Stroke Quality Standard

8/9/2019 Stroke Quality Standard

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NATIONAL INSTITUTE FOR HEALTH ANDCLINICAL EXCELLENCE

IMPLEMENTATION DIRECTORATE

QUALITY STANDARDS PROGRAMMEQuality s tandard topic: Stroke

Output: Quality Standard advice to the Secretary of State for Health

Scope:Care provided to adult patients with stroke by healthcare staff during the course of diagnosisand initial management, acute phase care, rehabilitation and long-term management.

Policy context:Department of Health National Stroke Strategy (2007). National Audit Office Department of Health: Progress in improving stroke care (2010) . National Audit Office Department of Health: Reducing brain damage: faster access to betterstroke care (2005) .

Key development sources:Royal College of Physicians (RCP) National clinical guideline for stroke (2008) , whichincorporates the National Institute for Clinical Excellence (NICE) clinical guideline 68

Diagnosis and initial management of acute stroke and transient ischaemic attack (2008 ; NHS Evidence accredited).

Overview of statements:The 21 key priorities for implementation from the RCPs guideline were developed by theTopic Expert Group (TEG) into 13 draft quality statements. Of the remaining384 recommendations, 8 were discussed further and resulted in 7 additional draft qualitystatements. A total of 20 draft quality statements were presented for consultation and fieldtesting, each with associated quality measures. Following consultation and field testingfeedback, the TEG prioritised 11 statements for inclusion into the final quality standard. Thisstandard does not cover the important area of secondary prevention of stroke in primary

care, because it is already addressed by the Quality and Outcomes Framework (QOF). Forfurther information on stroke indicators, see The Information Centres Indicators for QualityImprovement .

Further explanation of the methodology used can be found in the Quality StandardsProgramme interim process guide .

Quality measures: The quality measures accompanying the quality standard are intended to improve thestructure, process and outcomes of health and social care. They are not a new set oftargets or mandated indicators for performance management. Quality measures are wordedas high level quality indicators. Furthermore, the quality measures may be supplementedwith indicators developed by The NHS Information Centre through their Indicators for
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081062http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081062http://www.nao.org.uk/publications/0910/stroke.aspxhttp://www.nao.org.uk/publications/0910/stroke.aspxhttp://www.nao.org.uk/publications/0506/reducing_brain_damage.aspxhttp://www.nao.org.uk/publications/0506/reducing_brain_damage.aspxhttp://www.nao.org.uk/publications/0506/reducing_brain_damage.aspxhttp://bookshop.rcplondon.ac.uk/details.aspx?e=254http://bookshop.rcplondon.ac.uk/details.aspx?e=254http://guidance.nice.org.uk/CG68http://guidance.nice.org.uk/CG68http://guidance.nice.org.uk/CG68http://guidance.nice.org.uk/CG68https://mqi.ic.nhs.uk/PerformanceIndicatorChapter.aspx?number=1.09.06https://mqi.ic.nhs.uk/PerformanceIndicatorChapter.aspx?number=1.09.06https://mqi.ic.nhs.uk/PerformanceIndicatorChapter.aspx?number=1.09.06https://mqi.ic.nhs.uk/Default.aspxhttps://mqi.ic.nhs.uk/Default.aspxhttps://mqi.ic.nhs.uk/Default.aspxhttps://mqi.ic.nhs.uk/Default.aspxhttp://www.nice.org.uk/media/61B/AC/DevlopingNICEQualityStandardsInterimProcessGuide.pdfhttp://www.nice.org.uk/media/61B/AC/DevlopingNICEQualityStandardsInterimProcessGuide.pdfhttp://www.nice.org.uk/media/61B/AC/DevlopingNICEQualityStandardsInterimProcessGuide.pdfhttp://www.nice.org.uk/media/61B/AC/DevlopingNICEQualityStandardsInterimProcessGuide.pdfhttp://www.ic.nhs.uk/services/measuring-for-quality-improvementhttp://www.ic.nhs.uk/services/measuring-for-quality-improvementhttp://www.ic.nhs.uk/services/measuring-for-quality-improvementhttp://www.nice.org.uk/media/61B/AC/DevlopingNICEQualityStandardsInterimProcessGuide.pdfhttp://www.nice.org.uk/media/61B/AC/DevlopingNICEQualityStandardsInterimProcessGuide.pdfhttps://mqi.ic.nhs.uk/Default.aspxhttps://mqi.ic.nhs.uk/Default.aspxhttps://mqi.ic.nhs.uk/PerformanceIndicatorChapter.aspx?number=1.09.06http://guidance.nice.org.uk/CG68http://guidance.nice.org.uk/CG68http://bookshop.rcplondon.ac.uk/details.aspx?e=254http://www.nao.org.uk/publications/0506/reducing_brain_damage.aspxhttp://www.nao.org.uk/publications/0506/reducing_brain_damage.aspxhttp://www.nao.org.uk/publications/0910/stroke.aspxhttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081062


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2 Quality standard for stroke

Quality Improvement Programme. If such quality indicators do not currently exist it isintended that the quality measures should form the basis for audit criteria developed andused locally to improve the quality of healthcare. It is also noted that at present there arelimited health outcome measures that can be used as quality measures: the focus of thequality measures is on improving health outcomes through improving processes of care thatare considered to be linked to health outcomes.

