Learn more about stroke

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Scottish Stroke Care Audit

Annual Meeting

24th June 08

RCPE

Acknowledgements

• Robin Flaig

• Mike McDowall

• Audit coordinators

• Contributing clinicians and managers

• Margaret Farquhar & team RCPE

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

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

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

Data Quality

• Complete ascertainment?

• Data extraction?– Finding info– Clinical support

• Keeping up to date

National Performance

72

5144

78

57

77

56 51

86

6670

100

80

100

0

20

40

60

80

100

120

SU

SU<1d

Swal

l <1d

CT <2

d

Aspiri

n <2d

2005 2007 NHSQIS

Comparisons between hospitals

Inpatients

Stroke unit care

Organised inpatient (stroke unit) careAbsolute outcomes at 6-12 months

-3 (-6, -1)*26 %22 %Dead

-2 (-5, 0)*20 %18 %Institutional care

0 (-2, 3)16 %16 %Home (dependent)

5 (1, 8)*38 %44 %Home, (independent)

Risk differenceControlStroke unitOutcome

SUTC (2001)SUTC (2001)

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

Hospital

8

7

6

5

4

3

2

1

0

Mean (

days)

20052007

Year

Hospital

100

80

60

40

20

0

Perc

enta

ge

20052007

Year

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

Hospital

100

80

60

40

20

0

Perc

enta

ge

20052007

Year

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

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?

Why is access getting worse?

• Lack of SU beds?

• Filled with non stroke patients?

• Problems with discharge?

Swallow screen

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

Mean delay (days) from admission to Swallow screen

Hospital

5

4

3

2

1

0

Mean d

ays

to S

wallo

w s

creen

2005

2007

Year

% of patients with a Swallow screen on day of admission

(NHS QIS Standard = 100%)

Hospital

100

80

60

40

20

0

Perc

enta

ge

20052007

Year

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?

Brain scanning

Brain scanning

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

Mean delay (days) from admission to Scan

Hospital

Scotlan

d

Wes

tern

Isles

Shetlan

d

Orkne

y

VH, K

irkca

ldy

QMH

Caithne

ss

Belfo

rd

Lorn

& Is

lands

Raigmor

eDGRI

Bord

ers

Forth

Vall

ey

Wish

aw

Monkla

nds

Hairmyr

es

Crossh

ouse

AyrVO

LRAH

IRH

SGH

WI,

Glasgo

w

Stob

hill

RI, G

lasgow

WGH

SJH

RIE

PRI

Ninew

ells

ARI

7

6

5

4

3

2

1

0

Mean (

days)

20052007

Year

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

Hospital

100

80

60

40

20

0

Perc

enta

ge

20052007

Year

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

Early aspirin use

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

Effect of aspirin in acute stroke: hours from stroke onset

% of patients with Ischaemic event given Aspirin ≤2 days of admission

(NHS QIS Standard = 100%)

Hospital

100

80

60

40

20

0

Perc

enta

ge

20052007

Year

Almost everyone is improving?

• Protocol or ICP?

• Rapid scanning?

• No scanning?

• Immediate reporting or PACS on ward?

• Nurse prescription?

Blood pressure loweringafter stroke

PROGRESS - StrokeAll participants

Pro

por

tion

wit

h e

ven

t

Follow-up time (years)

28% risk reduction95%CI 17 - 38%

p<0.0001

0.00

0.05

0.10

0.15

0.20

0 1 2 3 4

PlaceboActive

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

Hospital

100

80

60

40

20

0

Perc

enta

ge

20052007

Year

% of stroke patients discharged alive on any anti-hypertensive

medication

Hospital

100

80

60

40

20

0

Perc

enta

ge

20052007

Year

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?

Antiplatelet or anticoagulant treatment after ischaemic

stroke

Absolute effects of antiplatelet treatment - % with vascular

events

0

5

10

15

20

25

Acute stroke Secondary prevention

AntiplatletControl

Treat 100036 avoid event in 29 months

Treat 10009 avoid event in 2 weeks

% of Ischaemic patients discharged on Antiplatelet, Warfarin

Hospital

100

80

60

40

20

0

Perc

enta

ge

20052007

Year

% of Ischaemic patients discharged on Antiplatelet, Warfarin

Hospital

100

80

60

40

20

0

Perc

enta

ge

20052007

Year

Lowering cholesterol after ischaemic stroke

% discharged on statin

Hospital

100

80

60

40

20

0

Perc

enta

ge

20052007

Year

Warfarin for patients with ischaemic events and Atrial

Fibrillation

Effect on stroke risk in the randomised trials of warfarin vs aspirin in fibrillating patients

