatient Standards: for some time we have been aware of a relative deficiency in this area and in the last three months have totally reconfigured the TIA clinic. This now allows a 5 day service run by local physicians rather than a remote one day a week service. Full implementation has taken place throughout June 2019 so we would expect to see referral to attendance times drop within the reporting year 2020. The practical difficulties of covering two remote island groups comprising 20% of the population cannot be overestimated here especially with dwindling air links for various reasons. We will continue to work hard in this area to improve outcomes.

● Thrombolysis Standards: in common with other Health Boards covering the more remote areas of Scotland, thrombolysis remains a significant challenge within the one hour door to needle time. Our numbers remain relatively small (nine in the current review period) and one or two cases just out with the 60 minute window will bring down the average as can be seen in 2018. We continue to work with the Scottish Ambulance Service and local frontline staff to make this process as smooth as possible with a close eye on safety. This is an areas we feel will be difficult to improve on significantly from the current status but will strive to do so. We are planning regular update training for all staff involved in 2019/20 and will re-evaluate the response to this.

Thus, overall we are pleased to see areas of improvement throughout this period in the Stroke Audit and this year’s results have generated areas for development most notably in the whole service change for the TIA clinic. We hope to see associated improvements relating to these changes in the 2019 and 2020 reports. In addition we are aware of the need to continually try and save minutes off our Thrombolysis times in anticipation of the national changes to come in Thrombectomy where time again will be critical to good patient care.


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Appendix B: List of Tables and ChartsTable/ Chart

NumberTitle

Page Number

Table 1.1 Scottish Stroke Care Standards Implemented 1st April 2016 (Following review of Scottish Stroke Care Standards 2013).

iii

Chart 1.1 (Health Board) Percentage of stroke patients receiving an ‘appropriate’ Stroke Care Bundle (i.e. Stroke Unit admission, swallow screen, brain scan and aspirin), 2017 and 2018 data (based on final diagnosis).

v

Chart 1.2 (Hospital) Percentage of stroke patients receiving an ‘appropriate’ Stroke Care Bundle (i.e. Stroke Unit admission, swallow screen, brain scan and aspirin), 2017 and 2018 data (based on final diagnosis).

vi

RAG Scottish Stroke Improvement Programme - RAG chart and RAG status. 3

Chart 3.1 Percentage of stroke patients admitted to a Stroke Unit within 1 day of admission to hospital, 2017 and 2018 data (based on final diagnosis).

8

Chart 3.2 Percentage of stroke patients with a swallow screening within 4 hours of admission, 2017 and 2018 data (based on final diagnosis).

9

Chart 3.3 Percentage of stroke patients with a brain scan within 24 hours of admission, 2017 and 2018 data (based on final diagnosis).

10

Chart 3.4 Percentage of acute ischaemic stroke patients given aspirin in hospital within 1 day of admission, 2017 and 2018 data (based on final diagnosis).

11

Chart 3.5 Percentage of stroke patients with a swallow screen by number of hours to swallow screen, 2018 data (based on final diagnosis).

12

Chart 3.6 Percentage of stroke patients with a brain scan by number of hours to scan, 2018 data (based on final diagnosis).

13

Chart 3.7 Percentage of acute ischaemic stroke patients given aspirin in hospital by number of days to receipt, 2018 data (based on final diagnosis).

14

Chart 3.8 Comparison of initial diagnosis of stroke versus final diagnosis of stroke, 2018 data). 15

Table 3.1 Stroke Unit Information. 16

Chart 4.1 Percentage of patients with definite cerebrovascular diagnosis seen in specialist stroke/ TIA clinic with referral to examination time within 4 days, 2017 and 2018 data.

19

Chart 4.2 Percentage of patients with definite cerebrovascular diagnosis seen in specialist stroke/ TIA clinic with referral to examination time (days): same day and within 1, 2, 3 & 4 days, 2018 data.

20

Chart 4.3 Median waits since stroke event to points on the outpatient imaging timeline, 2017 and 2018 data.