All quality measures are specified in the form of a numerator and a denominator, whichdefine a proportion (numerator/denominator). It is assumed that the numerator is a subset ofthe denominator population.

For example, if the quality measure is:Numerator the number of carers who have written information about the patientsdiagnosis and management plan.Denominator the number of carers of patients with stroke.

The correct proportion is the number of carers of patients with stroke who have writteninformation. The numerator does not include carers who have written information but whoare not carers of patients with stroke.

Diversity, equality and language:Good communication between health and social care professionals and patients isessential. Treatment and care, and the information patients are given about it, should beculturally appropriate. It should also be accessible to people with additional needs such asphysical, sensory or learning disabilities, and to people who do not speak or read English.Patients should have access to an interpreter or advocate if needed.


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Quality Standard for s troke

The quality standard for stroke requires that stroke services should becommissioned from and coordinated across all relevant agencies to encompass thewhole stroke care pathway. An integrated approach to pr ovision of services isfundamental to the delivery of high-quality care to patients with stroke.

Number Quality statements1 People seen by ambulance staff outside hospital, who have sudden onset of

neurological symptoms, are screened using a validated tool to diagnose stroke ortransient ischaemic attack (TIA). Those people with persisting neurologicalsymptoms who screen positive using a validated tool, in whom hypoglycaemiahas been excluded, and who have a possible diagnosis of stroke, are transferred

to a specialist acute stroke unit within 1 hour. 2 Patients with acute stroke receive brain imaging within 1 hour of arrival at thehospital if they meet any of the indications for immediate imaging.

3 Patients with suspected stroke are admitted directly to a specialist acute strokeunit and assessed for thrombolysis, receiving it if clinically indicated.

4 Patients with acute stroke have their swallowing screened by a specially trainedhealthcare professional within 4 hours of admission to hospital, before beinggiven any oral food, fluid or medication, and they have an ongoing managementplan for the provision of adequate nutrition.

5 Patients with stroke are assessed and managed by stroke nursing staff and atleast one member of the specialist rehabilitation team within 24 hours ofadmission to hospital, and by all relevant members of the specialist rehabilitationteam within 72 hours, with documented multidisciplinary goals agreed within5 days.

6 Patients who need ongoing inpatient rehabilitation after completion of their acutediagnosis and treatment are treated in a specialist stroke rehabilitation unit.

7 Patients with stroke are offered a minimum of 45 minutes of each active therapythat is required, for a minimum of 5 days a week, at a level that enables thepatient to meet their rehabilitation goals for as long as they are continuing tobenefit from the therapy and are able to tolerate it.

8 Patients with stroke who have continued loss of bladder control 2 weeks afterdiagnosis are reassessed to identify the cause of incontinence, and have anongoing treatment plan involving both patients and carers.

9 All patients after stroke are screened within 6 weeks of diagnosis, using avalidated tool, to identify mood disturbance and cognitive impairment.

10 All patients discharged from hospital who have residual stroke-related problemsare followed up within 72 hours by specialist stroke rehabilitation services forassessment and ongoing management.

11 Carers of patients with stroke are provided with a named point of contact forstroke information, written information about the patients diagnosis andmanagement plan, and sufficient practical training to enable them to provide care.


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Quality standard for stroke

Quality statement 1

Quality statement People seen by ambulance staff outside hospital, who have suddenonset of neurological symptoms, are screened using a validated toolto diagnose stroke or transient ischaemic attack (TIA). Those peoplewith persisting neurological symptoms who screen positive using avalidated tool, in whom hypoglycaemia has been excluded, and whohave a possible diagnosis of stroke, are transferred to a specialistacute stroke unit within 1 hour.

Quality measure Structure:(a) Evidence of local arrangements to ensure that a validated tool isused by ambulance staff to screen for stroke or TIA in people withsudden onset of neurological symptoms.

(b) Evidence of local arrangements to ensure those people withpersistent neurological symptoms who screen positive using avalidated tool, in whom hypoglycaemia has been excluded, who havea possible diagnosis of stroke, are transferred to a specialist acutestroke unit within 1 hour.

Process:(a) Proportion of people with sudden onset of neurological symptomswho are screened for stroke or TIA outside hospital by ambulancestaff using a validated tool.Numerator the number of people screened for stroke or TIA using avalidated tool.Denominator the number of people with sudden onset ofneurological symptoms seen outside hospital by ambulance staff.

