1. Learn more about stroke Free on line e-learning resource www.strokecorecompetencies.org

2. Scottish Stroke Care Audit Annual Meeting 24 th June 08 RCPE

3. Acknowledgements Robin Flaig Mike McDowall Audit coordinators Contributing clinicians and managers Margaret Farquhar & team RCPE

4. Menu A Scottish perspective Performance of individual hospitals 2005 – 2007 learning lessons from good and bad practice –Inpatients –Outpatients Swallowing - Karen Krawczyk Plans to review NHSQIS standards Future plans for the audit Tea Carotid endarterectomy

5. Reasons for variation in “Performance” Method of collection data Definitions, case ascertainment and audit period Method of analysing data Which numerator and denominator Chance Actual performance of service

6. Proportions Numerator / Denominator = Proportion 100 patients admitted 60 enter stroke unit Proportion is 60/100 = 0.6 or 60% NHS QIS ask % admitted SU within 1 day Denominator is 100 for NHSQIS standards? Most challenging

7. Data Quality Complete ascertainment? Data extraction? –Finding info –Clinical support Keeping up to date

8. National Performance

9. Comparisons between hospitals Inpatients

10. Stroke unit care

11. Organised inpatient (stroke unit) care Absolute outcomes at 6-12 months -3 (-6, -1)*26 %22 %Dead -2 (-5, 0)*20 %18 %Institutional care 0 (-2, 3)16 % Home (dependent) 5 (1, 8)*38 %44 %Home, (independent ) Risk difference ControlStroke unit Outcome SUTC (2001)

12. Mean delay (days) from admission to entry into any Stroke Unit

13. % of patients admitted to a Stroke Unit ≤ 2 days of admission (NHS QIS Standard = 70%)

14. % of patients admitted to a Stroke Unit ≤ 2 days of admission (NHS QIS Standard = 70%)

15. How did you improve access? Direct admissions? Day & night? Medical staffing out of hours? Do you have a medical assessment unit? How many beds for how many admissions? Fixed bed numbers or flexible? Ring fenced beds? How do you clear your beds?

16. Why is access getting worse? Lack of SU beds? Filled with non stroke patients? Problems with discharge?

17. Swallow screen

18. Why screen for swallowing problems 50% of patients cannot swallow safely Increased risk of pneumonia & death Need for fluids Need for nutrition – modified diet or tube Need for medication

19. Mean delay (days) from admission to Swallow screen

20. % of patients with a Swallow screen on day of admission (NHS QIS Standard = 100%)

21. How did you improve performance? Who does the screening? How were they trained? Where do they do it? How is it documented? Are they missing cases?

22. Brain scanning

23. To exclude alternative diagnoses To distinguish haemorrhage and infarction To allow safe use of antithrombotic treatment

24. Mean delay (days) from admission to Scan

25. % of patients Scanned ≤2 days of admission (NHS QIS = 80%)

26. Brain scanning Most places with a scanner meet NHSQIS standards HTA review suggested immediate scan is most cost effective timing English strategy emphasises earlier scanning ? A case for changing the NHSQIS standard

27. Early aspirin use

28. Effect of two weeks of aspirin in acute ischaemic stroke Treat 1000 patients 9 avoid recurrence 12 avoid death or dependency 10 more make a complete recovery

29. Effect of aspirin in acute stroke: hours from stroke onset

30. % of patients with Ischaemic event given Aspirin ≤2 days of admission (NHS QIS Standard = 100%)

31. Almost everyone is improving? Protocol or ICP? Rapid scanning? No scanning? Immediate reporting or PACS on ward? Nurse prescription?

32. Blood pressure lowering after stroke

33. PROGRESS - Stroke All participants Proportion with event Follow-up time (years) 28% risk reduction 95%CI 17 - 38% p<0.0001 0.00 0.05 0.10 0.15 0.20 01234 Placebo Active

34. % of stroke patients discharged alive on any anti-hypertensive medication

36. Why such variation in blood pressure lowering? Chance – low numbers? Different views on risks vs benefits? Preferring to start after discharge Different levels of co-morbidity? Presence or absence of protocols? Data collection?