21

Table 4.1 Patients with ischaemic diagnosis seen in specialist stroke/ TIA clinics and on anticoagulation at onset of current cerebrovascular event or on aspirin or another antiplatelet at first assessment, 2018 data.

22

Chart 5.1 Ischaemic stroke/ TIA patients with current atrial fibrillation (AF) and on anticoagulation at onset of the current cerebrovascular event or prescribed/ recommended anticoagulation at discharge, Scotland, 2013 - 2018 data (final diagnosis).

23

Table 6.1 Thrombolysis - numbers thrombolysed by NHS Board in 2018. Also give rate per million population, and percentage of all strokes, and ischaemic strokes treated.

26

Chart 6.1 Funnel plots showing Mean door-to-needle time by first hospital (Mon – Fri 9-5). 28


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Table/ Chart Number

TitlePage

Number

Chart 6.2 Funnel plots showing Mean door-to-needle time by first hospital (Not Mon-Fri 9-5). 29

Chart 6.3 Percentage of patients receiving thrombolysis within 30, 60 & 75 minutes of arrival at first hospital, 2018 data.

30

Table 7.1 Carotid Endarterectomy - number of patients receiving a carotid endarterectomy in acute hospitals in Scotland during Jan-Dec 2018.

33

Chart 7.1 Percentage of patients undergoing a carotid intervention within 14 days of the event that led the patient to first seek medical assistance, 2017 and 2018 data.

34

Chart 7.2 Percentage of patients undergoing a carotid intervention within 14 days of the carotid pathway entry date*, 2017 and 2018 data.

35

Chart 9.1 90-day mortality for 2018 admissions by NHS board. 38

Chart 9.2 90-day mortality W-score for 2018 admissions by NHS board. 39

Chart 9.3 Mean 90-day home-time for 2018 admissions by NHS board. 40

Note The list of tables and charts above excludes additional content that is only available from the Excel file which supplements this report. The

Excel file is available from the Scottish Stroke Care Audit web site at http://www.strokeaudit.scot.nhs.uk. The additional content provides extra detail and covers the topics: length of stay for stroke patients, comparison of initial diagnosis and final diagnosis, the proportion of thrombolysed patients receiving repeat scans, the distribution of time between stroke event and carotid intervention and trends in the annual performance of NHS boards for the main inpatient stroke standards.

http://www.strokeaudit.scot.nhs.uk


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Appendix C: Stroke Improvement Plan Priorities & Actions RAG

Action Aim NAC Lead Benchmark Criteria

Priority 1. Early recognition of Transient Ischaemic Attack (TIA) and stroke by the general public, Scottish Ambulance Service (SAS), NHS 24, primary care hospital front door services and social care staff.

1 Public campaign to raise awareness of stroke symptoms [(Face Arm Speech Time (to call 999) (FAST)]

Deliver public education to increase awareness of common symptoms of stroke and TIA, and the need to seek emergency medical care.

David Clark BLACK No evidence of a FAST campaign.

RED No plan for an annual FAST campaign.

AMBERMCN has considered a further campaign using the available funding but as yet has no delivery plan.

GREENMCN has run a further campaign using the available funding.

COMPLETEMCN delivers annual campaigns which are evaluated.

2 Improve early identification of stroke and TIA by engagement with SAS, primary care and hospital emergency departments.

Establish links to the MCN with all of these staff groups, SAS, primary care and hospital emergency departments and develop a mechanism to deliver education.

Katrina Brennan / SAS

BLACKNo FAST training delivered with any of these staff groups

REDAdhoc training delivered to some of these staff groups,

AMBERAdhoc training delivered to most of these staff groups,

GREENEstablished training programme underway with some of these staff groups.

COMPLETE

Established training programmes with all staff groups and evidence of a rolling programme of education which is evaluated.

Priority 2. Appropriate pre-hospital protocols to ensure rapid admission, early diagnosis and treatment.