(b) Proportion of people with persisting neurological symptoms whoscreen positive using a validated tool, in whom hypoglycaemia hasbeen excluded, who have a possible diagnosis of stroke, who aretransferred to a specialist acute stroke unit within 1 hour.Numerator the number of people who are transferred to a specialistacute stroke unit within 1 hour.Denominator the number of people with persisting neurologicalsymptoms who screen positive using a validated tool, in whomhypoglycaemia has been excluded, who have a possible diagnosis ofstroke.


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Descript ion of whatthe qualitystatement meansfor each audience

Service providers ensure that there are agreed local policies andprotocols for ambulance staff to use validated tools to screen forstroke or TIA in people with sudden onset of neurological symptomsoutside hospital, and that there is immediate access (1 hour) to aspecialist acute stroke unit for those with persisting neurologicalsymptoms.

Ambulance personnel ensure that they use a validated tool toscreen for stroke or TIA in people with sudden onset of neurologicalsymptoms outside hospital. They ensure that people with persistingneurological symptoms who screen positive using a validated tool, inwhom hypoglycaemia has been excluded, and who have a possiblediagnosis of stroke, are transferred to a specialist acute stroke unitwithin 1 hour.

Commissioners ensure that services are in place for ambulance staffto assess people who have sudden onset of neurological symptomsoutside hospital using a validated tool. They ensure that services arein place for people with persisting neurological symptoms who screenpositive using a validated tool, in whom hypoglycaemia has beenexcluded, and who have a possible diagnosis of stroke, to betransferred to a specialist acute stroke unit within 1 hour.

People with sudden onset of neurological symptoms can expect to beassessed by ambulance staff using a validated tool to diagnosestroke or TIA. People with persisting neurological symptoms whoscreen positive using a validated tool, in whom hypoglycaemia has

been excluded, and who have a possible diagnosis of stroke, canexpect to be transferred to a specialist acute stroke unit within 1 hour.

Definitions The goal of 1 hour set by this statement has been selected to takeinto account the differences between urban, rural and remotelocations. However, trusts can set appropriate targets for their localservice configurations.

Examples of validated tools are Face-Arm-Speech-Test (FAST) or theRecognition of Stroke in the Emergency Room (ROSIER) Scale.

Symptoms are assumed to be persistent if they are still present whenambulance staff arrive at the patients location.

Data source Structure: Local data collection.

Process: Trusts can collect data via the Sentinel Stroke Audit andthrough local data collection.
http://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspxhttp://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspxhttp://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspxhttp://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspx


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Quality statement 2

Quality statement Patients with acute stroke receive brain imaging within 1 hour ofarrival at the hospital if they meet any of the indications for immediateimaging.

Quality measure Structure: Evidence of local arrangements to ensure patients withacute stroke receive brain imaging within 1 hour of arrival at thehospital if they meet any of the indications for immediate imaging.

Process: Proportion of patients with acute stroke who meet any ofthe indications for immediate imaging who have had brain imagingwithin 1 hour of arrival at the hospital.Numerator the number of patients who have had brain imagingwithin 1 hour of arrival at the hospital.

Denominator the number of patients with acute stroke attendinghospital who meet any of the indications for immediate imaging.


Service providers ensure facilities and protocols are available forpatients to receive brain imaging within 1 hour of arrival at the hospitalif they meet any of the indications for immediate imaging.

Healthcare professionals ensure that patients under their care withacute stroke receive brain imaging within 1 hour of arrival at thehospital if the criteria for immediate imaging are met.

Commissioners ensure that services they commission enablepatients to receive brain imaging within 1 hour of arrival at the hospitalif they meet any of the indications for immediate imaging.

Patients with acute stroke with any of the indications for immediatebrain imaging can expect to receive this within 1 hour of arrival at thehospital.

Definitions NICE clinical guideline 68 states that brain imaging should beperformed immediately for people with acute stroke if any of thefollowing apply: Indications for thrombolysis or early anticoagulation treatment (forfurther information, please refer to NICE technology appraisal 122 Alteplase for the treatment of acute ischaemic stroke .) On anticoagulant treatment. A known bleeding tendency. A depressed level of consciousness (Glasgow Coma Scorebelow 13). Unexplained progressive or fluctuating symptoms. Papilloedema, neck stiffness or fever. Severe headache at onset of stroke symptoms.
http://guidance.nice.org.uk/CG68/NICEGuidance/pdf/Englishhttp://guidance.nice.org.uk/CG68/NICEGuidance/pdf/Englishhttp://guidance.nice.org.uk/TA122/Guidancehttp://guidance.nice.org.uk/TA122/Guidancehttp://guidance.nice.org.uk/TA122/Guidancehttp://guidance.nice.org.uk/TA122/Guidancehttp://guidance.nice.org.uk/CG68/NICEGuidance/pdf/English


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Process: Trusts can collect data via the Sentinel Stroke Audit , Hospital Episode Statistics (HES) data and through local datacollection.
http://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspxhttp://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspxhttp://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspxhttp://www.hesonline.nhs.uk/http://www.hesonline.nhs.uk/http://www.hesonline.nhs.uk/http://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspx


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Quality statement 3

Quality statement Patients with suspected stroke are admitted directly to a specialistacute stroke unit and assessed for thrombolysis, receiving it ifclinically indicated.

