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Slide 1
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Stroke Services in WalesStroke Services in WalesAn UpdateAn Update
Anne FreemanAnne Freeman
Consultant Physician Royal Gwent Consultant Physician Royal Gwent HospitalHospital
Clinical Lead AWSSICClinical Lead AWSSIC
Slide 2
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
RCP Audit 2008RCP Audit 2008Organisational Report August 2008Organisational Report August 2008
Stroke Unit provision in UK Hospitals
% of sites with stroke unit 2006 2008England 98% 96%Wales 50% 45%N Ireland 92% 92%
% of sites with stroke units who have all 5 SUTC characteristicsEngland 73%Wales 80%N Ireland 64%
Slide 3
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Criteria for judging quality of acute and Criteria for judging quality of acute and combined stroke unitscombined stroke units(SUTC characteristics)(SUTC characteristics)`̀
These characteristics are not all evidence based but were developed using the consensus of an expert working group – the Intercollegiate Stroke Working Party:
• Continuous physiological monitoring (ECG, oximetry, blood pressure)
• Access to scanning within 3 hours of admission• Policy for direct admission from A&E/front door• Specialist ward rounds at least 5 times a week• Acute stroke protocols/guidelines
Slide 4
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
ORGANISATION OF STROKE CARE BY ORGANISATION OF STROKE CARE BY DOMAINSDOMAINS
8 areas assessed by the proforma1. Acute Stroke Care2. Organisation of Care3. Consultant physician time (overall)4. Inter disciplinary Services (for sites with a
stroke unit)5. TIA/neurovascular Services6. Continuing Education in stroke7. Team working –Team meetings8. Communication with Patients and Carers
Slide 5
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Range of Scores for WalesRange of Scores for Wales
Wales Range across 20 units: 23 -77 (evenly
distribributed)
EnglandMedian about 75 (50-90)
Northern IrelandRange about 15 - 78
Slide 6
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Changes from 2006 in WalesChanges from 2006 in Wales
2008• 13 sites in bottom range• 6 sites in middle range• 1 top range
Change from 2006• 1 site moved up to top• 3 sites moved up to middle• 1 site moved down to bottom• All others stayed the same
Slide 7
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Top Ten RecommendationsTop Ten Recommendations
1. All patients with acute stroke should be admitted directly to an acute stroke unit
2. Thrombolysis should only be provided when all the other components of acute stroke care are of high quality
3. Comply with the recommendations in the NICE guidelines for Acute Stroke and TIA
4. Development of seven day rehabilitation services should be made a priority
5. Stroke services should urgently review policies that exclude certain groups from admission to the stroke unit
Slide 8
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Recommendations continuedRecommendations continued
6. Patients without stroke should not occupy beds on the stroke unit while stroke patients are managed off the unit
7. Levels of nurse staffing on acute stroke units needs to be increased in many units
8. Social worker involvement as an integral part of the stroke team is essential and should be mandatory for every stroke service
9. Early supported discharge services should be made available for all patients
10. All services managing patients with TIA should have systems in place in line with the recommendations in the National Stroke Strategy and the NICE guidelines for Acute Stroke and TIA.
