Sentinel Stroke National Audit Programme (SSNAP) Acute Organisational Audit December 2012

General Audit Information Data collection period: 23 July – 7 Sept 2012 Snapshot of stroke services as on: 2 July 2012 Reports: to trusts: 21 November 2012 public report: 5 December 2012 There was 100% participation in England, Wales and Northern Ireland.

Stroke Caseload National My Site 5276 stroke beds in 189 sites 4458 stroke patients on the day of the audit 5% of stroke patients not in stroke unit beds 1% on ‘acceptable’ other wards 1% on general assessment/decision beds (non acceptable location) 3% on other ‘non-acceptable’ wards Median ratio of SU beds to stroke inpatients on the day of the audit: 1.15 P36, p38 *Acceptable ‘other’ locations are coronary care unit (CCU), intensive care unit (ITU) and high dependency unit (HDU) **Non-acceptable ‘other’ locations are care of the elderly ward, neurology ward, generic rehabilitation unit, general medical ward, ‘others’ & ‘unknown’.

Annual Caseload National My Site Number of patients admitted with stroke per site between 1 April 2011 – 31 March 2012 Median = 413 p39

Types of stroke beds: My Site Type 1: Beds solely for first 72 hours of care YES/NO Type 2: Beds solely for beyond 72 hours of care YES/NO Type 3: Beds for both first 72 hours of care YES/NO and post 72 hour care   p37

Presentation, assessment and initial treatment Ambulance National My Site FAST-Track arrangements with ambulance 98% Yes/No Patients transferred directly to SU by ambulance clinicians 29% Telemedicine National My Site Use of Telemedicine 61% (107) Yes/No Remote viewing for brain imaging 96% (103) Video enabled clinical assessment 76% (81) P40,

Thrombolysis

Thrombolysis Provision My site’s provision =

Percentage of stroke inpatients thrombolysed between 1 April 2011 and 31 March 2012 National median = 6.7% My site =

Decision making for thrombolysis – Normal Hours National My Site Consultant physician in person 98% Yes/No Consultant physician via telemedicine 12% Consultant physician via telephone 16% Registrar 11% Lower grade doctor 1% Stroke nurse band 8 Stroke nurse band 7 Stroke nurse band 6 Stroke nurse band 5 3% p44

Decision making for thrombolysis – Out of Hours National My Site Consultant physician in person 51% Yes/No Consultant physician via telemedicine 52% Consultant physician via telephone 29% Registrar 6% Lower grade doctor 1% Stroke nurse band 8 Stroke nurse band 7 Stroke nurse band 6 2% Stroke nurse band 5 p44

Thrombolysis Rota National My Site Number of Consultant level doctors on thrombolysis rota Median 6 (IQR 3-9) Consultant speciality on thrombolysis rota National My Site Stroke physician 91% Yes/No Neurologist 25% Care of the elderly 36% Cardiologist 4% General medicine physician 12% A&E Acute physician 16% Other 3% P45,

Stroke Units Service provided on stroke units in the first 72 hours

Patient admission to stroke unit Type 1 Beds Type 3 Beds National My Site All patients are always directly admitted 7% (6) 11% (14) All patients are directly admitted except if another predominant acute condition 51% (42) 32% (39) All patients are directly admitted except when no bed available 37% (31) 47% (57) Only those who may be eligible for thrombolysis are directly admitted 0% (0) Only those who receive thrombolysis are directly admitted 2% (2) Some patients are directly admitted but not as outlined in any of the categories above 10% (12) Patients are never directly admitted p47

Exclusion from stroke unit Type 1 and Type 3 beds Type 1 Beds Type 3 Beds National My Site Any of the types of exclusion criteria: 5% Yes/No/NA 0% Age-related Stroke severity Pre-existing dementia 1 site No rehabilitation potential End of life care 3 sites P48 NA if your site does not have that ‘Type’ of bed

84% monitor at least one bed 7 Acute Criteria Type 1 Beds Type 3 Beds National My Site Continuous physiological monitoring 76% monitor 100% of beds Yes/No/NA 84% monitor at least one bed Immediate access to scanning 100% 99% Admission procedure 58% 43% Specialist ward rounds 7 days a week 53% 30% Acute stroke protocols/guidelines Nurses trained in swallow screening 98% Nurses trained in stroke assessment and management 95% P49 NA if your site does not have that ‘Type’ of bed