Quality measure Structure: Evidence of local arrangements to ensure that patientswith suspected stroke are admitted directly to a specialist acute strokeunit and are assessed for thrombolysis, receiving it if clinicallyindicated.

Process:(a) Proportion of patients admitted directly to a specialist acute strokeunit and assessed for thrombolysis.Numerator the number of patients admitted directly to a specialist

acute stroke unit and assessed for thrombolysis.Denominator the number of patients with suspected stroke admittedto hospital.

(b) Proportion of patients with suspected stroke assessed forthrombolysis who receive it in accordance with NICE technologyappraisal guidance 122 (2007) and NICE clinical guideline CG68(2008) . Numerator the number of patients who received thrombolysis inaccordance with NICE technology appraisal guidance 122 (2007) andNICE clinical guideline CG68 (2008) .

Denominator the number of patients with suspected strokeassessed to require thrombolysis.


Service providers ensure that patients with suspected stroke areadmitted directly to a specialist acute stroke unit to be assessed forthrombolysis, receiving it if clinically indicated.

Healthcare professionals admit all patients with suspected strokedirectly to a specialist acute stroke unit to be assessed forthrombolysis, which is administered if clinically indicated.

Commissioners ensure services admit all patients with suspectedstroke directly to a specialist acute stroke unit to be assessed forthrombolysis, which is administered if clinically indicated.

Patients with suspected stroke can expect to be admitted directly to aspecialist acute stroke unit to be assessed for thrombolysis, which isadministered if clinically indicated.
http://guidance.nice.org.uk/TA122http://guidance.nice.org.uk/TA122http://guidance.nice.org.uk/TA122http://guidance.nice.org.uk/TA122http://guidance.nice.org.uk/CG68http://guidance.nice.org.uk/CG68http://guidance.nice.org.uk/CG68http://guidance.nice.org.uk/CG68http://guidance.nice.org.uk/TA122http://guidance.nice.org.uk/TA122http://guidance.nice.org.uk/TA122http://guidance.nice.org.uk/CG68http://guidance.nice.org.uk/CG68http://guidance.nice.org.uk/CG68http://guidance.nice.org.uk/TA122http://guidance.nice.org.uk/CG68http://guidance.nice.org.uk/CG68http://guidance.nice.org.uk/TA122http://guidance.nice.org.uk/TA122


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Definitions Direct admission to a specialist acute stroke unit includes those whofirst attended emergency departments. It is not defined as transfersfrom other departments such as medical assessment units oremergency admission units.

Each specialist acute stroke unit should have immediate access to: clinical staff specially trained in the delivery of acute medical care tostroke patients, including the diagnostic and administrationprocedures needed for the safe and effective delivery of thrombolysis nursing staff trained in the management of acute stroke, coveringboth its neurological and general medical aspects imaging and laboratory services specialist rehabilitation staff.


Process: Trusts can collect data via Stroke Improvement ProgrammeNational Project 2009-10 (SINAP), HES data and through local datacollection.
http://www.improvement.nhs.uk/stroke/NationalProjects/tabid/56/Default.aspxhttp://www.improvement.nhs.uk/stroke/NationalProjects/tabid/56/Default.aspxhttp://www.improvement.nhs.uk/stroke/NationalProjects/tabid/56/Default.aspxhttp://www.improvement.nhs.uk/stroke/NationalProjects/tabid/56/Default.aspxhttp://www.hesonline.nhs.uk/http://www.hesonline.nhs.uk/http://www.hesonline.nhs.uk/http://www.hesonline.nhs.uk/http://www.improvement.nhs.uk/stroke/NationalProjects/tabid/56/Default.aspxhttp://www.improvement.nhs.uk/stroke/NationalProjects/tabid/56/Default.aspx


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Quality statement 4

Quality statement Patients with acute stroke have their swallowing screened by aspecially trained healthcare professional within 4 hours of admissionto hospital, before being given any oral food, fluid or medication, andthey have an ongoing management plan for the provision of adequatenutrition.

Quality measure Structure: Evidence that arrangements are in place to ensure that allpeople with acute stroke have their swallowing screened and have anongoing management plan for the provision of adequate nutrition,administered by a specially trained healthcare professional.

Process: Proportion of patients with acute stroke who have theirswallowing screened by a specially trained healthcare professional

within 4 hours of admission to hospital, before being given any oralfood, fluid or medication.

(a) Numerator the number of patients who have their swallowingscreened by a specially trained healthcare professional within 4 hoursof admission to hospital, before being given any oral food, fluid ormedication.Denominator the number of patients with acute stroke admitted tohospital.