1 Pre-alert by SAS The SAS should pre alert Emergency Departments of the arrival of FAST positive stroke patients with an onset time of < 4 ½ hours or an unknown onset time.

This element will be monitored using pre alert data soon to be available from SAS.

Katrina Brennan/ SAS

BLACKNo pre-alerts made from SAS to Emergency Departments.

REDInconsistent pre-alerts made from SAS to Emergency Departments.

AMBERPre-alerts normally made but no record of consistency.

GREEN Pre-alert consistently made.

COMPLETEAudit data evidences consistent pre-alert.

2 Early imaging Imaging services should work with stroke services, Emergency Departments, and other services where patients with stroke/TIA may present, to provide rapid access to CT or MR brain imaging (as appropriate) for all patients with suspected stroke, and those patients with TIA in whom brain imaging is clinically indicated; timely access to carotid imaging for patients with TIA and minor stroke should also be provided.

Joanna Wardlaw

This Element measured by SSCA Data


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3 Thrombolysis Process and pathway

Develop effective processes and pathways to ensure that the national Scottish Stroke Care Standard for thrombolysis is met.

Validation of this element will be supported using thrombolysis data from SSCA.

Peter Langhorne

BLACK No process or pathway in place .

RED

Emergency Department or Stroke team process or pathway available for potential thrombolysis patient but not utilised.

AMBER

Emergency Department or Stroke team process or pathway available for potential thrombolysis patient but utilised only on an ad hoc basis.

GREEN

Emergency Department or Stroke team process or pathway available for potential thrombolysis patients and used consistently in some departments and the SSCA thrombolysis standard is being achieved.

This element will be validated using SSCA data.

COMPLETE

Emergency Department or Stroke team process or pathway available for potential thrombolysis patients and used consistently in all departments across the Board Area and the SSCA thrombolysis standard is being consistently achieved.

This element will be validated using SSCA data.

Priority 3. Delivery of Stroke Bundle – (The fourth element of the Stroke Care Bundle (CT scan) is listed under Priority 2, Action 2.)

1 Ensure early access to stroke unit

Acute stroke patients will be admitted rapidly to a stroke unit and remain in that care setting for as long as is clinically necessary.

Peter Langhorne

This element measured by SSCA data

2 Swallow screen • Stroke services should ensure swallow screening is part of the stroke admission protocol and provide a programme of education to support delivery.

• Swallow screening is a pass/fail procedure to rapidly identify patients who require referral for comprehensive swallowing assessment to inform appropriate management;

• Keeping patients nil by mouth for extended periods pending screening reduces patient satisfaction and may present other health risks such as missed medications; and

• The swallow screening procedure requires close observation of both non-swallowing and swallowing behaviours that require sound clinical judgement and competence to practice.

Sheena Borthwick


3 Evidence based interventions: Intermittent Pneumatic Compression (IPC)

• Ensure that protocols are in place and effectively implemented to guide the appropriate use of:Intermittent Pneumatic Compression (IPC) for venous thromboembolism prophylaxis offering sequential compression in patients who are immobile after a stroke.

Validation of this element will be supported using IPC (User Defined Field) data from SSCA.

Martin Dennis

BLACK IPC not available in any stroke unit.

RED IPC only available in some stroke units.

AMBER IPC available in all stroke units.

GREEN

IPC available in all stroke units but not consistently offered as a treatment This element will be validated using SSCA data.

COMPLETE

IPC available in all stroke units and are consistently offered as a treatment This element will be validated using SSCA data.

• Thrombolysis This element measured by SSCA data

• Aspirin This element measured by SSCA data


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Priority 4. Developing a skilled and knowledgeable workforce

1 Health and social care staff in hospital and community settings are trained to an appropriate level.

• Utilise the education training template to accurately record training requirements and delivery and demonstrate appropriate levels of training; and NHS boards use the information collated from the education template to identify and address training needs at all levels.

Core training areas are defined as swallow screen, STAT (thrombolysis), IPC and Core competencies.