Acute Stroke Care Type 1 Beds Type 3 Beds National (n=83) My Site Stroke unit with all 7 acute criteria 29% Yes/No/NA 12% Stroke unit with 5 or more acute criteria 90% 88% P49 Choose ‘NA’ if your site does not have that ‘Type’ of bed

Exclusion from the stroke unit Type 2 beds Type 2 Beds National My Site Any of the types of exclusion criteria: 5% Yes/No/NA Age-related Stroke severity Pre-existing dementia 1 site No rehabilitation potential 3 sites End of life care 4 sites P51 NA if your site does not have that ‘Type’ of bed

Ward Rounds Type 2 beds Frequency of stroke consultant ward rounds National My Site 7 days per week 12% Yes/No/NA 5-6 days per week 65% Less than 5 days per week 24% P51 NA if your site does not have that ‘Type’ of bed

Staffing on the Stroke Unit

Staffing – Whole Time Equivalents National My Site % Yes Median WTE per 10 beds Yes/No WTE per 10 beds 0.0 0.2 1.1 1.3 0.5 0.1 p54

6 or 7 day therapy working p30 23% of sites have 6 or 7 day working for at least two of: physiotherapy, occupational therapy, and speech and language therapy. My site is/is not one of these sites

Specialist stroke assessment and management nurses Nurses trained in stroke assessment and management usually on duty at 10am National – total stroke units My Site Median per 10 beds Per 10 beds Weekdays 1.7 Saturdays 1.5 Sundays/Bank Holidays p53

Staffing – Access to clinical psychologists National My Site Access to clinical psychologist(s) 52% (99) YES/NO If yes, within 5 days 75% (74/99) YES/NO/NA p55

Palliative Care National My Site Palliative care patients are treated on the stroke unit 99% YES/NO If yes, Liverpool Care Pathway (or equivalent in Wales) used p56

Team Meetings

National My Site National My Site Frequency of team meetings National My Site Less than once a week 0% Once a week 24% Twice a week 15% More than twice a week 61% Regularly attend meetings: National My Site Clinical Psychology 26% Yes/No Dietetics 60% Medicine (Senior Doctor) 98% Nursing 99% Occupational Therapy Physiotherapy Social Work 66% Speech & Language Therapy 89% p56

Team meetings – Patients discussed National My Site All stroke unit patients are discussed in team meetings 99% Yes/No SOME stroke inpatients on other wards are discussed in these meetings 80% Yes/No/NA All stroke patients on other wards are discussed in these meetings 83% p56

5 SUTC criteria National My Site Clinician formally recognised as having principle responsibility for stroke services 100% Yes/No Formal links with patients and carers for communication on Service provision Audit Service reviews & future plans 53% Multidisciplinary Team Meetings (at least once a week) 99% Patient information displayed in unit/ward 93% Continuing education Funding for external courses At least one staff day paid for between 1 April 2011 and 31 March 2012 88% p58

Number of SUTC criteria achieved National My Site 2 3 (2%) Yes/No 3 21 (11%) 4 83 (44%) 5 82 (43%) Sum from p58

Medical Assessment Units - MAU

MAUs National My Site Are stroke patients ever in general assessment / decision beds e.g. MAU 68% Yes/No Stroke patients in MAU are seen by a stroke specialist consultant 81% Yes/No/NA Number of days per week on which a stroke patient would be seen by a stroke specialist Median = 5 days p59

6 Acute Criteria on MAUs MAU Beds National My Site Continuous physiological monitoring Median = 6 Yes/No Immediate access to scanning 98% Admission procedure 13% Specialist ward rounds 7 days a week Nurses trained in swallow screening 61% Nurses trained in stroke assessment and management 33% ALL SIX ACUTE CRITERIA 2% p59

Management of stroke services

Investment in stroke specialist staff National My Site Number of programmed activities (PAs) for stroke consultant physicians Median = 20 Number of PAs for direct clinical care for stroke Median = 14 Education for staff National My Site Funding for external courses available for nurses and therapists 88% Number of staff days paid for between 1 April 2011 and 31 March 2012 Median = 21 days p61