(b) Numerator the number of patients with an ongoing management

plan for the provision of adequate nutrition.Denominator the number of patients with acute stroke admitted tohospital.


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Service providers ensure facilities and protocols are available toensure that each patient with acute stroke has their swallowingscreened by a specially trained healthcare professional within 4 hoursof admission to hospital, and prior to the oral administration of food,fluid or medication, and that each patient has an ongoingmanagement plan for the provision of adequate nutrition.

Healthcare professionals are trained to screen the swallowing ofpatients with acute stroke within 4 hours of admission before beinggiven any oral food, fluid or medication, and that they implementongoing management plans for the provision of adequate nutrition.

Commissioners ensure that services are in place for patients withacute stroke to have their swallowing screened by a specially trainedhealthcare professional within 4 hours of admission, prior to the oraladministration of food, fluid or medication, and for the implementation

of an ongoing management plan for the provision of adequatenutrition.

Patients admitted with acute stroke can expect to have theirswallowing screened by a specially trained healthcare professionalwithin 4 hours of admission, before being given any food, drink ormedication by mouth, and also to have an ongoing management planfor the provision of adequate nutrition.

Definitions: Professionals trained to perform a swallow screen include nurses,doctors, and speech and language therapists.


Process: Trusts can collect data via the Sentinel Stroke Audit , SINAP , HES data and through local data collection.
http://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspxhttp://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspxhttp://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspxhttp://www.improvement.nhs.uk/stroke/NationalProjects/tabid/56/Default.aspxhttp://www.improvement.nhs.uk/stroke/NationalProjects/tabid/56/Default.aspxhttp://www.improvement.nhs.uk/stroke/NationalProjects/tabid/56/Default.aspxhttp://www.hesonline.nhs.uk/http://www.hesonline.nhs.uk/http://www.hesonline.nhs.uk/http://www.improvement.nhs.uk/stroke/NationalProjects/tabid/56/Default.aspxhttp://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspx


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Quality statement 5

Quality statement Patients with stroke are assessed and managed by stroke nursingstaff and at least one member of the specialist rehabilitation teamwithin 24 hours of admission to hospital, and by all relevant membersof the specialist rehabilitation team within 72 hours, with documentedmultidisciplinary goals agreed within 5 days.

Quality measure Structure: Evidence of local arrangements to ensure that servicesare commissioned to provide patients with stroke with prompt accessto specialist rehabilitation services.

Process:(a) Proportion of patients with stroke assessed and managed bystroke nursing staff and at least one member of the specialist

rehabilitation team within 24 hours of admission to hospital.Numerator the number of patients assessed and managed bystroke nursing staff and at least one member of the specialistrehabilitation team within 24 hours of admission to hospital.Denominator the number of patients with a new stroke episodeadmitted to hospital.

(b) Proportion of patients with stroke assessed and managed by allrelevant members of the specialist rehabilitation team within 72 hoursof admission to hospital.Numerator the number of patients assessed and managed by all

relevant members of the specialist rehabilitation team within 72 hoursof admission to hospital.Denominator the number of patients with a new stroke episodeadmitted to hospital.

(c) Proportion of patients with stroke with documentedmultidisciplinary goals agreed within 5 days of admission to hospital. Numerator the number of patients with documented multidisciplinarygoals agreed within 5 days of admission to hospital. Denominator the number of patients with a new stroke episodeadmitted to hospital.


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Service providers ensure protocols are in place so that patients withstroke are assessed and managed by stroke nursing staff and at leastone member of the specialist rehabilitation team within 24 hours ofadmission to hospital, and by all relevant members of the specialistrehabilitation team within 72 hours, with documented multidisciplinarygoals agreed within 5 days of admission to hospital.

Health and social care professionals ensure that patients withstroke are assessed and managed by stroke nursing staff and at leastone member of the specialist rehabilitation team within 24 hours ofadmission to hospital, and by all relevant members of the specialistrehabilitation team within 72 hours, with documented multidisciplinarygoals agreed within 5 days of admission to hospital.

Commissioners ensure that services are in place so that patientswith stroke can be assessed and managed by stroke nursing staff andat least one member of the specialist rehabilitation team within24 hours of admission to hospital, and by all relevant members of thespecialist rehabilitation team within 72 hours, with documentedmultidisciplinary goals agreed within 5 days of admission to hospital.

Patients with stroke can expect to be assessed and managed bystroke nursing staff and by at least one member of the specialistrehabilitation team within 24 hours of admission to hospital, and by allrelevant members of the specialist rehabilitation team within 72 hours,with documented multidisciplinary goals agreed within 5 days ofadmission to hospital.

Definitions Given the range of problems faced by patients with stroke, the core ofthe specialist rehabilitation team will include physiotherapy,occupational therapy, speech and language therapy, and psychology.Support and input from social work, dietetics, pharmacy, orthotics andorthoptics should be available as required to address patients needs.


