National Stroke Audit - Acute Services 2015 Your hospital’s slide-deck

National Stroke Audit Acute Services 2015 Introduction The National Stroke Audit – Acute Services comprises two elements: Completed by 185 hospitals. Examining the resources, processes and infrastructure in place to support best practice stroke care. Delivered in two forms; short (focused on protocols for ED assessment and transfer) and a long (115 questions). Enabling reporting of stroke services against each required element outlined in the Acute Stroke Services Framework (2015). Completed between 1 June and 28 August 2015, participants were asked to answer questions as of 1 June An Organisational Survey of stroke services across Australia. A retrospective Clinical Audit of 4,087 patient case notes. Completed by 112 hospitals Examines processes of acute care, outlined in the Clinical Guidelines, such as diagnostic procedures, early interventions, multidisciplinary care and compliance with evidence-based recommendations. Participating hospitals reviewed case notes of 40 or more consecutive patients admitted from September and discharged by February Reporting based on adherence to 19 ACSQHC Acute Stroke Clinical Standard Indicators (2015).

How to make the most of your hospital’s National Stroke Audit 2015 results.. Provide a clear picture of both the process of care and organisational issues that impact on stroke service delivery. Benchmark the quality of stroke care in your hospital against other hospitals that manage similar numbers of stroke admissions. Identify potential strengths and weaknesses in the management of stroke and allow recipients to identify focus areas for ongoing quality improvement activities.

Populating your hospital’s slide- deck template Your slide-deck is intended to be interactive, please add or remove slides to suit your hospital’s individual needs and interests. To populate, refer to the following locations within your hospital’s site report or the National Stroke Audit Acute Services Report 2015, which can be downloaded below: National report Acute Stroke Services Framework Page 15-22; table 4-10 for ‘peer hospital benchmarks’ (data split by hospital volume) Acute Stroke Clinical Care Standard Indicators Page 26-28; table for all state-specific data. Site Report Organisational Survey data Tab E; column E; row Acute Stroke Services Framework data Tab F, column D; row 2-26 Patient demographics data Tab A; column H-J; row 3-24 Acute Stroke Clinical Care Standard Indicators data Tab B; column B for your site’s results Tab B; column J-N for ‘peer hospital’ benchmarks (data split by hospital volume)

Response rate Participating hospitals by location Organisational SurveyClinical Audit TotalPublicPrivateTotalPublicPrivate Australia ACT NSW NT QLD SA TAS VIC WA

Response rate Stroke patient admissions for participating hospitals completing the Organisational Survey State Total reported stroke admissions previous year Total < ACT NSW NT QLD SA TAS VIC WA

Organisational Survey Acute Stroke Services Framework Key findings Amongst hospitals admitting 50 or more stroke patients per year, only one was found to have all 24 elements of the framework. 10 hospitals who had 10 or less of the framework elements and the median number of elements was 18. The median number of elements met increased with the volume of stroke patients admitted.

Organisational Survey Adherence to the Acute Stroke Services Framework Plot your hospital’s results by positioning the dotted line along the X-axis..

Organisational Survey Acute Stroke Services Framework – Pre-hospital and ED Element of service – Pre-hospital and ED Australia (N=108) Peer hospitals My site Yes/No Organised pre-hospital services (includes use of validated screening tools by paramedics, appropriate pre-notification systems) n, (%) 65 (60) Coordinated regional stroke systems (includes protocols for hospital bypass, transfer from non- stroke hospital to PSS or CSS, and between a PSS and CSS) n, (%) 73 (68) Coordinated emergency department systems (includes use of validated screening tools; agreed triage categories; protocols for tPA intervention e.g. “Code Stroke”; pathways to facilitate urgent access to imaging etc) n, (%) 96 (89)

Organisational Survey Acute Stroke Services Framework – Imaging Element of service – Imaging Australia (N=108) Peer hospitals My site Yes/No Onsite CT brain (24/7) including CT angiography n, (%) 104 (96) Carotid imaging within 24 hours n, (%) 95 (88) Advanced imaging capability (e.g. MRI/MRA, catheter angiography). n, (%) 95 (88)

Organisational Survey Acute Stroke Services Framework - Hyper-acute treatments Element of service – Hyper-acute treatments Australia (N=108) Peer hospitals My site Yes/No On-site endovascular stroke service (24/7) n, (%) 11 (10) On-site neurosurgical services (e.g. for hemicraniectomy due to large middle cerebral artery infarcts) n, (%) 28 (26) Delivery of intravenous tissue plasminogen activator (tPA) n, (%) 82 (76) Ability to provide acute monitoring (telemetry and other physiological monitoring) for at least 72 hours n, (%) 100 (93)

Organisational Survey Acute Stroke Services Framework – Organised stroke services Element of service – Organised stroke services Australia (N=108) Peer hospitals My site Yes/No Stroke unit* n, (%) 87 (81) Acute stroke team n, (%) 96 (89) Routine use of guidelines, care plans and protocols n, (%) 45 (42) Dedicated stroke coordinator position 59 (55) Dedicated medical lead n, (%) 71 (66) Access to HDU / ICU (for complex patients) n, (%) 103 (95) Access and collaboration with other specialist services (cardiology, palliative care, vascular) n, (%) 71 (66)

Organisational Survey Acute Stroke Services Framework – Rehabilitation Element of service – Rehabilitation Australia (N=108) Peer hospitals My site Yes/No Coordination with rehabilitation service providers (this should include a standardised process, and/or a person, used to assess suitability for further rehabilitation) n, (%) 94 (87) Early assessment using standardised tools to determine individual rehabilitation needs and goals (ideally within hours). There should also be standardised processes that ensure ALL stroke patients are assessed for rehabilitation n, (%) 83 (77) Routine involvement of carers in the rehabilitation process n, (%) 106 (98)

