Stroke Services in Scottish Hospitals · 2016-08-03 · 2012 National Report - Stroke Services in...

2012 National ReportStroke Services in Scottish Hospitals

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2012 National Report - Stroke Services in Scottish Hospitals

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Contents

List of Tables and Charts .............................................................................. ii

Map of Scotland showing all hospitals in Health Boards contributing to the Scottish Stroke Care Audit ............................................................... iii

1. Introduction ............................................................................................... 11.1 Organisational structure of the Scottish Stroke Care Audit ..................................... 31.2 This report ............................................................................................................... 4

2 Future Plans .............................................................................................. 82.1 What have we achieved in 2011-2012? .................................................................. 82.2 What’s next in 2012-2013? ................................................................................... 10

3 Inpatients ..................................................................................................113.1 Summary and key findings relating to inpatient data ............................................ 113.2 Stroke Unit Information ......................................................................................... 133.3 Hospital Data ........................................................................................................ 17

4 Outpatients .............................................................................................. 264.1 Summary and key findings relating to outpatient data .......................................... 264.2 Hospital data ......................................................................................................... 26

5 Anticoagulation ....................................................................................... 285.1 Inpatient data ........................................................................................................ 285.2 Outpatient data ..................................................................................................... 31

6 Thrombolysis ........................................................................................... 32

7 Case Studies: Improving the quality of stroke care in Scotland ........ 367.1 NHS Fife ............................................................................................................... 367.2 NHS Lothian.......................................................................................................... 387.3 NHS Western Isles ................................................................................................ 40

8 Use of SSCA data in research ................................................................ 418.1 Comparison of routine hospital admissions data with SSCA data – an overview .... 418.2 Comparison of routine hospital admissions data with SSCA data

in NHS Grampian .................................................................................................. 438.3 Scottish Stroke Research Network ....................................................................... 45

List of References ....................................................................................... 46

Appendix A: Managed Clinical Networks .................................................. 47

Appendix B: Additional Information .......................................................... 55

Acknowledgements ..................................................................................... 56

Contacts ....................................................................................................... 57


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List of Tables and ChartsTable/ Chart

NumberTitle Page

NumberTable 1 Stroke Unit Information. 13Table 2 Ischaemic stroke patients with current atrial fibrillation (AF) and anticoagulation on

admission or discharge, 2011 data.28

Table 3 Haemorrhagic stroke patients with current atrial fibrillation (AF) and anticoagulation on admission or discharge, 2011 data.

29

Table 4 Patients with ischaemic diagnosis, seen in neurovascular clinics, with current atrial fibrillation (AF) and on anticoagulation, 2011 data.

30

Table 5 Thrombolysis - numbers thrombolysed by Board and hospital, 2009-2011 data. 32Table 6 Thrombolysis - numbers thrombolysed and crude rate per 100,000 by Health Board of

residence of patient, 2011 data.34

Table 7 Thrombolysis - numbers thrombolysed as percentage of stroke patients, Scotland, 2008-2011.

34

Table 8* NHS Lothian audit of brain imaging of all acute stroke patients: May 2011. 31Chart 1 (Health Board) Percentage of stroke patients eligible for HEAT target and admitted to

a Stroke Unit within 1 day of admission using HEAT target definition, 2010 and 2011 data.6

Chart 2 ‘Bundle’ analysis for patients eligible for HEAT target - percentages who also receive swallow screen, brain imaging and aspirin within NHS QIS standards, 2011 data (based on initial diagnosis).

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Chart 3 (Hospital) Length of stay for stroke patients - percentage of stay in Stroke Unit and percentage of patients admitted to a Stroke Unit during their stay, by hospital, 2011 data (based on final diagnosis).

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Charts 4a-4o Performance against NHS QIS standards, by Health Board, 2010 and 2011 data. 18Chart 5 Percentage of stroke patients admitted to Stroke Unit by number of days to Stroke Unit

admission, 2011 data.23

Chart 6 Percentage of stroke patients with a swallow screening by number of days to swallow screening, 2011 data.

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Chart 7 Percentage of stroke patients with a brain scan by number of days to scanning, 2011 data.

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Chart 8 Percentage of stroke patients with a brain scan by number of hours to scan compared to percentage scanned same day, 2011 data.

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Chart 9 Percentage of acute ischaemic patients given aspirin in hospital by number of days to receipt, 2011 data.

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Chart 10 Percentage of ischaemic patients given aspirin or alternative antiplatelets within 1 day of admission, 2011 data.

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Chart 11 Percentage of patients with definite cerebrovascular diagnosis seen in neurovascular clinic with referral to examination time (days): same day and within 1, 2-3 and 4-7 days, 2011 data.

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Chart 12 Percentage of total days from last event to examination showing components: event-to-referral, referral-to-referral-received, referral-received-to-appointment, appointment-to-examination, 2011 data.

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Chart 13 Percentage of eligible stroke patients thrombolysed within one hour of arrival at hospital, by admitting hospital, 2011 data.

35

Chart 14* NHS Fife Bundle analysis. 38Chart 15* Percentage of total by data source, 2006 - 2009. 43Figure 1* Distribution of stroke records for Scotland between the SSCA and SMR01. 42

* Table 8, Chart 14, Chart 15 and Figure 1 are sourced from other Health Boards rather than ISD and are only available to view in the main report.

† Some of the tables in this Excel workbook have analogous 2010 analyses for comparison with 2011.


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Map of Scotland showing all hospitals in Health Boards contributing to the Scottish Stroke Care Audit


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1. Introduction“Stroke, along with heart disease has been a clinical priority for NHS Scotland for over 15 years. Our Better Heart Disease and Stroke Care Action Plan, which I launched in 2009, reflects our commitment to improving all aspects of stroke care and sets out a wide ranging series of measures to achieve this aim. Our approach is paying dividends. We have exceeded the target of achieving a 50% reduction in the rate of premature deaths from stroke over the 15 years from 1995. I would like to take this opportunity to highlight the dedication, commitment and hard work of all NHSScotland staff who have contributed to this fantastic achievement.The audit data for 2012 shows continued improvement in stroke care, however while this progress is encouraging, we recognise that there remains more to do.We expect that the HEAT target for stroke unit admissions, introduced in April 2011, will help ensure that people get access to specialist stroke care as soon as possible, which

has been shown to improve outcomes for people who’ve had a stroke. The HEAT target requires that by March 2013, 90% of all patients admitted to hospital with a diagnosis of stroke are admitted to a stroke unit on the day of admission, or the day following presentation. This year’s audit is the first time that data on the target have been made available and these show Health Boards are making steady progress towards meeting it which will undoubtedly help reducing premature mortality, reduce disability and help people live longer, fuller lives.These data also show welcome improvements in access to stroke thrombolysis and pre-hospital care and I look forward to seeing further improvements in these areas in future years.The information contained in this Scottish Stroke Care Audit report represents a powerful driver for change. I expect each Health Board to continue to work with their stroke Managed Clinical Network and use the audit to drive continuous improvement in all aspects of stroke care.”

Nicola Sturgeon, Deputy First Minister and Cabinet Secretary for

Health, Wellbeing and Cities Strategy May 2012

Stroke is a key health issue for the people of Scotland and the Scottish NHS. It is the third commonest cause of death in Scotland and the most common cause of severe physical disability amongst Scottish adults. About 13,000 people in Scotland have a stroke each year and more than 3,000 of them are under 65 years of age. Stroke patients occupy 7% of all NHS beds and their health care costs at least £100million per year – around 5% of the entire Scottish NHS budget.

The economic cost of stroke to Scotland in terms of lost employment and the cost of support in the community is significant, whilst the impact on family members or friends who care for stroke survivors is huge.


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The evidence for the benefits of organised specialist stroke care in improving outcomes is clear. The Scottish Stroke Care Audit (SSCA) has been collecting information about stroke care since 2002 and includes all hospitals managing acute stroke in Scotland. Since its inception the SSCA has helped to drive evidence-based improvements in stroke care which have contributed to falling mortality rates and improved outcomes for Scottish stroke patients.

The first report containing SSCA data was published in 2005. There have been significant improvements since then in the number of patients admitted to a Stroke Unit at any time during their admission, an increase from 71% to 87%.

There have been other significant improvements against NHS Quality Improvement Scotland (QIS)* standards between 2005 and 2011:

● The percentage of stroke patients admitted to a Stroke Unit on day of admission has increased from 28% to 45%.

● The percentage of stroke patients admitted to a Stroke Unit by the day following admission increased from 49% to 72%.

● The percentage of stroke patients who had brain imaging on day of admission has increased from 27% to 57%.

● The percentage of stroke patients who had a swallow screen on day of admission has increased from 47% to 65%.

● The percentage of patients who had an ischaemic stroke who were prescribed aspirin by one day after admission has increased from 41% to 72%.

● The percentage of patients who were seen within 7 days from referral at a specialist neurovascular clinic has increased from 30% to 83%.

*NB: Healthcare Improvement Scotland (HIS) took over responsibilities of NHS QIS on 1st April 2011.

The Scottish Government recognises the key role of the SSCA in measuring performance against the national stroke care standards and monitoring Health Boards’ progress against the 2009 Better Heart Disease and Stroke Care Action Plan’s aims1. The SSCA publishes an Annual National Report which is sent to Health Boards, Healthcare Improvement Scotland (HIS) and the Scottish Government Health Department as well as being made publicly available on the SSCA website (http://www.strokeaudit.scot.nhs.uk/reports.html). In 2010 the SSCA started producing monthly reports for Stroke Managed Clinical Networks (MCNs) in Health Boards and individual hospitals to ensure awareness of the stroke standards and facilitate timely review of local performance.