Process: Trusts can collect data via the Sentinel Stroke Audit , SINAP , HES data and through local data collection.
http://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspxhttp://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspxhttp://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspxhttp://www.improvement.nhs.uk/stroke/NationalProjects/tabid/56/Default.aspxhttp://www.improvement.nhs.uk/stroke/NationalProjects/tabid/56/Default.aspxhttp://www.hesonline.nhs.uk/http://www.hesonline.nhs.uk/http://www.hesonline.nhs.uk/http://www.hesonline.nhs.uk/http://www.improvement.nhs.uk/stroke/NationalProjects/tabid/56/Default.aspxhttp://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspx


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Quality statement 6

Quality statement Patients who need ongoing inpatient rehabilitation after completion oftheir acute diagnosis and treatment are treated in a specialist strokerehabilitation unit.

Quality measure Structure: Evidence of local arrangements to ensure all patients whoneed ongoing inpatient rehabilitation after completion of their acutediagnosis and treatment are treated in a specialist strokerehabilitation unit.

Process: Proportion of patients who need ongoing inpatientrehabilitation after completion of their acute diagnosis and treatmentwho are treated in a specialist stroke rehabilitation unit.Numerator the number of patients who are treated in a specialist

stroke rehabilitation unit.Denominator the number of patients who need ongoing specialiststroke rehabilitation after completion of their acute diagnosis andtreatment.


Service providers ensure all patients who need ongoing inpatientrehabilitation after completion of their acute diagnosis and treatmentare treated in a specialist stroke rehabilitation unit.

Healthcare professionals treat patients who need ongoing inpatientrehabilitation after completion of their acute diagnosis and treatmentin a specialist stroke rehabilitation unit.

Commissioners ensure that specialist stroke rehabilitation units arecommissioned to treat patients who need inpatient rehabilitation aftercompletion of their acute diagnosis and treatment.

Patients who need ongoing inpatient rehabilitation after completion oftheir acute diagnosis and treatment can expect to be treated in aspecialist stroke rehabilitation unit.

Definitions: A specialist stroke rehabilitation unit should meet all of the followingcriteria: It should be a discrete unit within the hospital. It should have a coordinated multidisciplinary team that meets atleast once a week to exchange information about patients. Staff should have specialist expertise in stroke and rehabilitation. Educational programmes and information should be provided forstaff, patients and carers.


Process: Trusts can collect data via the Sentinel Stroke Audit andthrough local data collection.
http://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspxhttp://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspxhttp://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspxhttp://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspx


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Quality statement 7

Quality statement Patients with stroke are offered a minimum of 45 minutes of eachactive therapy that is required, for a minimum of 5 days a week, at alevel that enables the patient to meet their rehabilitation goals for aslong as they are continuing to benefit from the therapy and are able totolerate it.

Quality measure Structure: Evidence that local arrangements are in place for theprovision of a minimum of 45 minutes of each active therapy for aminimum of 5 days a week that enables patients with stroke to meettheir rehabilitation goals.

Process: Proportion of patients with stroke who are offered45 minutes of each active therapy that is required, for as long as they

are continuing to benefit from the therapy and are able to tolerate it.Numerator the number of patients who are offered a minimum of45 minutes of each active therapy for a minimum of 5 days a week.Denominator the number of patients with a new stroke episode inhospital.


Service providers ensure that there are agreed local policies andprotocols to offer patients with stroke a minimum of 45 minutes ofeach active therapy that is required, for a minimum of 5 days eachweek, that enables them to meet their rehabilitation goals for as longas they continue to benefit from the therapy and are able to tolerate it.

Healthcare professionals offer patients with stroke a minimum of45 minutes of each active therapy that is required, for a minimum of5 days a week, to enable them to meet their rehabilitation goals, foras long as they continue to benefit from the therapy and are able totolerate it .

Commissioners ensure that active therapy services are available tooffer patients with stroke a minimum of 45 minutes of each activetherapy that is required, for a minimum of 5 days each week, thatenables them to meet their rehabilitation goals for as long as theycontinue to benefit from the therapy and are able to tolerate it.

Patients with stroke can expect to be offered at least 45 minutes ofeach active therapy, for a minimum of 5 times each week, to enablethem to meet their rehabilitation goals, as long as they are continuingto benefit from it and are able to tolerate it.


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Definitions Therapy services are defined as physiotherapy, occupational therapy,and speech and language therapy. Individual patients may requiretreatment from other professionals such as psychology and dietetics.

Active therapy is defined as face-to face-contact, which may beindividual or group treatment, and may include tele-therapy. It doesnot include administrative tasks related to patients.Tolerate is defined as having sufficient physical and mental capacityto be able to participate in the treatment, and individual patientsconsenting to treatment.Continue to benefit is defined as showing evidence on objectiveassessment of improving over time.This standard applies to therapy delivered in both hospital andcommunity settings.