(Hart et al 1999)

% of Patients in AF discharged on Warfarin

Hospital

100

80

60

40

20

0

Perc

enta

ge

20052007

Year

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

Outpatients

High early risk of stroke after TIA

0

2

4

6

8

10

12

14

0 7 14 21 28

Days

Ris

k o

f st

roke

(%

)

OXVASC

OCSP

Lancet 2005; 366: 29-36

10% risk of stroke by 7 days

EXPRESS: Clinic-referred population

0

2

4

6

8

10

0 30 60 90

Days from medical attention

Ris

k o

f st

roke

(%

)

P<0.0001

Slow clinic

Same day clinic

Mean (days) from receipt of referral to examination

Hospital

50

40

30

20

10

0

Mean (

days)

20052007

Year

Patients with Days from receipt of referral to examination <14 days

– NHS QIS (80%)

Hospital

100

80

60

40

20

0

Perc

enta

ge

20052007

Year

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

Hospital

100

80

60

40

20

0

Perc

enta

ge

20052007

Year

How do you do it?

• Method of getting referrals?

• Management of clinic slots?

• Number of clinic slots – capacity?

• Informing patients of appointments

Delays in accessing Neurovascular clinic

• Is the NHSQIS standards of 14 days out of date?

Mean (days) from examination to 1st Carotid Duplex

Hospital

30

25

20

15

10

5

0

Mean (Days)

20052007

Year

Mean days from Examination to Brain Scan, for Scan done

Hospital

50

40

30

20

10

0

Mean (Days)

20052007

Year

NHS QIS swallowing

Karen Krawczyk

Reviewing NHS QIS standards

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

Consultation on the “Refreshed Stroke Strategy”

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

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

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

Tea

Oxford, EnglandHenry Barnett

London, Ontario

MelbourneNovember, 2000

Carotid surgery

The vast majority of TIA patients do not get near a surgeon!

1000TIA patients

300recognised by GP

and referred tohospital

40with severe

stenosis

500present to

medical attention

250in the carotid

territory

30willing to takerisk of surgery

The effectiveness of surgery with increasing delays

32.7

16.0

11.2 9.413.8

3.4

0.0 -2.9

-20.0

-10.0

0.0

10.0

20.0

30.0

40.0

50.0

0-2 2-4 4-12 12+

Weeks between symptomatic event and randomisation

AR

R (

%),

95

% C

I

70-99% 50-69%

Number patients who had a Carotid Interventions performed in 2007

60

50

40

30

20

10

0

Num

ber

of patients

Mean number of days from event to Carotid Surgery

180

160

140

120

100

80

60

40

20

0

Mean (days)

Average delays (days) from event to surgery

0.0

20.0

40.0

60.0

80.0

100.0

120.0

ARI

Ninewel

ls PRI

Straca

thro

Tays

ide O

ther

sou

rces RIE

St Joh

nsW

GH

RI-G

Stobh

illW

I-GSGH

IRH

RAH Ayr

Cross

house

Hairm

yres

Forth

Valle

y

Borde

rsDGRI

Raigm

ore

QMH

VH, Kirk

caldy

Scotla

nd

Me

dia

n d

ela

y (

da

ys

)

seen to op

referral to seen

exam to referral

event to exam

Reducing delays to surgery in Lothian

17 19

7 4

77

32

14 11

9

6

9

20

8

8

0

10

20

30

40

50

60

2004 2005 2006 2007

Year

Med

ian

del

ay (

day

s)

Event to exam Exam to ref Ref to seen Seen to surg

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

Percentage of patients who Survived 30 days from intervention

100

80

60

40

20

0

Hospital

Perc

enta

ge

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

50

40

30

20

10

0

Str

oke

within

30 d

ays

of in

terv

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

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?

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?

Other Issues

• Should the final report contain a commentary on the results?

Learn more about stroke

Free on line e-learning resource

www.strokecorecompetencies.org

Percentage of Ischaemic patients discharged on a Statin or in a

relevant Trial

Hospital

100

80

60

40

20

0

Perc

enta

ge

20052007

Year