Organisational Survey Acute Stroke Services Framework – Data and quality improvement Element of service – Data and quality improvement Australia (N=108) Peer hospitals My site Yes/No Regular data collection and stroke specific quality improvement activities n, (%) 87 (81)

Organisational Survey Acute Stroke Services Framework – Telehealth and regional responsibility Element of service – Telehealth and regional responsibility Australia (N=108) Peer hospitals My site Yes/No Provision of telehealth services for acute assessment and treatment n, (%) 45 (42) Regional responsibility (e.g. coordination across a local health district) n, (%) 55 (51)

Organisational Survey Acute Stroke Services Framework – TIA services Element of service – TIA services Australia (N=108) Peer hospitals My site Yes/No Rapid (within 48 hours) Transient Ischaemic Attack (TIA) assessment clinics/services n, (%) 41 (38)

Clinical Audit Patient demographics Australia (N=4087) n (%) or median (IQR) My site (N=) n (%) or median (IQR) Male 2244 (55) Median Age (Q1 Q3)* 76 (65-84) Aboriginal and/or Torres Strait Islander background ^ 109 (3) Non-English speaking background with requirement for interpreter 238 (6) Ischaemic stroke 3213 (79) Intracerebral haemorrhage 550 (14) Unknown stroke type 324 (8) Independence prior to admission (mRS 0-2) 3274 (80) Independence within 72 hours of admission (mRS 0-2) 1443 (35) In-hospital stroke151 (4)

Clinical Standard Indicators - Key findings: Provision of early assessment was poor with only just over a third (38%) of patients screened One third of people arriving by ambulance were not transported to hospitals offering thrombolysis and only 17% of ischaemic stroke patients arriving within 4.5 hours received thrombolysis. Whilst 67% of patients received stroke unit care, only 38% of stroke patients spent at least 90% of their time on a stroke unit Early assessment by a physiotherapist was achieved in 68% of cases. Other measures appear encouraging; 87% of patients started rehabilitation during the acute admission. Secondary prevention measures were poor - one third of patients with ischaemic stroke and more than one third of patients with atrial fibrillation were not discharged on recommended secondary prevention medication. Provision of risk factor modification advice (56%) and care plans (56%) was poor nationally and across all states Clinical Audit ACSQHC Acute Stroke Clinical Standard Indicators - National performance

Clinical Audit Early assessment Australia (N=4087) Peer hospitals My site Assessment in the emergency department n, (%) 1294 (38)

Clinical Audit Time-critical therapy Australia (N=4087) Peer hospitals My site Time (minutes) to brain scan from arrival to ED median (IQR) 1:32 (0:46-3:05)

Australia (N=4087) Peer hospitalsMy site Thrombolysis in ischaemic stroke patients (with exclusions) n, (%) 231 (8) Thrombolysis in ischaemic stroke patients who arrive within 4.5 hours of symptom onset n, (%) 198 (24) Thrombolysis within 60 minutes of hospital arrival n, (%) 59 (26) Clinical Audit Time-critical therapy

Australia (N=4087) Peer hospitalsMy site Time from onset of symptoms to thrombolysis median (IQR) 2:50 (2:03-3:39) Median door to needle time median (IQR) 2:50 (2:03-3:39) Clinical Audit Time-critical therapy

Clinical Audit Stroke unit care Australia (N=4087) Peer hospitalsMy site Admission into a stroke unit n, (%) 2724 (67) 90% of acute hospital care on a stroke unit n, (%) 1579 (39)

Clinical Audit Early rehabilitation Australia (N=4087) Peer hospitalsMy site Assessment for rehabilitation by a physiotherapist within hours of hospital admission n, (%) 2761 (68) Rehabilitation therapy within 48 hours of initial assessment n, (%) 2399 (82) Treatment for a rehabilitation goal commencing during an acute hospital admission n, (%) 2648 (87)

Clinical Audit Minimising risk of another stroke Australia (N=4087) Peer hospitalsMy site Discharged on antihypertensive medication (haemorrhagic stroke patients) n, (%) 137 (66) Discharge on statin, antihypertensive and antithrombotic medications (ischaemic stroke patients) n, (%) 1120 (64)

Clinical Audit Minimising risk of another stroke Australia (N=4087) Peer hospitalsMy site Discharge on oral anticoagulants for atrial fibrillation (ischaemic stroke patients) n, (%) 304 (62) Patient receives risk factor modification advice before leaving the hospital n, (%) 1273 (56)

Clinical Audit Carer training and support Australia (N=4087) Peer hospitalsMy site Carer support needs assessment n, (%) 271 (59) Patient carer receives training n, (%) 2399 (82)

Clinical Audit Transition from hospital care Australia (N=4087) Peer hospitalsMy site Patient receives written care plan n, (%) 1486 (56)

National Stroke Audit - Acute Services 2015 Recommendations 1.Review the organisation of stroke services to ensure: a.comprehensive stroke services available b.improved stroke unit access (improved bed management & hospital bypass). 2.Appoint stroke coordinators in all stroke units. 3.Develop processes to support higher rates of care planning and secondary prevention management. 4.Drive greater improvements in stroke care quality by enhancing the way in which the quality of stroke care is monitored.

National Stroke Audit - Acute Services 2015 Key findings and recommendations for my hospital..