Research Capacity National My Site Number of stroke studies registered with your Research & Development Department Median = 4 1 or more 92% Yes/No 3 or more 74% p64

Quality improvement - Management Level of management that takes responsibility for follow-up of results and recommendations of the National Stroke Audit National My Site Executive on the Board 66% Yes/No Non-executive on the Board 12% Chairman of Clinical Governance (or equivalent) 33% Directorate Manager 82% Stroke Clinical Lead 85% Other 31% No specific individual 0% Not known p61

Strategic group responsible for stroke 93% of sites have a strategic group responsible for stroke. These groups included in their membership: Number of members at the time of the audit: p62 My site has strategic group for stroke: YES/NO Composition of group:

Patient and Carer Views National My Site Report produced between 1 April 2011 and 31 March 2012 which analysed the views of stroke patients 68% Yes/No Patient surveys and/or reports discussed in a formal meeting and plans devised to act upon findings 82% p62

Leadership

Leadership – meetings with trust management My site =

Leadership – meetings with neighbouring trusts’ clinicians My Site =

Leadership – strategic planning meetings My Site =

Patient support and communication

Patient support and communication – Discharge planning National My Site Patients given a personalised rehabilitation discharge plan 86% Yes/No Stroke service has formal links with patients and carers organisations for communication on all 3 of: service provision, audit, and service reviews and future plans 53% Stroke service has formal links with community user groups for stroke 89% Policy to give patients a named contact on transfer from hospital to community 76% p65

Support for working age patients National My Site Provision of service which actively supports stroke patients to remain in, return to or withdraw from work 68% Yes/No Provision of service which actively provides educational or vocational training 50% p65

Communication with patients and carers Stroke unit Outpatients National My Site The organisation of the ward/unit enables patients to have access to their management plan 82% Yes/No Patient information literature displayed in ward/unit: Patient versions of national or local guidelines/standards Social services local community care arrangements 88% The Benefits Agency 86% Information on stroke 100% Secondary prevention advice 98% p66

Pathway at discharge

Specialist Early Supported Discharge Team (ESD) My Site = Yes/No p67 89% of ESD teams have at least 4 specialities, including PT, OT and SLT. My site was/was not one of these sites

Specialist ESD waiting times Waiting time less than 48 hours National My Site 19% 38% 89% 67% 53% 82% 64% 84% 37% p67

Non-specialist Early Supported Discharge (ESD) Team 40% of non-specialist ESD teams have at least 4 specialities, including PT, OT and SLT. My site was/was not one of these sites.

Non-specialist ESD waiting times Waiting time less than 48 hours National My Site 0% 7% 62% 43% 69% 56% 24% 67% 25% p68

Longer term specialist Community Rehabilitation Team My Site = p69 81% of community rehab teams have at least 4 specialities, including PT, OT and SLT. My Site =

Specialist Community Rehabilitation waiting times Waiting time less than 48 hours National My Site 4% 12% 22% 23% 27% 42% 24% 30% p69

Longer term non-specialist Community Rehabilitation Team 61% of non-specialist community rehab teams have at least 4 specialities, including PT, OT and SLT. My site was/was not one of these sites.

Non-specialist Community Rehabilitation waiting times Waiting time less than 48 hours National My Site 0% 3% 25% 24% 22% 35% 46% 7% 28% p70

TIA/Neurovascular services

High-risk TIA patients My site’s timescale for inpatients = My site’s timescale for outpatients =

Low-risk TIA patients My site’s timescale for inpatients = My site’s timescale for outpatients =

Trust level summary of results

Domain 1 - Acute care organisation My site’s score: Lower scores Intermediate scores Higher scores 67 sites (35%) scored 0-62.5 81 sites (43%) scored 66.7-75.0 42 sites (22%) Scored 87.5-100

Domain 1 - Acute care organisation   Maximum score if, My site Quality of care of stroke units treating patients within the first 72 hours of stroke applying seven acute features* 7 features Number of patients thrombolysed from 1 April 2011 – 31 March 2012 (Q1.6) AS A PERCENTAGE OF the total number of patients admitted with stroke between 1 April 2011 – 31 March 2012 (QB6)** More than 10% patients thrombolysed Level of thrombolysis provision – hours per day and days per week on- and off-site 24/7 on- and/or off-site Score domain 1 100 * Continuous physiological monitoring (ECG, oximetry, blood pressure), Immediate access to scanning for urgent stroke patients, direct admission from A&E/front door, specialist ward rounds on 7 days a week, acute stroke protocols/guidelines, nurses trained in swallow screening, nurses trained in stroke assessment and management ** Sites which provide less than 24/7 thrombolysis onsite are removed from the denominator for this element of the domain i.e. they are scored out of 6 rather than 8. p27