Slide 9
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Further detailsFurther details
http://sentinelstrokeaudit.rcplondon.ac.uk
Slide 10
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
RCP Process Audit 2008RCP Process Audit 2008 Clinico-demographic resultsClinico-demographic results
National England Wales N. Ireland
Sites 216 184 18 11
(Patients) 11,369 10,007 863 355
% new institutionalised on D/C 11 12 7 11
% D/C Barthel of 20 39 39 45 41
% D/C Barthel of <10 17 17 12 19
Mean Age 76.5 75.6 74.7 73.6
Mean LOS to D/C or death 24 23 25 25
Slide 11
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement CollaborativeRCP Process Audit 2008RCP Process Audit 2008
Overall results for 9 key process indicators in Overall results for 9 key process indicators in 20082008
National England Wales N. Ireland
Patients- 90% stay in a stroke unit 58 59 41 59
Screened for swallow within 24 hrs adm 72 74 52 70
Brain Scan < 24hrs 59 59 54 56
Aspirin < 24hrs 85 85 85 82
PT Assessment <72 hours adm 84 85 70 85
OT Assessment < 4 working days adm 66 68 43 73
Weighed 72 73 59 68
Mood Assessed by discharge 65 66 46 80
Rehab Goals set by MDT 86 87 74 83
Average for 9 indicators 72 73 58 73
Slide 12
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Results in Wales since 2004Results in Wales since 2004
2004 2006 2008
Patients 667 925 863
1 Patients – 90% stay in a stroke unit
N/A 39 41
2 Swallow screen within 24 hrs of admission
51 55 52
3 Brain scan < 24 hours of stroke not comparable
38 50
4 Aspirin by 48 hours of stroke
73 76 85
5 PT assessment < 72 hrs of admission
49 54 70
6 OT assessment < 4 working days of admission
N/A 30 43
7 Weighed 51 54 59
8 Mood assessment by discharge
47 53 46
9 Rehab goals agreed by MDT
67 70 74
Slide 13
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Site variation for the process domains in 2008Site variation for the process domains in 2008
Slide 14
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
How domain scores are obtainedHow domain scores are obtained
D1 Initial patient assessment Screen for swallowing 24 hours Visual Fields Sensory Testing Brain scan within 24 hours of stroke
D2 Multi-disciplinary assessment Swallow assessment by SALT within 72 hours PT assessment within 72 hours Initial assessment of communication by 7
days OT assessment within 4 working days SW assessment within 7 days of referral
Slide 15
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
How domain scores are obtainedHow domain scores are obtained
D3 Screening and functional assessment Patient weighed at least once Evidence of mood assessed Cognitive status assessed Screening for malnutrition D4 Care Planning Evidence of rehab goals Plan to promote urinary continence Receiving nutrition within 72 hours
Slide 16
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
How domain scores are obtainedHow domain scores are obtained
D5 Communication with patients and carers Discussion with patient about diagnosis Carer needs for support assessed separately Skills taught to care for patient at home Follow up appointment at 6 weeks Driving advice D6 Acute Care Aspirin <48 hours of stroke 90% of care in a SU Admitted to an acute or combined SU < 4
hours Receiving fluids < 24 hours % of applicable patients thrombolysed
Slide 17
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
9 key indicators9 key indicators
Comparing sites in Wales/regions
Slide 18
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Mid and West WalesMid and West Wales•
2008 score 2008 2006 * 75 Middle Upper * 35 Lower Lower * 59 Middle Middle * 42 Lower Lower * 53 Lower Lower * 36 Lower Middle * 31 Lower Lower * 64 Middle Middle•
Slide 19
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
North WalesNorth Wales
2006 2008
* 60 Middle Middle * 61 Middle Upper * 66 Middle N/A
Slide 20
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
South East WalesSouth East Wales
Slide 21
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Top Ten Areas with recommendations Top Ten Areas with recommendations for change in Process of Carefor change in Process of Care
1. Work with all agencies to raise the public awareness of stroke to speed up access to hospital following stroke
2. Organise hospital care so that patients are admitted directly to an acute stroke unit from A&E and all suitable patients can be treated with thrombolysis as
quickly as possible
3. Improve the training and support given to junior doctors and staff from non stroke disciplines who undertake initial clerking of stroke patients
4. There should be regular quality control to ensure that documentation is complete
5. Brain scanning should be speeded up in many units
Slide 22
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
5. Ensure that all acute stroke units have effective multidisciplinary teams and working
6. Find the 25% of patients who do not currently get to a stroke unit and do something for them
7. Take urinary continence more seriously
8. Manage all patients so as to avoid chest infection and urinary tract infection and identify and treat infections early when they do occur
9. Communicate better with patients and relatives, particularly about the stroke diagnosis and prognosis and how to prevent further strokes
10. Give the correct advice is given to patients who drive
Slide 23
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Profession Specific AuditProfession Specific Audit
• Autumn 2008• Second Pilot for RCP• Tools provided by RCP but modified by the
Rehab subgroup of WSA• 20 sets of notes per discipline
Slide 24
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Involved….Involved….