(NB-STAT will be discounted as a ‘red’ area for stroke unit staff if STAT training is evidenced for appropriate staff along the pathway. So if thrombolysis is delivered at the front door (e.g. A&E, Emergency Receiving Unit) and training is prioritised to front door staff, this should be documented as the pathway and evidence of training provided, in terms of numbers/ percentage of front door staff STAT trained. This STAT training would then ideally be extended to stroke unit staff).

BLACK No process or pathway in place

REDAvailable but not implemented, 3 or more than 3 core areas are ‘red’ (‘red’ is defined as <50% of staff trained).

AMBER

Plan to implement or partially implement, 2 or more core areas are

‘red’ (‘red’ is defined as <50% of staff trained).

GREEN

Implemented but not consistently delivered, 1 core area ‘red’, or all core areas are delivered, (i.e. no core areas are red) (‘red’ is defined as <50% of staff trained).

COMPLETE

Complete and embedded in practice, whole stroke education template achieved and evidenced.

Priority 5. Early diagnosis & treatment for non-admitted patients

1 A specialist service to deliver immediate specialist advice suspected for TIA and stroke patients.

Stroke services should provide GPs, Emergency Departments and other services, where patients with TIA/stroke may present, with immediate access to advice from a stroke specialist.

Martin Dennis BLACK

No plan to provide same day access to advice from specialist and no TIA pathway for Primary Care in place.

RED

Plan to provide access to advice from specialist on day of request and / or shared protocols for appropriate interventions.

AMBERSpecialist advice only available on some days and pathways not consistently adhered to.

GREEN7 day / week but daytime only access to stroke specialist service.

COMPLETE24/7 access to stroke specialist service for advice.

2 Service to provide early access to confirmatory clinical assessment

A specialist service should be available to confirm the diagnosis of TIA/stroke, to differentiate these from mimics and to provide early access to brain and vascular imaging.

Validation of this element will be supported using outpatient data from SSCA.

Martin Dennis BLACK

No service providing rapid assessment of patients with possible TIAs and minor strokes.

REDA service which provides rapid assessment but does not exceed the national standard for access.

AMBER

A service which provides rapid assessment which exceeds the national standard for access but cannot demonstrate that it offers same day brain or carotid imaging.

GREEN

A service which provides rapid assessment which exceeds the national standard for access and can demonstrate that it provides same day brain or carotid imaging.

COMPLETE

A service which provides rapid assessment which exceeds the national standard for access and can demonstrate that it provides same day brain and carotid imaging.


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Priority 6: Appropriate Secondary Prevention

1 Anti-coagulation for patients in AF

Patients should have a 12 lead ECG to detect persistent AF. Selected patients with Ischaemic stroke or TIA should have prolonged ECG monitoring to detect paroxysmal AF. The following criteria might be used to select patients:

a. No known history of Atrial fibrillation and

b. No contraindication or definite indication for lifelong oral anticoagulation, with any of the following:

i. History of frequent palpitation

ii. Syncope or pre-syncope

iii. Recent Myocardial infarction

iv. Recent cardiac surgery

v. Cardiac failure

vi. Ischaemic stroke/TIA affecting more than one vascular territory

vii. A cortical ischaemic stroke/TIA with no other explanation.

Christine McAlpine

BLACK Ad hoc service.

RED

Stroke services should have written, locally agreed criteria, to select those patients with stroke or TIA who should be offered prolonged ECG monitoring to detect paroxysmal AF.

AMBER

Patients meeting those criteria should have prompt access to at least 72 hours of ECG monitoring to detect paroxysmal AF.

GREEN

The results of the prolonged monitoring should be available within two weeks of referral for monitoring to facilitate early secondary prevention.

COMPLETE

Oral anticoagulation should be discussed with the patients and commenced if appropriate within a month of the stroke/TIA?

Data should be available to confirm that patients meeting the criteria for ECG monitoring are receiving this, that results are available within the two weeks and that patients found to be in atrial fibrillation are offered anticoagulation with a NOAC or Warfarin within a month of their stroke/TIA.