37. Antiplatelet or anticoagulant treatment after ischaemic stroke

38. Absolute effects of antiplatelet treatment - % with vascular events Treat 1000 36 avoid event in 29 months Treat 1000 9 avoid event in 2 weeks

39. % of Ischaemic patients discharged on Antiplatelet, Warfarin

41. Lowering cholesterol after ischaemic stroke

43. % discharged on statin

44. Warfarin for patients with ischaemic events and Atrial Fibrillation

45. Effect on stroke risk in the randomised trials of warfarin vs aspirin in fibrillating patients (Hart et al 1999)

46. % of Patients in AF discharged on Warfarin

47. Why such variation in Warfarin use? Chance – low numbers Different views on risks vs benefits Delaying treatment till after discharge Different levels of co-morbidity Variation in quality of anticoagulation service

48. Outpatients

49. High early risk of stroke after TIA 0 2 4 6 8 10 12 14 07 2128 Days Risk of stroke (%) OXVASC OCSP Lancet 2005; 366: 29-36 10% risk of stroke by 7 days

50. EXPRESS: Clinic-referred population 0 2 4 6 8 10 0306090 Days from medical attention Risk of stroke (%) P<0.0001 Slow clinic Same day clinic

51. Mean (days) from receipt of referral to examination

52. Patients with Days from receipt of referral to examination <14 days – NHS QIS (80%)

53. Patients with Days from receipt of referral to examination <7 days - NHS QIS (80%)

54. How do you do it? Method of getting referrals? Management of clinic slots? Number of clinic slots – capacity? Informing patients of appointments

55. Delays in accessing Neurovascular clinic Is the NHSQIS standards of 14 days out of date?

56. Mean (days) from examination to 1st Carotid Duplex

57. Mean days from Examination to Brain Scan, for Scan done

58. NHS QIS swallowing Karen Krawczyk

59. Reviewing NHS QIS standards

60. Plan Raise the standards to fit in with latest evidence and SIGN guidelines –Earlier scanning -? 80% in 1 day –Earlier access to SU - ? 80% in 1 day –Earlier access to Neurovascular clinics – 90% in 7 days –Target for thrombolysis –Targets for applying secondary prevention Publish revised criteria with SIGN guidelines in Dec 08 Scope major revision to cover whole patient pathways – aim 2010

61. Consultation on the “Refreshed Stroke Strategy”

62. Future plans for audit ISD taking over management of audit Possible restructuring –Local data entry and storage as now but download into central data repository –Allow local data analysis –Quality assurance and linkage easier –Easier maintenance of software

63. Other stroke related national audits SAIVMS – an audit of the management of Intracranial vascular malformations SCIP – using routine data to monitor survival after carotid intervention SHARE – a planned audit to monitor delivery of thrombolysis in Scotland

64. Scottish Hyperacute stroke Activity Register and Evaluation (SHARE) Aims to monitor introduction of thrombolysis services in Scotland Funded by Scottish Government for 2 yrs Lead by Peter Langhorne Collect minimum dataset on each treated patient Allow data entry by several means –SSCAS –Web –SITS

65. Tea

66. Oxford, England Henry Barnett London, Ontario Melbourne November, 2000 Carotid surgery

68. The vast majority of TIA patients do not get near a surgeon! 1000 TIA patients 300 recognised by GP and referred to hospital 40 with severe stenosis 500 present to medical attention 250 in the carotid territory 30 willing to take risk of surgery

69. The effectiveness of surgery with increasing delays 32.7 16.0 11.2 9.4 13.8 3.4 0.0 -2.9 -20.0 -10.0 0.0 10.0 20.0 30.0 40.0 50.0 0-22-44-1212+ Weeks between symptomatic event and randomisation ARR (%), 95% CI 70-99%50-69%

70. Number patients who had a Carotid Interventions performed in 2007

71. Mean number of days from event to Carotid Surgery

72. Average delays (days) from event to surgery

73. Reducing delays to surgery in Lothian

74. Reducing the delays to carotid surgery Reducing delays to TIA assessment Streamline investigation –Same day confirmatory scan for significant stenosis –Agreed protocol with surgeons Faxed referrals Involving enough surgeons to ensure capacity Appropriate surgical prioritisation

75. Percentage of patients who Survived 30 days from intervention

76. % of patients who had a stroke within 30 day of a carotid intervention

77. Scottish Carotid Interventions Project (SCIP) Partnership between ISD and vascular surgeons Use of routine data to monitor survival after surgery Can link operations to subsequent events but accuracy unclear Aims to improve data quality over several cycles

78. Carotid endarterectomy Should we continue to monitor delays? Should we monitor outcomes? What is happening in rest of UK? –UK Carotid Endarterectomy Audit Should we set NHSQIS standard –80% operated within 30 days of referral to neurovascular services? –Median delay should be <20 days?

79. Other Issues Good to include audits of – all NV clinics –Thrombolysis –Carotid endarterectomy –Other aspects of care? Do we have the resources to do all of this?

80. Other Issues Should the final report contain a commentary on the results?

81. Learn more about stroke Free on line e-learning resource www.strokecorecompetencies.org

85. Percentage of Ischaemic patients discharged on a Statin or in a relevant Trial