In April 2011 a government HEAT target for stroke was initiated: “By March 2013 90% of patients admitted with acute stroke should be in a Stroke Unit by the day after hospital admission”; there was an interim target of 80% by March 2012. The SSCA monitors Boards’ progress towards meeting the HEAT target, with quarterly reports to each Board. The SSCA data shows a steady improvement in performance towards this target, much of which has been achieved by local redesign of services with considerable work by all the teams involved.

The SSCA will continue to work with all Health Boards to monitor stroke service performance, develop new audit fields as treatment changes and progresses, and help NHS Scotland provide the best care possible for people who have had a stroke.

The purpose of this report is to summarise the SSCA data for 2011 in the context of both previous performance and national standards, and help drive further improvements in service provision.

Many improvements are already taking place - for example in section 7 you can read case studies detailing changes to the stroke services in Fife, Lothian and Western Isles. In Appendix A we detail

http://www.strokeaudit.scot.nhs.uk/reports.html


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the many actions being taken by Health Boards to achieve further improvements in the delivery of stroke care across Scotland. We hope you find the report interesting and informative.

Contributions to this reportThis years report has been written by members of the SSCA Report Writing Sub-Group of the Steering Committee with contributions from colleagues within Health Boards across Scotland. In section 7 we present a selection of case studies providing examples of work that has been carried out in Boards to improve the delivery of stroke care for patients.

Each Health Board has a Stroke MCN and the audit helps the MCNs plan the work required to improve their local stroke services. All the Stroke MCNs have active involvement from people who have had a stroke and from their families and friends; stroke survivors and their carers are encouraged to look at the audit information and comment on it. There is also lay and voluntary organisation representation on the SSCA Steering Committee and feedback from service users is very welcome.

1.1 Organisational structure of the Scottish Stroke Care Audit

The Scottish Stroke Care Audit is a national audit within the Scottish Healthcare Audits at the Information Services Division (ISD) of NHS National Services Scotland (NSS).The audit has its own Steering Committee reporting directly to the National Advisory Committee for Stroke (NACS) at the Scottish Government and providing strategic direction and clinical input to the audit team, optimising the use of the data. See the SSCA website (http://www.strokeaudit.scot.nhs.uk/about/SteerGp.htm) for details of the Steering Committee.

The organisational structure of the SSCA is:

Professor Martin Dennis Chairman of the Steering Committee

Hazel Dodds National Clinical Co-ordinator

Robin Flaig Quality Assurance Manager

David Murphy Senior Information Analyst

Lee Barnsdale Principal Analyst with IT responsibility

Alan Reekie Senior Information Analyst

Funding for the central coordination of the SSCA for 2012/13 is £117k provided by NACS. Funding for the SSCA data collection has been included in each Health Boards’ general allocation. Each Health Board is expected to continue to collect the audit data. Audit staff are employed in each Health Board and are supported by their Stroke MCN. Staffing levels vary widely between hospitals. Audit staff responsibilities include case ascertainment, data collection, completion of forms and data entry. In all Health Boards other than NHS Lanarkshire data are entered into the Scottish Stroke Care Audit System (SSCAS). In NHS Lanarkshire a locally developed system (Stroke Audit In Lanarkshire (SAIL)) is used to collect inpatient and outpatient data. Data from SAIL are sent directly to ISD on a monthly basis and are included in National Reporting. Data validation is built into the computer systems, with additional local validation at point of data entry.

The information presented in this report highlights the variation in the quality of stroke services across Scotland.

http://www.strokeaudit.scot.nhs.uk/about/SteerGp.htm

http://www.strokeaudit.scot.nhs.uk/about/SteerGp.htm


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1.2 This report

This years report includes data for 2011 for Scotland overall and for each individual hospital managing acute stroke patients in Scotland. The data presented in this report unless otherwise stated are based on final diagnosis of stroke and not initial diagnosis as in the Monthly Reports.

An overview of initial and final diagnosis of stroke is included in the web tables from SSCAS data (excluding those admitted in NHS Lanarkshire). In summary, of the 8,480 patients admitted during 2011 with a diagnosis of stroke (initial or final), 6,304 (74%) of these had an initial diagnosis of stroke which was then confirmed. 1,253 (15%) were admitted with an initial diagnosis of stroke which was not confirmed; 923 (11%) were not initially diagnosed as a stroke but had a final diagnosis of stroke.

Throughout 2011 the SSCA team continued to review the analysis of the data collected and modified definitions when necessary, therefore calculations in this years report may not match exactly those presented in previous reports. Individual hospitals’ data are displayed in charts. Supplemental detailed charts and tables for this report are available on the SSCA website (http://www.strokeaudit.scot.nhs.uk/reports.html).

There was an issue with data collection in the Western Isles in 2011 and when reviewed it was agreed that the data were incomplete and inaccurate in some areas. Due to this Western Isles inpatient data is not presented in the 2012 National Report. Outpatient and thrombolysis data have been included.

In addition to this main report a Public Summary of the National Report suitable for members of the public will be distributed to Health Boards and other interested organisations. It will also be available on the SSCA website.

1.2.1 NHS QIS standards 2009The NHS QIS standards for stroke care were revised in June 2009. The analyses contained in this report assess performance against these standards.

Topic NHS QIS standards for stroke care, June 2009Access to Stroke Unit services

60% on day of admission (Day 0) and 90% within 1 day of admission (Day 1)

Brain imaging 80% on day of admission (Day 0)Swallow screen 100% on day of admission (Day 0)Aspirin administration 100% of ischaemic strokes within 1 day of admission (Days 0 and 1)Delay from receipt of referral to specialist neurovascular clinic

80% are examined within 7 days of receipt of referral

Thrombolysis 5 patients treated per 100,000 population per year80% receive the bolus within one hour of arrival at hospital

Carotid Intervention (not collected/ reported in 2011. Data collection commenced July 2012.)

80% undergoing carotid endarterectomy for symptomatic carotid stenosis have the operation within 14 days of the most recent stroke event

These standards continue to focus on those parameters which have the best evidence for having an effect on patient outcomes.




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A review of the NHS QIS standards for stroke care is currently taking place. This will be undertaken by the SSCA Steering Committee in collaboration with Stroke MCNs and endorsed by NACS and HIS.

1.2.2 Stroke Care HEAT Target, 2011The SIGN guideline 1082 on the management of patients with stroke or transient ischaemic attack (TIA) emphasises the importance of getting patients to specialist stroke services quickly to allow prompt diagnosis and treatment. The Better Heart Disease and Stroke Care Action Plan1, suggests that there are a number of ways mortality could be reduced, including getting more people into a Stroke Unit within one day of their stroke, as there is good evidence that this improves survival.

A HEAT target related to admission to Stroke Unit was implemented on 1st April 2011 as at this point none of the Health Boards had met the NHS QIS standards for admission to a Stroke Unit.

What are HEAT Targets?HEAT targets are a core set of ministerial objectives, targets and measures for NHS Scotland. The targets are set each year after consultation with stakeholders and cover a variety of areas. Progress is measured throughout the year and Health Boards are held to account during annual review with the Scottish Government.

The key targets fall into four main areas:

Health Improvement – improving health and life expectancy;

Efficiency and Governance Improvements – continuously improving the effectiveness and efficiency of the NHS in Scotland;

Access to services – recognising patients’ need for quicker and easier use of NHS services; and

Treatment appropriate to individuals – ensuring patients receive high quality services that meet their needs.

The HEAT target relating specifically to admission to Stroke Unit reads:

“To improve stroke care, 90% of all patients admitted with a diagnosis of stroke will be admitted to a Stroke Unit on the day of admission, or the day following presentation by March 2013.”

There was an interim target of 80% achievement by March 2012.

For the purpose of this target a Stroke Unit is defined as a designated ward satisfying the following conditions:

• A defined bed area where stroke patients are preferentially admitted;• Medical, nursing and allied health professionals in that area have undertaken specific

training in stroke; and• Patients are discussed at a multi-disciplinary meeting at least weekly.

The performance data for the HEAT Target is collected and reported via the SSCA. Health Boards are able to monitor their performance against the HEAT Target through monthly reports. Health Boards and the Scottish Government receive quarterly reports presenting performance against the HEAT target.


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Due to the number of beds and the small number of stroke admissions within the following hospitals: Galloway Community, Belford, Caithness and Gilbert Bain; it is not practical for them to have a defined Stroke Unit. We are comfortable however that a defined stroke pathway is in place in these hospitals and that the HEAT criteria are established within that pathway. All staff are trained to a minimum of Stroke Training and Awareness Resources (STARS) 1 level, there is a weekly Multi-disciplinary Team meeting and the patients are cared for by a physician with an interest in stroke.

Note that the denominator for the HEAT target excludes: in-hospital strokes, patients discharged within 1 day and transfers in from another hospital.