Domain 2 - Organisation of care My site’s score: Lower scores Intermediate scores Higher scores 56 sites (29%) Scored 0-45.0 89 sites (47%) Scored 50.0-80.0 45 sites (24%) Scored 85.0-100

Domain 2 - Organisation of care   Maximum score if, My Site All stroke patients in stroke unit beds (or in Intensive therapy unit, coronary care unit or high dependency unit) Yes Ratio of stroke unit beds to the number of inpatients with stroke on the day* More than or equal 1 Presence and composition of a stroke/neurology specialist early supported discharge (ESD) multidisciplinary team Yes and at least 4 disciplines including PT, OT and SALT Presence and composition of a stroke/neurology specialist community team for longer term management Access to at least one of PT, OT or SALT in specialist ESD team within 48 hours Score domain 2 100 * A value of 1.00 indicates that there are equal numbers of stroke patients and stroke unit beds on the day of the audit. If the number is less than 1.00, there are more stroke patients than stroke unit beds. p28

Domain 3 - Specialist roles My site’s score: Lower scores Intermediate scores Higher scores 66 sites (35%) Scored 0-60.0 78 sites (41%) Scored 62.5-80.0 46 sites (24%) Scored 81.3-100

Domain 3 - Specialist roles   Maximum score if, My Site Frequency of consultant ward rounds per week* on 7 days a week Presence of senior nurses and therapists (band 7 or above) on the SU Yes Access within 5 days to social work expertise, orthotics, orthoptics, podiatry Yes to all four specialties Palliative care patients treated on the SU Access to clinical psychologists and provision of following aspects of psychological care mood assessment higher cognitive function assessment mood treatment higher cognitive function treatment non-cognitive behavioural problems assessment and/or treatment Access and all five aspects of psychological care provided for inpatients and outpatients Provision of service which supports stroke patients to remain in, return to or withdraw from work and/or Provision of educational or vocational training Yes to either services provided Patients stay in bed until assessed by physiotherapist No Score domain 3 *14 sites which do not treat patients in the first 72 hours are removed from the denominator for this element of the domain i.e. they are scored out of 8 rather than 10. p29

Domain 4 - Interdisciplinary services (stroke unit) My site’s score: Lower scores Intermediate scores Higher scores 54 hospitals (29%) Scored 0-42.5 96 hospitals (51%) Scored 45.0-65.0 40 (21%) Scored 67.5-87.5

Domain 4 - Interdisciplinary services (stroke unit)   Maximum score* if, My Site Qualified nurses on duty at 10 am weekdays per 10 SU beds 2.26 or more Care assistants on duty at 10 am weekdays per 10 SU beds 2.05 or more Qualified therapy staff availability in WTE (Whole Time Equivalents) per 10 SU beds Clinical psychology 0.12 or more Dietetics 0.28 or more Occupational Therapy 1.365 or more Physiotherapy 1.61 or more Speech & Language Therapy 0.705 or more Pharmacy 0.26 or more 6 or 7 day working for occupational therapy, physiotherapy, speech and language therapy 6 or 7 day working for at least 2 disciplines Score domain 4 100 * The scoring and position in the quartiles for each of the specialties is based on the 2012 site variation. p30

Domain 5 - TIA/ Neurovascular clinic My site’s score: Lower scores Intermediate scores Higher scores 79 sites (42%) Scored 25-75.0 111 sites (58%) Scored 87.5-100 0 sites (0%) NA

Domain 5 - TIA/ Neurovascular clinic   Maximum score if, My Site TIA service can see, investigate & initiate treatment for all high-risk patients within 24 hours Same or next day (7 days a week) TIA service can see, investigate & initiate treatment for all LOW-risk patients within one week Within a week Usual waiting time to get carotid imaging (high-risk TIA) Usual waiting time to get carotid imaging (LOW-risk TIA) Score domain 5 100 p31