• Nursing• PT• OT• SALT• Dietetics• Psychology
• Podiatry• Social work
Slide 25
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
ProgressProgress
• Results not ready yet• To be presented to RCP later this
year• Will become part of the National
Sentinel Audit as from 2010
Slide 26
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Proposed RCP acute auditProposed RCP acute audit
• First 3 days• On line audit • Prospective• Detailed audit of process in first 72 hours• Pilot still to be done to assess tool• Unlikely to be UK wide until later this year• RCP have reassured us that we can defer
until at least after September
Slide 27
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
AOF Target- April 2009AOF Target- April 2009
• AOF Target for Stroke Services • WAG has set the following target in the Annual
Operating Framework for stroke services. • By March 2009, each patient suspected of or
confirmed as having had a stroke must be admitted to dedicated and co-located acute stroke beds staffed by a specialist multi-disciplinary medical and acute rehabilitation stroke team.
Slide 28
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Detailed DefinitionDetailed Definition“dedicated and co-located acute stroke “dedicated and co-located acute stroke
beds”beds”
These are hospital beds in a ward or part of a ward that are located very near one another (subject to issues of dignity and gender) and are guaranteed for admitting stroke patients who should have access to high quality specialist acute medical and rehabilitation stroke care.
Slide 29
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Such a service must satisfy the following quality indicators;
* Access to continuous physiology monitoring * Access to brain imaging within 24 hours;* A policy in place and adhered to for direct
admission from A & E;* Access to specialist ward rounds at least 5 times
a week;* Consultant physician with responsibility for
stroke;* Formal links with patient and carer organisations;* Multi-disciplinary meetings, at least weekly, to
plan patient care;* Provision of information to patients, about stroke;* Continuing education programmes for staff.
Slide 30
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
AOF Monitoring ToolAOF Monitoring Tool• Developed by Sarah Jones on behalf of SSIP• Based on the elements of the AOF • Reviewed by the team at NHH• Will be on the nww.stroke.wales.nhs.uk website• To be completed by end of April• Letter to service will be coming out very soon• Letter from Minister regarding assurance of AOF target
by 13th March• Informal visits in March/early April• Formal visits in May/June to verify compliance with
AOF and to assess any shortfall• Report to WAG by Mid June??
Slide 31
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Interim Organisational Audit RCP Interim Organisational Audit RCP 20092009
• Same format as 2008• Just the organisational element• No clinical audit on process of care• Agreed to participate• Timescale much the same as AOF
monitoring – end of April 2009• Hopefully will see improvement following
HM resources allocated to fund additional staff, etc
Slide 32
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Intelligent Targets
• Organisational• Process• Outcome
Slide 33
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Organisational- Uptake IndicatorsOrganisational- Uptake Indicators
• Use of Monitoring Tool
• Identified Clinical Champion and Specialist Stroke Team
• Evidence of progress on all intelligent targets
Slide 34
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Process Measures- Intelligent Process Measures- Intelligent TargetsTargets
• Demonstrate an ongoing improvement in compliance rate with 10 stroke care bundles
•4 TIA•4 Acute Stroke•2 Early Recovery and Rehabilitation
Slide 35
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Outcome MeasuresOutcome Measures
• Percentage of people with suspected TIA who go on to have a full stroke within 7 days
• Mortality Rates• Change in Functional Outcome• Average Length of Stay
• in hospital• on stroke unit• within stroke service
• Percentage of people who return to their usual place of residence
• Percentage of people who are re-admitted within 28 days
Slide 36
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Acute Phase Acute Phase Driver Driver
DiagramDiagram
Slide 37
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
TIA
Slide 38
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Early Recovery and Rehabilitation
Slide 39
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Slide 40
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Managing a complex system
Slide 41
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Slide 42
All Wales Stroke Services Improvement CollaborativeAll Wales Stroke Services Improvement Collaborative
Count the black dots !!Count the black dots !!
Any questions??