Chart 1 : (Health Board) Percentage of stroke patients eligible for HEAT target and admitted to a Stroke Unit within 1 day of admission using HEAT target definition, 2010 & 2011 data (based on initial diagnosis)

0

10

20

30

40

50

60

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80

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100

20102011NHS QIS 90% Interim 80%

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Ork

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*

Tays

ide

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s**

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Horizontal lines reflect NHS QIS standard (2009) and HEAT target (March 2013) to admit 90% of stroke patients to a Stroke Unit within 1 day of admission (solid line) and HEAT interim target (March 2012) for 80% of stroke patients to be admitted to a Stroke Unit within 1 day (dashed line).

* Due to the number of beds within some of the hospitals in the Health Boards indicated and the small numbers of stroke admissions to these hospitals it is not practical to have a defined Stroke Unit. We have confirmed however that a defined stroke pathway is in place in these hospitals and that the HEAT criteria are established within that pathway. NHS Orkney do not have a Stroke Unit or designated stroke beds but patients are airlifted to Aberdeen Royal Infirmary and a proportion arrive in sufficient time to be admitted to the Stroke Unit.

** Western Isles 2011 data omitted because of data collection issues.

As noted above the evidence for the benefits of organised specialist stroke care in improving outcomes is now clearly established.

Care bundles are an element of the Scottish Patient Safety Programme (SPSP) used as a structured way to improve processes of care and patient outcomes.

Care bundles are usually a group of 3-5 straight forward sets of practices that when performed collectively, reliably and continuously have been proven to improve patient outcomes.

http://www.scottishpatientsafetyprogramme.scot.nhs.uk



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Chart 2 presents a ‘bundle’ analysis for patients eligible for the HEAT target, displaying percentages of patients who also received swallow screen, brain imaging and aspirin within NHS QIS standards. This compares care received by patients admitted to the Stroke Unit within one day of presentation and those admitted after this and those never admitted to a Stroke Unit. The data confirm that patients admitted to a Stroke Unit within one day of presentation achieve more standards than those admitted after this or those never admitted to a Stroke Unit.

Chart 2: ‘Bundle’ analysis for patients eligible for HEAT target - percentages who also receive swallow screen, brain imaging and aspirin within NHS QIS standards, 2011 data (based on initial diagnosis)

0

10

20

30

40

50

60

70

80

90

100

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SU >1 day or Not SUPe

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Note: Western Isles 2011 data omitted because of data collection issues.


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2 Future Plans

2.1 What have we achieved in 2011-2012?

The following progress has been made against the future plans described in last years report.

Distribution of Monthly Reports:Distribution of Monthly Reports to Stroke MCNs reflecting activity for the previous month and performance against standards continues. Clinicians and NHS managers use these reports to review processes of care and identify areas where improvement is required. The reports continue to be modified to maximise reliability and usefulness to the clinical teams.

Stroke Admission HEAT Target:As noted in section 1.2.2 the Stroke Admission HEAT Target was implemented on 1st April 2011. Quarterly reports have been produced throughout 2011. The fourth quarterly HEAT report was produced in April 2012. This noted that at end March 2012 all Health Boards were progressing well towards meeting the target and are currently on track in relation to trajectories set for 2012-13.

Development of new web based IT system for collection of SSCA data:The development of eSSCA took longer than anticipated and was not launched in 2011 as predicted. It was however successfully launched in June 2012 and is now used by all hospitals managing acute stroke patients across Scotland. eSSCA contains historical data from January 2010 to the present day.

Evaluation of Public Summary:The second version of the SSCA Easy Access Public Summary was published in June 2011. An evaluation of the design and content of the first version of the Public Summary was completed in December 2010 with valuable input from patients/ carers, voluntary organisations and health professionals who were also involved in the production of the 2011 Public Summary.

The SSCA National Meeting:The SSCA National Meeting held on Tuesday 20th September 2011 followed the successful format of the 2010 meeting and again evaluated well.

The 2012 SSCA Annual National Meeting will be held on Thursday 23rd August 2012 at the Royal College of Physicians, Queen Street, Edinburgh. Further information can be found on the SSCA website (http://www.strokeaudit.scot.nhs.uk/Meetings.htm).

Research Subgroup – Use of the SSCA data in research:The Research Subgroup (Dr MJ Macleod (chair), Professor M Dennis, Professor P Langhorne and Dr M Barber) of the SSCA Steering Committee continues to oversee the use of SSCA data in research. With the support of Chest Heart & Stroke Scotland (CHSS), Melanie Turner was appointed in 2011 as a research fellow to assist with data linkage and validation. The datasets will be primarily available for researchers based in Scotland who have contributed to the Audit, but open to other researchers also. Refer to section 8.2 for a short summary of Melanie’s work to date.

http://www.strokeaudit.scot.nhs.uk/Meetings.htm


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In 2011 SSCA data has contributed to research projects at Imperial College, London and the European Implementation Score (EIS) in addition to various projects within Scotland.

Information about the SSCA Research Subgroup and forms for requesting data are available on the SSCA website (http://www.strokeaudit.scot.nhs.uk/Research.html).

Thanks to Dr Mary-Joan Macleod, Stroke Physician, NHS Grampian.

Rehabilitation Subgroup:The SSCA Rehabilitation Subgroup (Dr C McAlpine (chair), K Brennan, T Jackson, M Smith and H Dodds) of the SSCA Steering Committee first met in October 2011. Work continues on the development of Rehabilitation and Organisational datasets. First drafts will be presented to the National Advisory Committee for Stroke at the Scottish Government and the SSCA Steering Committee in Autumn 2012.

Pre-hospital care:Development of a Pre-Hospital Dataset is ongoing. Work continues to marry data flows in the pre-hospital setting, i.e. Scottish Ambulance Service and NHS24. The proposal is to have a joined dataset held by ISD that can be linked to the SSCA data for further analysis of the patients’ pre-hospital journeys.

Thanks to Dr Malcolm Alexander, Associate Medical Director, NHS24.

Carotid Intervention data collection:Collection of Carotid Intervention data commenced in July 2012 following the launch of eSSCA. Analysis of these data will be presented in the 2013 National Report.

Audit Scotland review of stroke services in Scotland:In early 2012 Audit Scotland investigated the potential to undertake a performance audit on stroke services in Scotland. Following initial scoping of the project involving meetings with various members of stroke services in Scotland the Audit Scotland team decided there would be limited value in them doing more work at this time.

Letter from Audit Scotland –

“….. we have carried out scoping work on a potential performance audit on stroke services. We have decided not to proceed with a performance audit at this time as we do not think it would add enough value given other work and developments taking place. During scoping, we were reassured to see the high level of scrutiny and improvement work taking place in relation to stroke services. In particular, the Scottish Government’s work to implement the stroke actions in the Better Heart Disease and Stroke Care action plan, the Scottish Stroke Care Audit and the joint team from the Scottish Government and the SSCA carrying out visits and working with all the boards to help improve their performance. We considered focusing the audit on rehabilitation provided in the community after people are discharged. Again we do not think this is the right time for us to look at this as the Scottish Government and SCCA joint team is about to undertake work on rehabilitation services. In addition we are conscious of the changes associated with the further integration of health and social care over the coming months. I would like to take this opportunity to thank you for your help during the scoping stage of the audit. Your advice has been very useful. We plan to keep this topic under review and may consider undertaking a performance audit in the future.”

Catherine Young, Project Manager, Audit Scotland

http://www.strokeaudit.scot.nhs.uk/Research.html


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2.2 What’s next in 2012-2013?

Finalising Rehabilitation and Organisational Datasets:Following collaboration with the SSCA Steering Committee and NACS the Rehabilitation Sub-group will finalise development of the Rehabilitation and Organisational Datasets. Further work is required to determine how these data will be collected and by whom. The new forms will also require to be added to the eSSCA web based system. Funding needs to be secured for this development.

Improved validation of SSCA data:eSSCA, launched in June 2012, has increased validation embedded in the system improving the accuracy of SSCA data collected locally. Centrally, Robin Flaig (Quality Assurance Manager) will also carry out more in depth central validation of the SSCA data. As Systems Administrator for eSSCA Robin will be able to monitor missing data, incomplete data and issues with fields consistently completed as unknown, not recorded or ambiguous/ illegible. She will also closely monitor outputs from Monthly Reports and communicate more regularly with Audit Coordinators when she identifies missing data or issues with data submitted. This should ensure that SSCA data are more accurate, up to date and reliable.

Robin will report on validation findings in the 2013 National Report.

Pre-hospital care:Plan to progress development of Pre-Hospital Dataset and analysis of linked data described in section 2.1 above.

Carotid Intervention data collection:Collection of Carotid Intervention data began in July 2012. Analysis of these data will be presented in the 2013 National Report.

Ongoing redesign/ development of the SSCA:Development of additional supporting documentation, e.g. Audit Protocol/ Training Materials

Case Note Validation

Collaborative projects/ data linkage/ academic publications


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3 Inpatients

3.1 Summary and key findings relating to inpatient data

The Scotland wide data indicate that over 8,000 patients were hospitalised with stroke in 2011, very similar to the numbers in 2010. The total number of Stroke Unit beds has decreased from 801 in 2010 to 758 in 2011. However, crucially, the number of Acute Stroke Unit beds has increased and the number of stroke rehabilitation beds on non-acute sites has reduced (251 to 204). This may reflect consolidation of Stroke Unit beds on fewer sites and efforts to increase early access to Stroke Unit care in line with the HEAT target.

The mean length of stay (24.5 days) in hospital has fallen again (25.0 days in 2010) so that the number of hospital beds occupied by stroke patients has fallen (under 200,000 bed days in 2011).