2 Carotid endarterectomy for patients with recently symptomatic carotid stenosis

To modify the patient pathway to ensure that at least 80% of patients undergoing carotid endarterectomy for symptomatic carotid stenosis have the procedure within 14 days of their index TIA/stroke event (see details of Scottish Stroke Care Standards in Annex 2).

Martin Dennis


Priority 7. Transition to the community

1.1 Access to stroke therapy services.

Acute therapy assessment is provided by stroke specialists by day 3 of admission following a stroke.

Once available, data from the SSCA Rehab sprint audit will be used to support this benchmarking.

Thérèse Jackson / Mark Smith

BLACKNo acute therapy assessment is available or plan to develop services.

REDPlan in place to develop stroke specialist acute therapy assessment provision by day 3 following admission.

AMBERAcute therapy assessment is carried out by generic staff but not routinely by day 3.

GREENAcute therapy assessment is carried out by stroke specialists but not routinely by day 3 following admission.

COMPLETEAcute therapy assessment is carried out by stroke specialists and by day 3 of admission following a stroke.


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1.2 Access to Stroke Rehabilitation Services

Stroke rehabilitation services including In-patient stroke rehabilitation unit (SRU), early supported discharge (ESD) teams and community rehabilitation (CR) teams should be available in each health board.


BLACKNo In-patient SRU, ESD or Community Rehabilitation available.

RED

Plan to develop SRU, ESD & Community Rehabilitation is in place and implementation plan agreed by MCN.

AMBER

SRU, ESD & Community Rehabilitation available but not consistently across MCN area and is often generic in nature.

GREEN

SRU, ESD and Community Rehabilitation is available across MCN area but levels of input are insufficient to provide daily input (Mon-Fri) on the SRU and according to patient need for ESD & CR.

COMPLETE

SRU, ESD or Community Rehabilitation are available across the MCN area on a needs led basis (i.e., daily for SRU and according to patient need for ESD and CR).

2 Person-centred approach

Stroke services should implement a person-centred approach including goal setting in hospital and community services to ensure an individualised approach.


BLACKNo goal setting in place, or plan to establish goal setting process.

REDPlan to develop goal setting process in hospital stroke services and community rehabilitation services.

AMBER

Goal setting process is used in some hospital stroke services & community settings, but approaches are inconsistent.

GREENGoal setting is used across MCN area, but process is not multidisciplinary.

COMPLETE

Goal setting is established across the MCN area and is available in a multidisciplinary format in SRU, ESD and community rehabilitation services.

3.1 Specialist visual assessment and rehabilitation

Specialist visual assessment and rehabilitation services are available to all people with visual impairment following stroke across the MCN area.

Thérèse Jackson

BLACK

No referral process or documented pathway is available, or plan to develop one for people with visual problems following stroke.

REDPlan to develop referral process & pathway for people with visual problems following stroke.

AMBER

Documented referral process and pathway for specialised visual assessment services but availability limited and referral is ad hoc across MCN area.

GREEN

Documented referral process and pathway with provision and availability of specialised visual services in selected MCN areas.

COMPLETE

All those across the MCN area with identified visual problems after stroke have access to specialised visual assessment and rehabilitation services as required.


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3.2 Access to specialist clinical/neuro psychological services

Clinical/Neuro Psychological services are available to all patients across the MCN area who require specialised psychological assessment and intervention for the emotional and cognitive consequences of stroke.

BLACK

No specialised neuro psychological services are available for people who have had a stroke or plan to establish them.

RED

Plan to develop referral process & pathway for neuro psychological services for people who have had a stroke.

AMBER

Documented referral process and pathway for specialised neuro psychological services but availability limited and referral is ad hoc across MCN areas.

GREEN

Documented referral process and pathway with provision and availability of specialised neuro psychological services and consistent referral in selected MCN areas.

COMPLETE

All individuals (patients and family/carers) with identified emotional and/or cognitive problems after stroke have access to specialised neuro psychological assessment and intervention as required across all MCN areas (prevention, acute, post acute rehabilitation and community).

