1. SESSION 1: Responding to Unwarranted Clinical Variation: A Case Study Leanne Ovington Director of Nursing and Midwifery, Moruya and Batemans Bay Hospitals, Southern NSW LHD Catherine Barkley Allied Health Manager, Eurobodalla Community Health Service, Southern NSW LHD

2. A Local Stroke Service Response to Identification of Variation In Stroke Care Leanne Ovington, Director of Nursing and Midwifery, Moruya and Batemans Bay Hospitals; and Catherine Barkley, Allied Health Manager, Eurobodalla Community Health Service

3. Background ACI clinical variation audit at Batemans Bay Hospital in August 2013 identified issues with access to early diagnostics, access to speciality services, and complication rate in stroke patients Clinician concern locally regarding care of stroke patients, recent discussion at clinical case review meetings Audit results and joint presentation by ACI and BHI; –provided “evidence of a problem worth solving” –opportunity to focus on specific areas of clinical care –raised profile of stroke care with key clinicians

4. Possible solutions Multi-disciplinary working party (our stroke service!) was formed to review the audit and develop an action plan. Solutions were identified such as introducing a complex clinical pathway for the entire stroke journey, formal policies to refer to speciality services and education for clinical staff. Other issues were considered including lack of resources required locally for the complex clinical stroke pathway (i.e. CT and allied health access). Working party planned to develop pathway for initial stage (ED and first 24 hours on ward) in the first instance

5. Aim Improving the care of stroke patients who present to Emergency Departments in Eurobodalla Hospitals by introducing a standardised pathway for clinical care; Increasing the number of patients who access speciality services.

6. Intervention Plan Review of pathways from other services Local pathway developed was specific to local resources available Stakeholder input (including GPs, VMOS and Specialists) Pathway champion training ACI Education days held locally, over 100 local clinicians attended Launch with “stroke week”

8. Pathway compliance audit April 2014% (n) n=15 Comparison to UCV audit result August 2013 % (n) n =11 Full set of observations recorded100% (15) BSL recorded73% (11) GCS recorded87% (14) Oxygen applied86% (13) Initial appropriate tertiary hospital consultation80% (12) Dysphagia screen or NBM within 4 hours73% (11) Speech Pathology referral53% (8)63% (7) Aspirin administered/Aspirin not applicable66 % (10)20% (2) ECG recorded93% (14)91% (10) Urgent CT organised locally within 24 hours.73% (11)73% (8) Carotid imaging6% (1)18% (2) Admitted locally 40% (6)Only admitted patients included Transfer other facility 73% (11)0

9. Results Pathway compliance audit completed in April 2014, although tool was significantly different to UCV audit some comparisons can be made. No improvement to imaging within 24 hours however some patients may have received CT in the tertiary centre after transfer. Although the number of allied health referrals did not seem to improve the pathway audit looked at first 24 hours, clinical variation audit commented that timeliness needed to improve Aspirin administration in first 24 hours improved Of the 6 admitted to Batemans Bay Hospital 4 were discharged home, 2 later transferred and 2 deceased, in the UCV audit 2 were discharged home, 3 to rehab and 4 to aged care facilities. Of significant note is that 80% of patients at Batemans Bay Hospital had an initial tertiary hospital consultation in the emergency department in the pathway compliance audit

10. Conclusion Another clinical variation audit needs to occur to determine any improvement however assumptions can be made that if compliance with pathway is improved, clinical variation will decrease and outcomes will also improve.