The proportions of patients accessing Stroke Unit care at any time during their admission have risen from 82% in 2010 to 87% in 2011.

There have been further improvements over previous years in performance against NHS QIS standards for early access to Stroke Unit care. In 2010, 40% were admitted to a Stroke Unit on the day of admission, and 63% by the following day. In 2011, this had risen to 45% and 72% respectively. However, these figures are still someway short of the 60% (NHS QIS standard) and 90% (HEAT target) which services are striving to meet.

Given the evidence that Stroke Unit care is associated with fewer deaths and less residual disability this is extremely important. The data in Chart 2 (section 1.2.2) show that patients admitted to a Stroke Unit on the day of admission, or the day after, are much more likely to be treated in line with the other NHS QIS standards (i.e. early swallow screen, aspirin and brain imaging). Not surprising, since once patients are in a Stroke Unit environment where staff have been specifically trained to care for stroke patients they would be expected to receive the appropriate assessments and interventions.

There were smaller, but statistically significant, increases across Scotland in the proportions of patients having a swallow screen (61% to 65%) and brain scan (53% to 57%) on the day of admission. The proportion of patients with ischaemic strokes receiving early aspirin (72%) was the same as in 2010. This may reflect a reluctance among stroke physicians to start aspirin in patients who are already taking alternative antiplatelet drugs, such as clopidogrel, which is increasingly used for long term secondary prevention after TIA and ischaemic stroke.

These Scotland wide figures give an overall impression of continuing improvements in the standards of hospital care for stroke patients, at least with respect to those aspects of care covered by the NHS QIS standards and HEAT target. However, performance across Health Boards and hospitals vary greatly. Some easily exceed certain standards whilst others fall well short of the expected standard, and show little evidence of improvement. The Better Heart Disease and Stroke Care Action Plan1 commits Health Boards to work with their Stroke MCNs to ensure that all NHS QIS standards for stroke care are achieved or exceeded by 2012. Appendix A summarises the actions taken by each MCN to improve their stroke services.


12

Chart 3 (Hospital) Length of stay for stroke patients - percentage of stay in Stroke Unit and percentage of patients admitted to a Stroke Unit during their stay, by hospital, 2011 data (based on final diagnosis)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% Not SU% post-SU% in SU% pre-SU% Stayed in SU

Perc

enta

ge

Ayr

Cro

ssho

use

Bor

ders

DG

RI

GC

H*

QM

H

VH

K

FV

RH

SR

I

AR

I

Dr G

rays

GR

I

IRH

RA

H

Sou

th G

lasg

ow

WIG

Bel

ford

*

Cai

thne

ss*

L&I

Rai

gmor

e

Hai

rmyr

es

Mon

klan

ds

Wis

haw

RIE

SJH

WG

H

Bal

four

*

Gilb

ert B

ain*

Nin

ewel

ls

PR

I

Sco

tland

Square marker (□) on chart indicates percentage of stroke patients who spent part of their stay in a Stroke Unit.* Due to the number of beds within some of the hospitals in the Health Boards indicated and the small numbers of stroke

admissions to these hospitals it is not practical to have a defined Stroke Unit. We have confirmed however that a defined stroke pathway is in place in these hospitals and that the HEAT criteria are established within that pathway. NHS Orkney do not have a Stroke Unit or designated stroke beds but patients are airlifted to Aberdeen Royal Infirmary and a proportion arrive in sufficient time to be admitted to the Stroke Unit.



13

3.2 Stroke Unit Information

Table 1: Stroke Unit InformationHospital Name

Admits acute stroke

Number of acute stroke

dis-charged in 2011

Acute Stroke

Unit (ASU) beds

Integr-ated ASU/

Rehab Stroke

Unit (RSU) beds

RSU beds on

acute site

RSU beds off

acute site

Number of stroke bed days available per year

Mean length of stay (days)

Calcu-lated

no. strokebed days neededper year

Comments (e.g. Off-site Locations)

Ayr Hospital Yes 314 15 0 15 0 10,950 19.5 6,136

Crosshouse Hospital

Yes 326 21 0 0 20 14,965 29.1 9,491 All off site beds are located at Ayrshire Central Hospital.

Borders General Hospital

Yes 222 0 12 0 0 4,380 29.5 6,538 Stroke Unit has 3 single rooms and 2 bays of flexi beds to accommodate male and female admissions.

Dumfries & Galloway Royal Infirmary (DGRI)

Yes 208 9 0 0 0 3,285 19.8 4,115 Acute generic rehabilitation unit in DGRI (15 beds) accommodates stroke rehabilitation. Also 4 designated cottage hospitals providing rehabilitation across Dumfries and Galloway.

Galloway Community Hospital (GCH)

Yes 32 0 0 0 0 0 24.7 791 GCH admits acute stroke patients to a designated bed within the acute medical ward meeting the HEAT target criteria. Stroke rehabilitation is also provided in GCH in their rehabilitation unit.


14

Hospital Name

Admits acute stroke


dis-charged in 2011

Acute Stroke

Unit (ASU) beds

Integr-ated ASU/

Rehab Stroke

Unit (RSU) beds

RSU beds on

acute site

RSU beds off

acute site



Calcu-lated



Queen Margaret Hospital (QMH)

Yes 306 8 0 15 0 8,395 25.1 7,690 All off site beds for Victoria Hospital during 2011 were located at Cameron Hospital. It also has 6 beds for stroke patients aged under 65 years. The Acute Stroke Unit in QMH closed in January 2012 and all acute stroke patients in Fife are now admitted to the new Integrated Stroke Unit at Victoria Hospital. From January 2012 there are 20 rehabilitation beds at QMH. Cameron Hospital continues to have 12 >65 beds and 6 <65 beds.

Victoria Hospital Kirkcaldy (VHK)

Yes 255 0 23 0 12 12,775 29.2 7,452

Stirling Royal Infirmary* (SRI)

Yes 319 15 0 0 0 16,425 28.8 9,202 The Stroke Unit at the new Forth Valley Royal Hospital opened in July 2011. From this date all acute stroke patients were admitted to Forth Valley Royal Hospital. 10 off site stroke rehabilitation beds are currently in Bannockburn Hospital which will move to Stirling Community Hospital.

Falkirk and District Royal Infirmary*

No 0 0 30 0

Forth Valley Royal Hospital (FVRH)

Yes 239 30 0 0 10 14,600 13.2 3,152

Aberdeen Royal Infirmary (ARI)

Yes 574 16 0 0 40 20,440 27.4 15,746 ARI off site beds include 34 beds at Woodend and 6 beds at Fraserburgh.

Dr Gray's Hospital

Yes 63 0 9 0 0 3,285 41.5 2,615 Patients are moved to Community Hospitals, in some instances to continue generic rehabilitation.

Glasgow Royal Infirmary (GRI)

Yes 509 0 38 0 12 18,250 21.0 10,692 Off site beds are located at Stobhill Hospital.

Western Infirmary Glasgow (WIG)

Yes 455 14 0 0 18 11,680 25.3 11,531 All off site beds are located at Gartnavel Hospital.


15

Hospital Name

Admits acute stroke


dis-charged in 2011

Acute Stroke

Unit (ASU) beds

Integr-ated ASU/

Rehab Stroke

Unit (RSU) beds

RSU beds on

acute site

RSU beds off

acute site



Calcu-lated



Southern General Hospital (SGH)

Yes 583 4 30 0 20 19,710 24.0 13,993 SGH Stroke Unit contains 4 hyperacute beds. All off site beds are located at the Victoria Infirmary.

Inverclyde Royal Hospital (IRH)

Yes 191 0 17 0 0 6,205 22.1 4,224 IRH service re-located to main hospital in 2010 with service re-design.

Royal Alexandra Hospital (RAH)

Yes 355 0 30 0 4 12,410 19.4 6,870 Rehab off site at Vale of Leven (4-6 beds).

Raigmore Hospital

Yes 415 0 22 0 0 8,030 21.8 9,029

Lorn & Islands Hospital (L&I)

Yes 44 0 6 0 0 2,190 21.8 958

Belford Hospital

Yes 21 0 0 0 0 0 16.8 352 Belford admits acute stroke patients to a designated bed within the acute medical ward meeting the HEAT target criteria.

Caithness General Hospital

Yes 45 0 0 0 0 0 20.9 942 Caithness admits acute stroke patients to a designated bed within the acute medical ward meeting the HEAT target criteria.

Hairmyres Hospital

Yes 308 0 20 0 0 7,300 18.8 5,778

Monklands Hospital

Yes 292 0 20 0 0 7,300 17.1 5,001

Wishaw General Hospital

Yes 357 0 25 0 0 9,125 19.0 6,793

Royal Infirmary of Edinburgh (RIE)

Yes 530 22 0 0 41 22,995 32.7 17,341 RIE off site beds are divided as follows: 19 beds at Liberton and 22 beds at Astley Ainslie Hospital. (A few patients also go to the Royal Victoria Hospital and Roodlands Hospital for rehabilitation).

St John’s Hospital (SJH)

Yes 185 0 22 0 0 8,030 31.9 5,895


16

Hospital Name

Admits acute stroke


dis-charged in 2011

Acute Stroke

Unit (ASU) beds

Integr-ated ASU/

Rehab Stroke

Unit (RSU) beds

RSU beds on

acute site

RSU beds off

acute site



Calcu-lated



Western General Hospital (WGH)

Yes 313 16 0 0 26 15,330 32.6 10,218 All off site beds are located at Royal Victoria Hospital.