3.3 Specialist Driving Assessment

Specialist advice with regards to return to driving following stroke is available to all patients across the MCN area.

BLACKNo local protocol or access to specialised advice is available, for return to driving following stroke.

RED

Plan to develop local protocol & access to specialised advice regarding the referral process & pathway for return to driving following stroke.

AMBER

Local protocol for return to driving assessment & access to specialised advice is available but not documented, and referral for assessment at a specialised driving assessment service is ad hoc across the MCN area.

GREEN

There is a documented referral process and pathway available, with provision of specialist advice for return to driving in some MCN areas.

COMPLETE

Clear, documented protocol for accessing specialist advice and referral to driving assessment at an accredited driving assessment service is evident across MCN area.

Priority 8. Living with stroke

1 Self management post discharge support

Multidisciplinary stroke teams provide a range of supported self management approaches including individual, group, written and online resources and can evidence the use of these.

Thérèse Jackson

BLACKNo self management approaches or resources are available.

REDPlan in place to develop self management approaches.

AMBER

Only written and online self management resources are available and are used locally and evidence of their use available.

GREEN

Individual or group self management options (as well as written and online) are available to some patients across the MCN area and evidence of their use available.

COMPLETE

Facilitated individual or group self management options (as well as written and online) are available to all patients across the MCN area and evidence of their use available.


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2 Exercise People being discharged home following stroke should have access to exercise after stroke services and given advice about increasing their physical activity levels where appropriate.

Mark SmithBLACK

Exercise after stroke services or advice regarding increasing physical activity are not available.

REDAdvice regarding increasing physical activity is available but an exercise after stroke service is not available.

AMBER

Advice regarding increasing physical activity is available and limited exercise after stroke services are available across some parts of the MCN area.

GREEN

Advice regarding increasing physical activity is available and exercise after stroke services are available across the MCN area.

COMPLETE

An established system to ensure advice regarding increasing physical activity is delivered and a clear process of referral into an exercise after stroke pathway is evident across the entire MCN area.

3 Living with stroke – vocational rehabilitation

Vocational rehabilitation services are available to people who wish to return to paid, unpaid or voluntary work.

Thérèse Jackson BLACK

No vocational rehabilitation services available for people who have had a stroke or plan to establish them .

RED

Plan to develop referral process & pathway for vocational rehabilitation services for people who have had a stroke.

AMBER

Vocational rehabilitation services exist for people who have had a stroke, however availability and referral is ad hoc across the MCN area.

GREEN

There is a documented referral process and vocational rehabilitation pathway available, with provision of specialist services in some MCN areas.

COMPLETE

All those across the MCN area with identified vocational rehabilitation needs after a stroke have access to specialised assessment and intervention services as required.

4 Access to stroke spasticity management services

Stroke services should implement a documented programme for prevention and management, including self-management, of post stroke spasticity. All staff should have completed training on prevention and management of post stroke spasticity (STARs). Patients and carers should receive information on spasticity management both verbally and in written/online format. Timeous stroke spasticity services are available to all patients across the MCN area who require specialist assessment and intervention.

BLACK

No documented pathway or referral process for post stroke spasticity management is available, or plan in place to develop one.

RED

Plans in place to develop referral process or documented pathway for spasticity management, including staff training and patient/carer information.

AMBER

Spasticity management pathway in place in some parts of the MCN area but approach is inconsistent. No specialist stroke spasticity services available.

GREEN

Spasticity referral process and documented pathway in place. Access to specialist, multidisciplinary spasticity services for some patients, but on an ad hoc basis throughout the MCN area.

COMPLETE

Spasticity referral process and documented management pathway in place. Timely specialist multidisciplinary stroke spasticity services, which include a specialist clinic and appropriate therapy follow up, are available across the entire MCN area.


