1. Moving Forward from the Sentinel Stroke Audit Tony Rudd Royal College of Physicians, London

2. or…. How to Use the Audit Data to Improve Stroke Care?

3. History of Stroke Audit in England/Wales and Northern Ireland  Intercollegiate Stroke Working Party established 1995  1 st audit 1998  Every 2 years since then with round 6 happening now  Evolution of audit questions over time but core dataset remained unchanged to enable year on year comparisons  100% participation since round 3  Public release of data since round 4

4. National Stroke Audit  5 cycles audit completed  Auditing Organisation of Care and Clinical Process. Not Outcome  Retrospective case note audit done every 2 years  Consecutive admissions over defined time period  Auditing against standards defined by  National Clinical Guidelines  Intercollegiate Stroke Working Party  NSF for Older People Standard 5  National stroke Strategy

5. National Stroke Audit  100% participation in England, Wales and Northern Ireland  Reports back to clinicians within 2 months of data submission  Benchmarked against national standards and other hospitals  Separate reports for  Countries  SHAs  Parliamentarians

6. How Precise Does One Measure of Performance Need To Be? To detect small differences reliably  over time  between units for example:  to confirm an increase in % given aspirin (50% to 80%) - 80pts  to confirm an increase in % admitted to stroke unit (50% to 60%) -800pts  to confirm a 4% absolute difference in mortality (24% to 20%) - 3400pts Martin Dennis (Personal Communication)

7. Early Stroke Audit Results (1998/9)  18% of patients through stroke unit  23% cognitive assessment  44% visual fields recorded  55% rehabilitation goals set  41% G.P. contacted within 3 days of discharge

8. Increase as a result of audit New stroke unit8 Increase in size of stroke unit6 Consultant stroke physician10 Specialist nurse for stroke10 Physiotherapists6 Occupational therapist5 Interdisciplinary care pathways30 Multidisciplinary documentation39 Information for patients and relatives52 Effect of First Audit

9. 12 Key Indicators over Time 2002 (%)2004 (%)2006 (%) Stroke Unit364662 >50% time SU274054 Swallow screen <24 hours 646366 Brain scan <24 hours 585942 Aspirin < 48 hours656871 PT < 72 hours596371

10. 12 Key Indicators over Time 2002 (%)2004 (%) 2006 (%) Weighed495257 Mood assessed by discharge 524755 Antithrombotic by discharge 9195100 Rehab goals documented 616876 Home visit736963 Average for 12 indicators 576165

11. Stroke: Aggregated Audit Score: Country Comparison

12. Variable performance within SHAs

13. Using National Audit to Effect Change  Regional Workshops  Slide toolkits  Performance indicators  Publicity and peer reviewed publications  Providing information to general public  Peer review  Informing policy

14. Stroke Workshops  Up to 17 regional workshops after each cycle of audit  Local and national presentations with examples of good practice and how to effect change

15. Slide Toolkits e.g. Mean % Patients having brain scan within 24 hours of stroke 28 42 33

16. Performance Management  Healthcare Commission uses for performance indicators  To identify ‘problem trusts’  Peer review

17. Publicity  Any publicity is good publicity  Press releases after each audit  Bad news works better! “I’ve been trying to get the trust to offer scanning for stroke patients for 5 years, within a day of receiving the audit report the chief executive had convened a meeting with stroke service and radiology” A stroke physician after publication of performance indicators 2004 audit  Peer reviewed publications

18. Peer Review  Detailed documentation submitted by the trust before the visit  1-2 day visit from multidisciplinary team including patient representative, manager, physician, therapists, nurses  Oral feedback at end of visit  Written report  1 year follow-up questionnaire

19. The Peer Review Process Trust approaches BASP or RCP Steering Group appoints visit Chairman Terms of Reference are agreed Preliminary data are requested 1 2 3 4

20. The Peer Review Process Chairman constitutes Visit Team Previsit data reviewed; Arrangements for visit agreed One-day visit takes place Report is completed and returned to the Trust 5 6 7 8

21. Peer Review  Targeting hospitals performing less well on audit  Invited visits to hospitals  Trusts pay to cover the costs  Only with the specific agreement of senior management  Defined topic for review e.g. acute care/TIA services/ Rehabilitation/Early Supported Discharge

22. Informing Policy  E.g. DH Stroke Strategy, National Audit Office, National Service Frameworks  Welsh Assembly

23. National Audit Office 2005 Highly critical of stroke services in England  Low levels of knowledge about stroke  Variability of services around the UK  Inadequate access to acute care  Difficulty getting urgent brain imaging  Low levels of specialist stroke staff  Discharge and longer term care problems  Management of TIA

25. TIA and Minor Stroke

26. Case History: Transient Ischaemic Attack  20 year old woman  Right sided weakness; full resolution in 1 hour  Initial CT normal

27. MRI Diffusion Weighted Image at 24 Hours

28. CT Angiogram

29. Neurovascular clinics England, Northern Ireland and Islands (218 sites) Wales (20 sites) Neurovascular clinic 81% (177)45% (9) Service which enables patients seen and investigated within 7 days 36% (79)15% (3)

30. Key Recommendations: TIA and Minor Stroke  Immediate aspirin  Immediate referral for urgent specialist assessment and investigation (base level of urgency on ABCD 2 score e.g. 4 or greater within 24 hours)  Lower risk TIA (ABCD 2 <4) patients within 7 days  If symptoms not resolved when first seen take directly to acute stroke service

31. Key Recommendations: TIA and Minor Stroke  Access to carotid imaging  Carotid surgery should be regarded as urgent procedure and should be performed within 48 hours of symptom onset (7 days in NICE guidance)  Where brain imaging required use MR DWI and available within 24 hours  Follow-up one month after the event

32. Possible Model for TIA Management  Admit high risk TIA patients or see same day on CDU  Carotid dopplers and MRI where indicated  Maybe suitable for thrombolysis if stroke while in hospital  Twice weekly clinics with no waiting list  Same day brain and carotid imaging  Cooperative hard working vascular surgeons!  Maximum 2 week wait (from symptoms) for carotid endarterectomy 48 hours Stoke Strategy)

33. ‘Hyper-acute’ Care