Balfour Hospital

Yes 26 0 0 0 0 0 72.7 1,891

Gilbert Bain Hospital

Yes 42 0 0 0 0 0 13.8 579 Gilbert Bain admits acute stroke patients to a designated bed within the acute medical ward meeting the HEAT target criteria.

Ninewells Hospital

Yes 411 18 0 0 1 6,935 19.5 8,023 Off site beds – Angus stroke rehab beds are located at Stracathro Hospital (10) and Dundee generic rehab beds at Royal Victoria Hospital.

Perth Royal Infirmary (PRI)

Yes 202 0 26 0 0 9,490 31.4 6,345

Western Isles Hospital (WI)

Yes 0 6 0 0

TOTALSR 8,142 188 306 60 204 274,480 24.5 199,383

Note: For the purpose of the SSCA and as presented in the table above, length of stay (LOS) is calculated according to the SSCA data definitions document, i.e. record the discharge date at the end of all care for that stroke event. This will include acute care and any period of stroke rehabilitation including that undertaken in a general rehabilitation unit but will not include slow stream rehabilitation or medicine of the elderly, NHS continuing care, transfer to ‘boarding bed’ or transfer due to other overriding diagnosis (for further information see www.strokeaudit.scot.nhs.uk)

* Forth Valley length of stay columns combine data for Stirling Royal Infirmary & Falkirk & District Royal Infirmary.R Total discharges, calculated stay and mean stay columns exclude Western Isles.

www.strokeaudit.scot.nhs.uk


17

3.3 Hospital Data

Previous reports presented results showing the performance of Health Boards and individual hospitals across each of the QIS standards on a NHS QIS standards and summary table, known as the RAG table (ie Red Amber Green, where the colour indicates performance). This year the performance of Health Boards and hospitals are presented in chart format only. To illustrate performance, eg from 2010 to 2011, the red, amber green approach remains, as before. However, performance (ie whether the results indicate improvement, no change or are worse since the previous year), is now measured more accurately and based on statistically significant change (see the chart key below) at the 95% confidence level (if one was to measure performance 100 times, one’s confidence interval would be expected to include the true proportion 95 out of these 100 times. The Health Board charts illustrating performance across each of the QIS standards in 2010 and 2011 are given below, while the hospital charts can be found on the SSCA website (www.strokeaudit.scot.nhs.uk).

Data now held centrally has been used to calculate the results shown in the charts below. They may not match exactly those presented in previous reports. Differences in performance may reflect real differences in the process of care but also differences in the way these data were collected between hospitals or over time. Although we have attempted to standardise the methods of case ascertainment, data extraction, definition of variables, data entry and analysis, inevitably individuals responsible for aspects of the audit were not always able to adhere strictly to the standards often for very practical reasons. The data used to calculate the figures presented in the charts below can be found in excel tables on the SSCA website (www.strokeaudit.scot.nhs.uk).

80 QIS standard (shown above the histogram bar for each QIS standard).

80 QIS standard is highlighted in blue if the 2011 result met or exceeded the standard.

2010 results

2011 results : statistically significant improvement since 2010

2011 results : no statistically significant change since 2010

2011 results : statistically significant decrease in performance since 2010

Why do some charts show the QIS standard is met (target figure highlighted in blue), but the 2011 estimate is below the standard?

In some instances although the estimate for 2011 may fall short of the QIS standard, the confidence interval exceeds the QIS standard. Therefore, statistically it is estimated that the QIS standard was met.


reasons.The




18

Charts 4a – 4o: Performance against NHS QIS standards, by Health Board, 2010 and 2011 data

4a. Performance against NHS QIS standards, 2010 and 2011 data - Scotland

40 63 61 53 72 8245 72 65 57 72 83

60

90

100

80

100

80

0

20

40

60

80

100

0

20

40

60

80

100

8519 8519 8519 8519 6737 51318174 8174 8174 8174 6582 6302

Per

cent

age

QIS standard

Admitted to SU on Day of Admission

Admitted to SU up to day after admission

Swallow screen/test on day of admission

Brain scan on day of admission

Aspirin up to day after admission

Specialist NV clinic within 7 days

2010 N =2011 N =

4b. Performance against NHS QIS standards, 2010 and 2011 data – Ayrshire and Arran

74 88 78 30 68 9476 89 77 32 71 93

60

90100

80

100

80

0

20

40

60

80

100

0

20

40

60

80

100

666 666 666 666 547 269629 629 629 629 502 298

Per

cent

age

QIS standard







2010 N =2011 N =

4c. Performance against NHS QIS standards, 2010 and 2011 data - Borders

31 59 72 67 82 7527 59 76 64 78 92

60

90

100

80

100

80

0

20

40

60

80

100

0

20

40

60

80

100

243 243 243 243 196 95231 231 231 231 192 122

Per

cent

age

QIS standard







2010 N =2011 N =


19

4d. Performance against NHS QIS standards, 2010 and 2011 data - Dumfries and Galloway

37 65 64 52 71 8750 77 72 62 73 92

60

90

100

80

100

80

0

20

40

60

80

100

0

20

40

60

80

100

261 261 261 261 199 193264 264 264 264 202 202

Per

cent

age

QIS standard

Admitted to SU onDay of Admission






2010 N =2011 N =

4e. Performance against NHS QIS standards, 2010 and 2011 data - Fife

33 62 60 56 77 8331 65 68 57 77 78

60

90

100

80

100

80

0

20

40

60

80

100

0

20

40

60

80

100

530 530 530 530 412 391572 572 572 572 477 361

Per

cent

age

QIS standard







2010 N =2011 N =

4f. Performance against NHS QIS standards, 2010 and 2011 data - Forth Valley

15 39 40 55 80 8926 56 57 56 85 87

60

90

100

80

100

80

0

20

40

60

80

100

0

20

40

60

80

100

565 565 565 565 426 246552 552 552 552 447 203

Per

cent

age

QIS standard







2010 N =2011 N =


20

4g. Performance against NHS QIS standards, 2010 and 2011 data - Grampian

54 62 52 47 73 7070 76 65 60 74 75

60

90

100

80

100

80

0

20

40

60

80

100

0

20

40

60

80

100

729 729 729 729 546 486657 657 657 657 513 483

Per

cent

age

QIS standard







2010 N =2011 N =

4h. Performance against NHS QIS standards, 2010 and 2011 data - Greater Glasgow and Clyde

41 61 58 51 60 7246 68 54 58 60 76

60

90

100

80

100

80

0

20

40

60

80

100

0

20

40

60

80

100

2213 2213 2213 2213 1786 10532074 2074 2074 2074 1655 1967

Per

cent

age

QIS standard







2010 N =2011 N =

4i. Performance against NHS QIS standards, 2010 and 2011 data - Highland

13 27 61 50 66 7724 42 60 51 66 80

60

90

100

80

100

80

0

20

40

60

80

100

0

20

40

60

80

100

493 493 493 359 287519 519 519 519 401 308

493

Per

cent

age

QIS standard







2010 N =2011 N =


21

4j. Performance against NHS QIS standards, 2010 and 2011 data - Lanarkshire

46 80 72 54 81 9844 81 69 54 82 91

60

90

100

80

100

80

0

20

40

60

80

100

0

20

40

60

80

100

917 917 917 917 795 1053947 947 947 947 810 1182

Per

cent

age

QIS standard







2010 N =2011 N =

4k. Performance against NHS QIS standards, 2010 and 2011 data - Lothian

32 65 58 69 79 7834 76 64 71 72 90

60

90

100

80

100

80

0

20

40

60

80

100

0

20

40

60

80

100

1160 1160 1160 1160 916 8491035 1035 1035 1035 851 828

Per

cent

age

QIS standard







2010 N =2011 N =

4l. Performance against NHS QIS standards, 2010 and 2011 data - Orkney

30 53 55 13 57 n/a28 80 68 16 81

60

90100

80

100

80

0

20

40

60

80

100

0

20

40

60

80

100

40 40 40 40 23 n/a25 25 25 25 16 n/a

Per

cent

age

QIS standard







2010 N =2011 N =


22

4m. Performance against NHS QIS standards, 2010 and 2011 data - Shetland

2 2 78 22 89 n/a100 100 95 30 72

60

90100

80

100

80

0

20

40

60

80

100

0

20

40

60

80

100

49 49 49 49 38 n/a40 40 40 40 32 n/a

Per

cent

age

QIS standard







2010 N =2011 N =

4n. Performance against NHS QIS standards, 2010 and 2011 data - Tayside

41 78 71 48 74 7451 86 85 60 86 75

60

90

100

80

100

80

0

20

40

60

80

100

0

20

40

60

80

100

612 612 612 612 465 200629 629 629 629 484 329

Per

cent

age

QIS standard







2010 N =2011 N =

4o. Performance against NHS QIS standards, 2010 and 2011 data - Western Isles

n/a n/a n/a n/a n/a 89 89

60

90

100

80

100

80

0

20

40

60

80

100

0

20

40

60

80

100

n/a n/a n/a n/a n/a 9n/a n/a n/a n/a n/a 19

There was an issue with data collection in Western Isles in 2011 and when reviewed it wasagreed that the data were incomplete and inaccurate in some areas. Due to this Western Islesinpatient data is not presented in the 2012 national report.P

erce

ntag

e

QIS standard







2010 N =2011 N =


23

Chart 5: Percentage of stroke patients admitted to Stroke Unit by number of days to Stroke Unit admission, 2011 data (based on final diagnosis)