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Appendix D: Additional InformationAdditional information is available on the SSCA website:

Aims, objectives and methods of the audit. http://www.strokeaudit.scot.nhs.uk/about.htm

Audit documentation, e.g. data collection forms. http://www.strokeaudit.scot.nhs.uk/about/Resources.html

Core dataset definitions. http://www.strokeaudit.scot.nhs.uk/about/Resources.html

Contact details of Project Team. http://www.strokeaudit.scot.nhs.uk/contact.htm

Previous Annual National Reports. http://www.strokeaudit.scot.nhs.uk/Reports/Reports.html

Information on requesting SSCA data for research purposes. http://www.strokeaudit.scot.nhs.uk/Research.html

Information on Quality Improvement and the Scottish Stroke Care Standards. http://www.strokeaudit.scot.nhs.uk/Quality.html

Information for patients and carers. http://www.strokeaudit.scot.nhs.uk/Patients.html.

Acknowledgements

This report could not have been written without the help of a great many people. This includes:

Patients with stroke who have contributed medical information to the audit; Audit, clinical, IT and Managed Clinical Network staff at all units participating in the audit who ran their local data collection, provided local reports and commented on drafts of this National Report;

Chief Executives in each NHS board who provided feedback about changes that improved performance in delivery of stroke care;

The SSCA Audit Team and ISD Publications Team as part of the Information Services Division of NHS National Services Scotland who co-ordinate and collate the necessary information to produce the report and support the publication of the National Report;

Members of the Report Writing Sub-Group of the SSCA Steering Committee who have contributed to the writing of and commented on drafts of this report; and

The Scottish Government through the CHD & Stroke Strategy providing funding for the Scottish Stroke Care Audit.

This Annual National Report was prepared by Professor Mark Barber, Katrina Brennan, Professor Martin Dennis, Professor Peter Langhorne, Neil Muir, Dr Mary-Joan Macleod, Dr Christine McAlpine, Prof Keith Muir, Mark Smith, Iain McDermid and David Murphy, with contributions from NHS boards and partner organisations.

Scottish Stroke Care Audit logo designed by Definitive Studio® Graphic Design and Communication.

This report is also available as an Easy Access Public Summary, this version of the report can be found on the SSCA website (http://www.strokeaudit.scot.nhs.uk/reports.html).

http://www.strokeaudit.scot.nhs.uk/about.htm

http://www.strokeaudit.scot.nhs.uk/about/Resources.html

http://www.strokeaudit.scot.nhs.uk/about/Resources.html

http://www.strokeaudit.scot.nhs.uk/contact.htm


http://www.strokeaudit.scot.nhs.uk/Research.html

http://www.strokeaudit.scot.nhs.uk/Quality.html

http://www.strokeaudit.scot.nhs.uk/Patients.html

http://www.strokeaudit.scot.nhs.uk/reports.html


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Any questions about the SSCA should be referred to the co-ordinating centre. Please refer questions on this report to Neil Muir.

For general questions about the audit please contact Neil Muir National Clinical Coordinator for the SSCA.

Neil Muir National Clinical Coordinator Gyle Square

phone: 0131 275 6089 1 South Gyle Crescent

email: [email protected] Edinburgh, EH12 9EB

Pamela MacleanRegional Clinical Coordinator Gyle Square

phone: 0131 314 1222 1 South Gyle Crescent


David MurphySenior Information Analyst Gyle Square

phone: 0131 275 6624 1 South Gyle Crescent,


Iain McDermidInformation Analyst Gyle Square

phone: 0131 275 7419 1 South Gyle Crescent,


If you have general questions about stroke care in Scotland please contact Professor Mark Barber, Chair of the Scottish Stroke Care Audit.

Professor Mark BarberLead Clinician and Chair of the SSCA

phone: 01236 748748

email: [email protected]






Stroke Care Audit Team Information Services Division (ISD)

Gyle Square 1 South Gyle Crescent Edinburgh, EH12 9EB

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Better data.

Documents

NSS Information and Intelligence · 2019-07-09 · 2019 National Report - Scottish Stroke Improvement Programme v Chart 1.1: (Health Board) Percentage of stroke patients receiving