Process: Trusts can collect data via HES data and through local datacollection.
http://www.hesonline.nhs.uk/http://www.hesonline.nhs.uk/http://www.hesonline.nhs.uk/http://www.hesonline.nhs.uk/


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Quality statement 8

Quality statement Patients with stroke who have continued loss of bladder control2 weeks after diagnosis are reassessed to identify the cause ofincontinence, and have an ongoing treatment plan involving bothpatients and carers.

Quality measure Structure: Evidence of local arrangements to ensure that patientswith loss of bladder control at 2 weeks are reassessed and havetreatment plans implemented involving both patients and carers.

Process: The proportion of patients with loss of bladder control at2 weeks who were reassessed to identify the cause, and had atreatment plan implemented involving patients and carers.

(a) Numerator the number of patients reassessed to identify thecause.Denominator the number of stroke patients with loss of bladdercontrol at 2 weeks.

(b) Numerator the number of patients with a treatment planinvolving both patients and carers.Denominator the number of patients with stroke who have loss ofbladder control at 2 weeks.


Service providers ensure that all patients with loss of bladder controlat 2 weeks are reassessed to identify the cause and have treatmentplans implemented, involving both patients and carers.

Health and social care professionals ensure that all patients withloss of bladder control at 2 weeks are reassessed to identify thecause and have a treatment plan implemented, involving bothpatients and carers.

Commissioners ensure that services are in place to ensure thatservice providers reassess and treat all patients with loss of bladdercontrol at 2 weeks appropriately.

Patients with loss of bladder control at 2 weeks can expect to bereassessed to identify the cause, and have a treatment planimplemented involving both patients and carers

Definitions Patients with stroke who have continued loss of bladder control2 weeks from diagnosis should only be discharged home withcontinuing incontinence after carers (family members) or patients arefully trained and adequate arrangements for social services and acontinuing supply of continence aids are confirmed and in place.


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Process: Local data collection. Trusts can collect data via theSentinel Stroke Audit and local data collection.
http://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspxhttp://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspxhttp://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspx


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Quality statement 9

Quality statement All patients after stroke are screened within 6 weeks of diagnosis,using a validated tool, to identify mood disturbance and cognitiveimpairment.

Quality measure Structure: Evidence that patients with stroke are screened within6 weeks of diagnosis, using a validated tool, to identify mooddisturbance and cognitive impairment.

Process: Proportion of patients with stroke who have been screenedwithin 6 weeks of diagnosis, using a validated tool, to identify mooddisturbance and cognitive impairment.

(a) Numerator the number of patients with stroke screened for mood

disturbance using a validated screening tool within 6 weeks of adiagnosis of stroke.Denominator the number of patients diagnosed with a new episodeof stroke.

(b) Numerator the number of patients with stroke who have beenscreened for cognitive impairment within 6 weeks of diagnosis.Denominator the number of patients diagnosed with a new episodeof stroke.


Service providers ensure that there are agreed local policies andguidelines for screening patients with stroke within 6 weeks ofdiagnosis, using a validated tool, to identify mood disturbance andcognitive impairment.

Healthcare professionals ensure patients with stroke are screenedfor mood disturbance and cognitive impairments using a validatedscreening tool within 6 weeks of diagnosis.

Commissioners ensure that services are in place to enable thescreening of all stroke patients for mood disturbance and cognitive

impairments using a validated screening tool within 6 weeks ofdiagnosis.

Patients with stroke can expect to be screened for mood disturbanceand cognitive impairments using a validated screening tool within6 weeks of diagnosis.


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Definitions: This standard applies in both hospital and community settings. Administration of the screening tools should be conducted by trainedstaff.

When using validated tools to identify mood disturbance or cognitiveimpairments, healthcare professionals should be mindful of the needto secure equality of access to treatment for patients from differentethnic groups (in particular those from different cultural backgrounds)and patients with disabilities.


Process: Local data collection. Trusts can collect data via theSentinel Stroke Audit , SINAP and local data collection.
http://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspxhttp://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspxhttp://www.improvement.nhs.uk/stroke/NationalProjects/tabid/56/Default.aspxhttp://www.improvement.nhs.uk/stroke/NationalProjects/tabid/56/Default.aspxhttp://www.improvement.nhs.uk/stroke/NationalProjects/tabid/56/Default.aspxhttp://www.improvement.nhs.uk/stroke/NationalProjects/tabid/56/Default.aspxhttp://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspx


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Quality s tatement 10

Quality statement All patients discharged from hospital who have residual stroke-relatedproblems are followed-up within 72 hours by specialist strokerehabilitation services for assessment and ongoing management.

Quality measure Structure: Evidence of local arrangements to ensure patientsdischarged from hospital who have residual stroke-related problemsare followed-up within 72 hours by specialist stroke rehabilitationservices for assessment and ongoing management.

Process: Proportion of patients discharged from hospital withresidual stroke-related problems who are followed up within 72 hoursby specialist stroke rehabilitation services for assessment andongoing management.