0

10

20

30

40

50

60

70

80

90

100

2 Days 1 Day Same DayNHS QIS 60%NHS QIS 90%

Perc

enta

ge

Ayr

Cro

ssho

use

Bor

ders

DG

RI

GC

H*

QM

H

VH

K

FV

RH

SR

I

AR

I

Dr G

rays

*

GR

I

IRH

RA

H

Sou

th G

lasg

ow

WIG

Bel

ford

*

Cai

thne

ss*

L&I

Rai

gmor

e

Hai

rmyr

es

Mon

klan

ds

Wis

haw

RIE

SJH

WG

H

Bal

four

*

Gilb

ert B

ain*

Nin

ewel

ls

PR

I

Sco

tland

Horizontal lines reflect NHS QIS standards (2009) to admit 60% of stroke patients on day of admission and 90% within 1 day of admission



Chart 6: Percentage of stroke patients with a swallow screening by number of days to swallow screening, 2011 data (based on final diagnosis)

0

10

20

30

40

50

60

70

80

90

100

2 Days 1 Day Same DayNHS QIS 100%

Perc

enta

ge

Ayr

Cro

ssho

use

Bor

ders

DG

RI

GC

H

QM

H

VH

K

FV

RH

SR

I

AR

I

Dr G

rays

GR

I

IRH

RA

H

Sou

th G

lasg

ow

WIG

Bel

ford

Cai

thne

ss L&I

Rai

gmor

e

Hai

rmyr

es

Mon

klan

ds

Wis

haw

RIE

SJH

WG

H

Bal

four

Gilb

ert B

ain

Nin

ewel

ls

PR

I

Sco

tland

Horizontal line reflects NHS QIS standard (2009) of 100% of stroke patients swallow screened on day of admissionNote: Western Isles 2011 data omitted because of data collection issues.


24

Chart 7: Percentage of stroke patients with a brain scan by number of days to scanning, 2011 data (based on final diagnosis)

0

10

20

30

40

50

60

70

80

90

100

2 Days1 DaySame DayNHS QIS 80%

Perc

enta

ge

Ayr

Cro

ssho

use

Bor

ders

DG

RI

GC

H

QM

H

VH

K

FV

RH

SR

I

AR

I

Dr G

rays

GR

I

IRH

RA

H

Sou

th G

lasg

ow

WIG

Bel

ford

Cai

thne

ss L&I

Rai

gmor

e

Hai

rmyr

es

Mon

klan

ds

Wis

haw

RIE

SJH

WG

H

Bal

four

*

Gilb

ert B

ain

Nin

ewel

ls

PR

I

Sco

tland

Horizontal line reflects NHS QIS standard (2009) of 80% of stroke patients to receive brain imaging on day of admission* NHS Orkney does not have a CT scanner. Patients are airlifted to Aberdeen Royal Infirmary and a proportion arrive in

sufficient time to have brain imaging within the required NHS QIS standard. Note: Western Isles 2011 data omitted because of data collection issues.

Chart 8: Percentage of stroke patients with a brain scan by number of hours to scan compared to percentage scanned same day, 2011 data (based on final diagnosis)

0

10

20

30

40

50

60

70

80

90

100

Over 24 Hours Within 24 HoursWithin 4 HoursSame DayNHS QIS 80%Pe

rcen

tage

Ayr

Cro

ssho

use

Bor

ders

DG

RI

GC

H

QM

H

VH

K

FV

RH

SR

I

AR

I

Dr G

rays

GR

I

IRH

RA

H

Sou

th G

lasg

ow

WIG

Bel

ford

Cai

thne

ss L&I

Rai

gmor

e

Hai

rmyr

es

Mon

klan

ds

Wis

haw

RIE

SJH

WG

H

Bal

four

*

Gilb

ert B

ain

Nin

ewel

ls

PR

I

Sco

tland

Horizontal line reflects NHS QIS standard (2009) of 80% of stroke patients to receive brain imaging on day of admissionSquare marker (□) on chart indicates scans done on the day of admission

* NHS Orkney does not have a CT scanner. Patients are airlifted to Aberdeen Royal Infirmary and a proportion arrive in sufficient time to have brain imaging within the required NHS QIS standard.



25

Chart 9: Percentage of acute ischaemic stroke patients given aspirin in hospital by number of days to receipt, 2011 data (based on final diagnosis)

0

10

20

30

40

50

60

70

80

90

100

2 Days 1 DaySame DayNHS QIS 100%

Perc

enta

ge

Ayr

Cro

ssho

use

Bor

ders

DG

RI

GC

H

QM

H

VH

K

FV

RH

SR

I

AR

I

Dr G

rays

GR

I

IRH

RA

H

Sou

th G

lasg

ow

WIG

Bel

ford

Cai

thne

ss L&I

Rai

gmor

e

Hai

rmyr

es

Mon

klan

ds

Wis

haw

RIE

SJH

WG

H

Bal

four

Gilb

ert B

ain

Nin

ewel

ls

PR

I

Sco

tland

Horizontal line reflects NHS QIS standard (2009) of 100% of ischaemic patients to receive aspirin within 1 day of admissionNotes: The denominator for the percentages excludes patients with valid contraindications to aspirin. Western Isles 2011 data omitted because of data collection issues.

Chart 10: Percentage of ischaemic patients given aspirin or alternative antiplatelets within 1 day of admission, 2011 data

0

10

20

30

40

50

60

70

80

90

100

Aspirin or AlternativeAspirin Only

NHS QIS 100% (Aspirin) Pe

rcen

tage

Ayr

Cro

ssho

use

Bor

ders

DG

RI

GC

H

QM

HV

HK

FV

RH

SR

I

AR

ID

r Gra

ys

GR

I

IRH

RA

H

Sou

th G

lasg

ow

WIG

Bel

ford

Cai

thne

ss L&I

Rai

gmor

e

Hai

rmyr

es

Mon

klan

ds

Wis

haw

RIE

SJH

WG

HB

alfo

urG

ilber

t Bai

n

Nin

ewel

ls

PR

I

Sco

tland

Horizontal line reflects NHS QIS standard (2009) of 100% of ischaemic patients to receive aspirin within 1 day of admissionNotes: For those hospitals using SSCAS (excludes NHS Lanarkshire data). The denominator for the percentages excludes

patients with valid contraindications to aspirin except for Known Allergy. This remains in the denominator to allow the aspirin and antiplatelet groups to be combined.

Western Isles 2011 data omitted because of data collection issues.


26

4 Outpatients

4.1 Summary and key findings relating to outpatient data

The number of hospitals collecting neurovascular clinic data has increased in 2011, though there are still a significant minority of hospitals offering this service that do not collect comprehensive data to reflect their performance. Data were collected on 6,484 patients with acute cerebrovascular disease seen in neurovascular clinics in 2011 compared with only 5,145 in 2010. This is a 26% increase in one year.

Despite the larger numbers of patients with cerebrovascular disease being entered into the audit, access to early TIA/ stroke clinics has been maintained. Eighty three percent are seen within 7 days of receipt of a referral, exceeding the NHS QIS standard of 80%. However, there is still variation between Health Boards and hospitals which means that some hospitals need to reduce delays. There is increasing evidence that very early initiation of treatments to reduce the risk of stroke after TIA, and minor strokes, is more effective than later treatment2. Hospitals will therefore need to strive for even shorter delays. Indeed, over 50% of those currently seen in neurovascular clinics are seen within 3 days of referral.

4.2 Hospital data

Chart 11: Percentage of patients with definite cerebrovascular diagnosis seen in neurovascular clinic with referral to examination time (days): same day and within 1, 2-3 and 4-7 days, 2011 data

0

10

20

30

40

50

60

70

80

90

100

4-7 Days2-3 Days1 Day Same DayNHSQISPe

rcen

tage

Ayr

Cro

ssho

use

Bor

ders

DG

RI

QM

H

VH

K

FVR

H

SR

I

AR

I

Dr G

rays

IRH

RA

H

Sou

ther

n G

ener

al*

Sto

bhill

*

VoL*

Vict

oria

Infir

mar

y*

WIG

*

L&I

Rai

gmor

e

Hai

rmyr

es

Mon

klan

ds

Wis

haw

SJH

WG

H

Nin

ewel

ls

PR

I

Stra

cath

ro

Wes

tern

Isle

s

Sco

tland

Horizontal line reflects NHS QIS standard (2009) of 80% of TIA patients are seen in a neurovascular clinic within 7 days of receipt of referral

* Not all Greater Glasgow & Clyde hospitals collected routine outpatient data for both 2010 & 2011 for the Scottish Stroke Care Audit. Apart from IRH and RAH, the GG&C columns in the chart below are for the <=7 days standard only and are sourced from local GG&C reporting systems. These relate to all patients referred to outpatient neurovascular clinics and not just those with a cerebrovascular diagnosis.