Domain 6 - Quality improvement, training & research My site’s score: Lower scores Intermediate scores Higher scores 54 sites (28%) Scored 14.3-64.3 102 sites (54%) Scored 66.1-92.9 34 sites (18%) Scored 96.4-100

Domain 6 - Quality improvement, training & research   Maximum score if, My Site Report on stroke service produced for trust board (e.g. on audit results) Yes Members of strategic group responsible for stroke Ambulance trust representative Clinician Patient representative PCT commissioner Social services Stroke Network representative Trust board member Funding for external courses available for nurses & therapists and at least 10 study days funded between April 2011 and March 2012 Clinical research studies 4 or more Score domain 6 100 p32

Domain 7 - Team meetings My site’s score: Lower scores Intermediate scores Higher scores 67 (35%) Scored 0-79.2 106 (56%) Scored 83.3-95.8 17 (9%) Scored 100-100

Domain 7 - Team meetings Maximum score if, My site   Maximum score if, My site Frequency of formal team meetings more than twice a week Members of the team Clinical Psychology Yes Dietetics Medicine (senior doctor) Nursing Occupational Therapy Physiotherapy Social Work Speech & Language Therapy All stroke unit inpatients discussed in the meetings Score domain 7 100 p33

Domain 8 - Communication with patients & carers My site’s score: Lower scores Intermediate scores Higher scores 48 (25%) Scored 12.5-62.5 112 (59%) Scored 64.1-93.8 30 (16%) Scored 95.3-100

Domain 8 - Communication with patients & carers   Maximum score if, My Site Stroke units Outpatients Patient have access to their management plan (Q9.1) Yes on both Availability of patient information on each of the following topics for stroke units & outpatients (Q9.2) Patient version of national or local guidelines/standards Social services Benefits agencies Secondary prevention advice Patients are given a personalised rehabilitation discharge plan (Q9.3) Yes Formal links with patients and carers organisations on ALL of the following: services provision, audit, and service reviews and future plans (Q9.4). Community user group for stroke (Q9.5) Policy to give patients a named contact on transfer from hospital to the community (Q9.6) Patient/carer views sought on stroke services (Q8.6) Continuous or more than 4 times a year Report produced within past 12 months which analysed views of patients (Q8.7) Score domain 8 100 p34

Total Organisational Score Lower scores Intermediate scores Higher scores 48 sites (25%) Scored 11.5-66.6 95 sites (50%) Scored 66.6-80.4 47 sites (25%) Scored 80.4-97.5 P24, p26 My total organisational score = In 2010 my site was in the Lower quartile/Middle half/Upper quartile In 2012 my site was in the Lower quartile/Middle half/Upper quartile

Total Organisational Score Summary of domain scores Lower scores Intermediate scores Higher scores My Site D1 Acute care organisation* 67 sites (35%) scored 0-62.5 81 sites (43%) scored 66.7-75.0 42 sites (22%) Scored 87.5-100 D2 Organisation of care 56 sites (29%) Scored 0-45.0 89 sites (47%) Scored 50.0-80.0 45 sites (24%) Scored 85.0-100 D3 Specialist roles 66 sites (35%) Scored 0-60.0 78 sites (41%) Scored 62.5-80.0 46 sites (24%) Scored 81.3-100 D4 Interdisciplinary services (Stroke Unit) 54 sites (29%) Scored 0-42.5 96 sites (51%) Scored 45.0-65.0 40 sites (21%) Scored 67.5-87.5 D5 TIA/ Neurovascular clinic 79 sites (42%) Scored 25-75.0 111 sites (58%) 0 sites (0%) NA D6 Quality improvement, training & research 54 sites (28%) Scored 14.3-64.3 102 sites (54%) Scored 66.1-92.9 34 sites (18%) Scored 96.4-100 D7 Team meetings Scored 0-79.2 106 sites (56%) Scored 83.3-95.8 17 sites (9%) Scored 100-100 D8 Communication with patients & carers 48 sites (25%) Scored 12.5-62.5 112 sites (59%) Scored 64.1-93.8 30 sites (16%) Scored 95.3-100 Organisational audit total score Scored 11.5-66.6 95 sites (50%) Scored 66.6-80.4 47 sites (25%) Scored 80.4-97.5 p24

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