Numerator the number of patients followed-up by specialist strokerehabilitation services for assessment and ongoing managementwithin 72 hours of discharge from hospital.Denominator the number of patients discharged from hospital withresidual stroke-related problems.


Service providers ensure that all patients discharged from hospitalwho have residual stroke-related problems are followed up within72 hours by specialist stroke rehabilitation services for assessmentand ongoing management.

Healthcare professionals ensure that patients with residualstroke-related problems are followed up by specialist strokerehabilitation services within 72 hours for assessment and ongoingmanagement.

Commissioners ensure that specialist stroke rehabilitation servicesare available so that all patients discharged from hospital who haveresidual stroke-related problems are followed up within 72 hours.

Patients with residual stroke-related problems can expect to be

followed up by stroke specialist rehabilitation services for assessmentand ongoing management within 72 hours of their discharge fromhospital.

Definitions Residual problems can include physical problems, loss of cognitive orcommunication skills, anxiety, depression or other psychologicalproblems.


Process: Local data collection. Trusts can collect data via HES data,the Sentinel Stroke Audit and through local data collection.
http://www.hesonline.nhs.uk/http://www.hesonline.nhs.uk/http://www.hesonline.nhs.uk/http://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspxhttp://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspxhttp://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspxhttp://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Pages/Audit.aspxhttp://www.hesonline.nhs.uk/


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Quality statement 11

Quality statement Carers of patients with stroke have: a named contact for strokeinformation; written information about patients diagnosis andmanagement plan; and sufficient practical training to enable them toprovide care.

Quality measure Structure:(a) Evidence of local arrangements to ensure that carers of patients withstroke have: a named contact for stroke information; written informationabout patients diagnosis and management plan; and sufficient practicaltraining to enable them to provide care.(b) Evidence that a carers experience survey has been completed.

Process: Proportion of patients with stroke whose carers have: a

named contact for stroke information; written information about patientsdiagnosis and management plan; and sufficient practical training toenable them to provide care.Numerator the number of carers who have:(a) a named contact for stroke information(b) written information about the patients diagnosis and managementplan(c) sufficient practical training to provide care.Denominator the number of carers of patients with stroke.

Descript ion ofwhat the qualitystatement meansfor each audience

Service providers ensure that local policies are in place to ensure thatthe carers of all patients with stroke have: a named contact for strokeinformation; written information about the patients diagnosis andmanagement plan; and sufficient practical training to enable them toprovide care. They obtain the carers opinion through a carersexperience survey.

Health and social care professionals ensure that carers of all patientswith stroke have: a named contact for stroke information; writteninformation about the patients diagnosis and management plan; andsufficient practical training to enable them to provide care.

Commissioners ensure that services are in place to enable carers ofevery patient with stroke to have: a named contact for strokeinformation; written information about the patients diagnosis andmanagement plan; and sufficient practical training to enable them toprovide care. Commissioners ensure that service providers obtain thecarers opinion through a carers experience survey.

Carers have: a named contact for stroke information; written informationabout the patients diagnosis and management plan; and sufficientpractical training to enable them to provide care. The carers opinion will

be obtained through a carers experience survey


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l d d f k

Definitions Written information for patients can be found in the RCP booklet Careafter stroke or transient ischaemic attack (2008) . Information aboutNICE guidance, written specifically for patients can be found in Stroke:understanding NICE guidance (NICE clinical guideline 68, 2008) .

Data Source Structure: Local data collection.

Process: Local data collection using a carer survey.

Commissioning for Quality and Innovation (2010/2011) PatientExperience Goal 2Improve response to personal needs of patientsEach describes a different element of the overarching theme responseto personal needs: Involvement in decisions about treatment and care. Hospital staff are available to talk about worries or concerns. Privacy when discussing the condition or treatment. Information about medication side-effects. Information about who to contact if worried about the condition afterleaving hospital.
http://bookshop.rcplondon.ac.uk/details.aspx?e=255http://bookshop.rcplondon.ac.uk/details.aspx?e=255http://bookshop.rcplondon.ac.uk/details.aspx?e=255http://bookshop.rcplondon.ac.uk/details.aspx?e=255http://guidance.nice.org.uk/CG68/PublicInfo/pdf/Englishhttp://guidance.nice.org.uk/CG68/PublicInfo/pdf/Englishhttp://guidance.nice.org.uk/CG68/PublicInfo/pdf/Englishhttp://guidance.nice.org.uk/CG68/PublicInfo/pdf/Englishhttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_091443http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_091443http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_091443http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_091443http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_091443http://guidance.nice.org.uk/CG68/PublicInfo/pdf/Englishhttp://guidance.nice.org.uk/CG68/PublicInfo/pdf/Englishhttp://bookshop.rcplondon.ac.uk/details.aspx?e=255http://bookshop.rcplondon.ac.uk/details.aspx?e=255

Documents

Stroke Quality Standard