27

Chart 12: Percentage of total days from last event to examination showing components: event-to-referral, referral-to-referral-received, referral-received-to-appointment, appointment-to-examination, 2011 data

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Appointmentto Examination

Referral-Received to Appointment

Referral to Referral Received

Event to Referral

Perc

enta

ge

Ayr

Cro

ssho

use

Bor

ders

DG

RI

QM

H

VH

K

FVR

H

SR

I

AR

I

Dr G

rays

IRH

RA

H

L&I

Rai

gmor

e

SJH

WG

H

Nin

ewel

ls

PR

I

Stra

cath

ro

Wes

tern

Isle

s

Tota

l*

Note: For those hospitals using SSCAS where all relevant dates (last event, referral, referral-received,appointment and examination) are present and ordered chronologically. Not all Greater Glasgow & Clyde (GG&C) hospitals collected routine outpatient data for 2010 & 2011 for the Scottish Stroke Care Audit. There are some indicative SSCAS data for two Clyde hospitals included in the chart. NHS Lanarkshire do not use SSCAS.

* Total column does not reflect Scotland-wide performance due to the omissions noted above.


28

5 AnticoagulationOral anticoagulation is recommended for patients with TIA/ minor ischaemic stroke with atrial fibrillation for the following reasons:

● In patients in atrial fibrillation early risk of recurrent stroke is around 5% within two weeks; ● In patients with atrial fibrillation treated with aspirin, the stroke risk is 10% per annum in

those with a previous stroke compared to 2.7% in those without a previous stroke; and ● This is reduced to 4% and 1.5% per annum respectively with oral anticoagulants.2

It has been noted that there are currently significant gaps in relation to the recording of anticoagulation use in the data. This is being addressed through training with the Audit Coordinators and will be monitored by the Quality Assurance Manager.

5.1 Inpatient data

Table 2: Ischaemic stroke patients with current atrial fibrillation (AF) and anticoagulation on admission or discharge, 2011 data (final diagnosis)

Note that some percentages are based on very small numbers of

records.

All Ischaemic stroke patients Ischaemic stroke patients discharged alive

2011 With current AF on Admission: With current AF on Discharge:

Hospital Number Number also on anti-

coagulation at admission

Percentage on anti-


Number Number also on anti-

coagulation at discharge

Percentage on anti-


Ayr Hospital 91 18 20 73 27 37

Crosshouse Hospital 90 16 18 67 40 60

Borders General Hospital 59 14 24 44 32 73

Dumfries & Galloway Royal Infirmary

52 8 15 43 33 77

Galloway Community Hospital 4 1 25 4 1 25

Queen Margaret Hospital 69 7 10 55 21 38

Victoria Hospital Kirkcaldy 45 9 20 40 15 38

Forth Valley Royal Hospital 54 12 22 47 17 36

Stirling Royal Infirmary 35 7 20 30 8 27

Aberdeen Royal Infirmary 128 36 28 114 66 58

Dr Gray's Hospital 11 5 45 11 6 55

Glasgow Royal Infirmary 118 21 18 102 53 52

Inverclyde Royal Hospital 36 12 33 27 12 44

Royal Alexandra Hospital 76 10 13 53 0 0


29


records.

All Ischaemic stroke patients Ischaemic stroke patients discharged alive




Percentage on anti-




Percentage on anti-


Southern General Hospital 168 32 19 142 93 65

Western Infirmary Glasgow 135 27 20 103 78 76

Belford Hospital 4 1 25 4 3 75

Caithness General Hospital 6 1 17 5 3 60

Lorn & Islands Hospital 7 5 71 7 2 29

Raigmore Hospital 89 15 17 73 6 8

Royal Infirmary of Edinburgh 136 40 29 109 46 42

St John's Hospital 12 7 58 9 3 33

Western General Hospital 88 16 18 73 36 49

Balfour Hospital 4 1 25 4 0 0

Gilbert Bain Hospital 11 1 9 11 3 27

Ninewells Hospital 96 31 32 83 60 72

Perth Royal Infirmary 52 15 29 44 27 61

Total* 1659 361 22 1361 683 50

* Total column does not reflect Scotland-wide performance due to the omissions noted below.Notes: Information only available for hospitals using SSCAS. NHS Lanarkshire omitted because SAIL extracts used for National

Report did not contain sufficient detail to examine this topic. Western Isles 2011 data omitted because of data collection issues.

Table 3: Haemorrhagic stroke patients with current atrial fibrillation (AF) and anticoagulation on admission or discharge, 2011 data (final diagnosis)


records.

All Haemorrhagic stroke patients Haemorrhagic stroke patients discharged alive




Percentage on anti-




Percentage on anti-


Ayr Hospital 10 2 20 4 0 0

Crosshouse Hospital 8 2 25 7 2 29

Borders General Hospital 3 2 67 1 0 0

Dumfries & Galloway Royal Infirmary

8 3 38 5 0 0


30


records.

All Haemorrhagic stroke patients Haemorrhagic stroke patients discharged alive




Percentage on anti-




Percentage on anti-


Galloway Community Hospital 1 1 100 0 0

Queen Margaret Hospital 3 2 67 2 1 50

Victoria Hospital Kirkcaldy 4 2 50 3 0 0

Forth Valley Royal Hospital 4 1 25 4 0 0

Stirling Royal Infirmary 2 1 50 2 0 0

Aberdeen Royal Infirmary 6 3 50 4 0 0

Dr Gray's Hospital 2 1 50 2 2 100

Glasgow Royal Infirmary 7 4 57 3 1 33

Inverclyde Royal Hospital 3 1 33 2 0 0

Royal Alexandra Hospital 6 3 50 2 0 0

Southern General Hospital 9 3 33 6 0 0

Western Infirmary Glasgow 12 5 42 7 2 29

Belford Hospital 0 0 0 0

Caithness General Hospital 0 0 0 0

Lorn & Islands Hospital 0 0 0 0

Raigmore Hospital 9 5 56 6 1 17

Royal Infirmary of Edinburgh 15 6 40 10 0 0

St John's Hospital 2 2 100 2 0 0

Western General Hospital 2 0 0 1 0 0

Balfour Hospital 0 0 0 0

Gilbert Bain Hospital 0 0 0 0

Ninewells Hospital 5 2 40 3 0 0

Perth Royal Infirmary 1 0 0 0 0

Total* 122 51 42 76 9 12


Report did not contain sufficient detail to examine this topic. Western Isles 2011 data omitted because of data collection issues.


31

5.2 Outpatient data

Table 4: Patients with ischaemic diagnosis, seen in neurovascular clinics, with current atrial fibrillation (AF) and on anticoagulation, 2011 data

Note that some percentages are based

on very small numbers of records.

Denominator Patients with ischaemic diagnosis seen in neurovascular clinics

during 2011

Patients with ischaemic diagnosis seen in neurovascular clinics

during 2011

Hospital With current AF With current AF and on

anticoagulation prior to

assessment at clinic

Percentage on anticoagulation

prior to assessment

With current AF and on

anticoagulation following

assessment at clinic

Percentage on anticoagulation

following assessment

Ayr Hospital 11 3 27 8 73Crosshouse Hospital 11 3 27 8 73Borders General Hospital 6 3 50 5 83Dumfries & Galloway Royal Infirmary

21 12 57 20 95

Queen Margaret Hospital 15 7 47 14 93Victoria Hospital Kirkcaldy

17 3 18 12 71

Forth Valley Royal Hospital

0 0 0

Stirling Royal Infirmary 6 4 67 4 67Aberdeen Royal Infirmary 27 14 52 22 81Dr Gray's Hospital 6 4 67 5 83Inverclyde Royal Hospital 13 7 54 5 38Royal Alexandra Hospital 1 1 100 1 100Southern General Hospital

1 0 0 0 0

Stobhill Hospital 1 0 0 0 0Vale of Leven General Hospital

12 4 33 8 67

Victoria Infirmary 10 3 30 10 100Lorn & Islands Hospital 5 0 0 4 80Raigmore Hospital 15 7 47 10 67St John's Hospital 13 5 38 11 85Western General Hospital 56 19 34 44 79Ninewells Hospital 1 0 0 1 100Perth Royal Infirmary 14 6 43 12 86Stracathro Hospital 4 1 25 1 25Western Isles Hospital 5 1 20 3 60Total* 256 99 39 202 79


Report did not contain sufficient detail to examine this topic.


32

6 Thrombolysis“At work they phoned for an ambulance. I was taken to the Western General Hospital in Edinburgh. At the hospital I was assessed by a doctor from the Stroke Unit. He figured out what was wrong pretty quickly and they took an x-ray to confirm the diagnosis. I was having an ischaemic stroke. The doctor knew that I needed thrombolysed. First of all he had to contact my family to get permission to go ahead. I think the thrombolysis happened about 4 hours after the stroke started. The doctors had done a brilliant job for me. I had limited physical symptoms”

(Patient, NHS Lothian)

Treatment within four and a half hours of ischaemic stroke with a clot-dissolving treatment (recombinant tissue plasminogen activator (rtPA)) is effective for selected patients with acute ischaemic stroke. Based on pooled study data, it is estimated that, between 5 and 10 extra people per 100 treated with thrombolysis are independent 3-6 months later. The earlier the medication can be administered, the more likely the patient is to have a good outcome.

Data on all patients thrombolysed in Scotland has been entered into the SSCA prospectively since January 2010, with retrospective data collected for 2009. The NHS QIS standard set in June 2009 was for a treatment rate of 5 patients per 100,000 population per year. If there are 8,000 new ischaemic strokes per year in Scotland, this equates to at least 3% of all new patients. This report includes an overview of the delivery of rtPA during 2009, 2010 and 2011.

Table 5: Thrombolysis - numbers thrombolysed by Board and hospital, 2009-2011 dataIn order to view these data in the context of the local demand (in particular population size and likely clinical need) we have expressed these results in terms of the population in each region. The original annual standard of 5 thrombolysis treatments per 100,000 population was exceeded in 2008 and the crude rate now stands at 11.6 for Scotland with modest variation between regions.

Hospital Number of patients receiving thrombolysis

in 2011

Number of patients receiving thrombolysis

in 2010


in 2009Scotland summary 649 543 411Ayrshire & Arran 16 11 7Ayr Hospital 11 7 7Crosshouse Hospital 5 4 0Borders 9 1 0Borders General Hospital 9 1 0Dumfries & Galloway 15 21 4Dumfries & Galloway Royal Infirmary 11 17 3Galloway Community Hospital 4 4 1Fife 33 18 8Queen Margaret Hospital 24 10 5Victoria Hospital Kirkcaldy 9 8 3Forth Valley 24 10 13


33

Hospital Number of patients receiving thrombolysis

in 2011


in 2010


in 2009Forth Valley (Stirling Royal & Falkirk and District General Hospital)

15 10 13

Forth Valley Royal Hospital 9 0 0Grampian 98 74 77Aberdeen Royal Infirmary* 85 70 68Dr Gray's Hospital** 13 4 9Greater Glasgow & Clyde 194 211 193Inverclyde Royal Hospital 0 0 0Royal Alexandra Hospital 4 7 5Royal Infirmary Glasgow 0 1 0Southern General Hospital* 86 103 109Stobhill Hospital 0 0 0Western Infirmary Glasgow 104 100 79Highland 48 39 34Belford Hospital 3 0 0Caithness General Hospital 5 5 2Lorn & Islands Hospital 0 0 0Raigmore Hospital 40 34 32Lanarkshire 53 44 13Hairmyres Hospital 17 0 0Monklands Hospital 12 20 0Wishaw General Hospital 24 24 13Lothian 73 81 43Royal Infirmary of Edinburgh 40 32 16St John's Hospital 19 16 4Western General Hospital 14 33 23Orkney 0 1 0Balfour Hospital 0 1 0Shetland 2 0 0Gilbert Bain Hospital 2 0 0Tayside 79 29 18Ninewells Hospital 60 20 13Perth Royal Infirmary 19 9 5Stracathro Hospital 0 0 0Western Isles 5 3 1Western Isles Hospital 5 3 1

* Data presented for Southern General Hospital, Glasgow and Aberdeen Royal Infirmary are incomplete for 2011. More patients than shown have been thrombolysed.

** For Dr Gray’s there were 13 patients thrombolysed in 2011 that were not entered in to SSCAS in time to be included in the rest of the report. These cases are however included in the thrombolysis tables.

Notes: Records are included if a thrombolysis date is present; a small proportion of these records will not have an associated thrombolysis time recorded.

For additional information about each hospitals current thrombolysis service please refer to the tables on the SSCA website (www.strokeaudit.scot.nhs.uk).



34

Table 6: Thrombolysis - numbers thrombolysed and crude rate per 100,000 by Health Board of residence of patient, 2011 data

Health Board of Residence* Number of patients receiving thrombolysis in 2011

Mid-Year Population Estimate 2010**

Crude Rate per 100,000

Scotland 621 5 222 100 11.9Ayrshire & Arran 33 366 860 9.0

Borders 8 112 870 7.1

Dumfries & Galloway 15 148 190 10.1

Fife 47 364 945 12.9

Forth Valley 25 293 386 8.5

Grampian*** 95 550 620 17.3

Greater Glasgow & Clyde 152 1 203 870 12.6

Highland 47 310 830 15.1

Lanarkshire 61 562 477 10.8

Lothian 71 836 711 8.5

Orkney 0 20 110 0.0

Shetland 2 22 400 8.9

Tayside 62 402 641 15.4

Western Isles 3 26 190 11.5

* A small proportion of records could not be assigned to a Health Board because they were either for non-Scottish residents or there was insufficient information to allow their assignment to a Health Board (e.g. partial or incorrect postcode).

** Population estimates from National Records of Scotland (formerly General Register Office for Scotland, which merged with National Archives of Scotland from 1st April 2011).

*** For NHS Grampian there were 13 patients thrombolysed at Dr Gray’s hospital in 2011 that were not entered in to SSCAS in time to be included in the rest of the report. These cases are however included in the thrombolysis tables.

Table 7: Thrombolysis - numbers thrombolysed as percentage of stroke patients, Scotland, 2008-2011

The numbers (percentage) of stroke patients being treated with rtPA have increased every year (table 7) and the overall thrombolysis treatment rates are exceeding the current standard: in 2011 8% of patients presenting to hospital with stroke were thrombolysed, compared to 6% in 2010. This equates to 11.6 per 100,000 population for 2011. Although these figures mask significant regional variations as demonstrated in tables 5 and 6, increased use of telemedicine along with increasing clinician confidence is helping to reduce this.

Year Number of patients thrombolysed (numerator)

Number of stroke patients (denominator)

Percentage Number of patients per 100,000 (target is 5)

2008 260 8439 3% 5

2009 411 8012 5% 8

2010 543 8478 6% 10

2011* 644 8187 8% 12

* 2011 row excludes Western Isles because of the exclusion of their data from column D. Also, there were 13 patients thrombolysed at Dr Gray’s (Grampian) in 2011 that were not entered in to SSCAS in time to be included in the rest of the report. These cases are however included in columns C and D of this thrombolysis table. This is the reason for the difference in the total number of patients thrombolysed and the total number of stroke patients when compared to other tables and charts in this report.


35

Across Scotland, only 27% of patients appear to be receiving treatment within one hour of admission to hospital (chart 13). While there is considerable variation between Health Boards, no hospital is achieving the standard of 80% treated within one hour of admission. This is an area that requires attention to maximise potential benefit of treatment for suitable patients.

There are no data on outcomes available for this report, but further analysis will be presented at the National Meeting in August and available on the website later this year.

Chart 13: Percentage of eligible stroke patients thrombolysed within one hour of arrival at hospital, by admitting hospital, 2011 data

0

10

20

30

40

50

60

70

80

90

100

PercentageNHSQIS 80%

Ayr

Cro

ssho

use

Bor

ders

DG

RI

GC

H

QM

H

VH

K

FVR

H

SR

I

AR

I

RA

H

Sou

th G

lasg

ow

WIG

Bel

ford

Cai

thne

ss

Rai

gmor

e

Hai

rmyr

es

Mon

klan

ds

Wis

haw

RIE

SJH

WG

H

Gilb

ert B

ain

Nin

ewel

ls

PR

I

Wes

tern

Isle

s

Sco

tland

Perc

enta

ge

Horizontal line reflects NHS QIS standard (2009) 80% of stroke patients thrombolysed within 1 hour of arrival at first hospitalNotes: Hospitals shown are those that provide a thrombolysis service. See Table 5 for further details. Some hospitals (e.g. Southern General Hospital) may receive a large proportion of transferred patients which will affect

their door-to-needle time performance. Some percentages are based on very small numbers and should be interpreted with caution. Data for Dr Gray’s Hospital not included as were incomplete for 2011.


36

7 Case Studies: Improving the quality of stroke care in Scotland

NHS Scotland aims to deliver the highest possible quality of healthcare services to people in Scotland and to be among the best in the world. Launched in May 2010, the Quality Strategy3 sets the overall direction for achieving this, now and in the future.

One of the quality ambitions is to deliver effective care ensuring that the most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated. The Scottish Government note that ‘applying information from quality data to drive consistently better care across NHS Scotland’ is a key component of this4.

Health Boards across Scotland are using improvement and/ or change methodologies to examine the stroke pathways in their area, identifying areas where improvements could be made and instigating change processes to ensure they are delivering an effective service to their patients.

This section presents case studies from three Scottish Health Boards where these methodologies have been used to investigate and change where necessary the delivery of stroke care or the stroke pathway in their local areas.

7.1 NHS Fife (Hazel Fraser, Stroke Co-ordinator)

Challenges in developing a care bundle for acute stroke in NHS Fife – improving patient safety as well as improving performance.NHS Fife looked at a variety of ways to improve performance against NHS QIS standards. In 2011 we trialled a care bundle looking at stroke care within 24 hours. Care bundles are one element of the Scottish Patient Safety Programme used to improve the safety and reliability of hospital care (http://www.scottishpatientsafetyprogramme.scot.nhs.uk).

A care bundle is a group of 3-5 specific interventions/ process of care that are known to significantly improve patient outcome if done together, rather than separately and every patient should get it every time. A need for improvement should be identified and elements should be achievable, measurable, evidence based and carried out within a defined time period. Completion of each element must be auditable with a simple yes or no response (not applicable or contraindicated can be used) and completion of the bundle means all elements are achieved.

Bundles in stroke care are fairly new. Information can be found from Australia (www.nhmrc.gov.au/nics), Wales (www.wales.nhs.uk/strokecarebundles) and England (www.advancingqualityalliance.nhs.uk). Some were sprint audits, others were retrospective review of case notes, and the Welsh bundles were broken into first hours, day, 3 days and 7 days.

NHS Fife stroke care bundle comprised CT scanning, swallowing screening, access to Acute Stroke Unit (ASU) and aspirin administration. This also enabled us to gather in depth/ specific information to inform change by examining each element, e.g. we took 4 patients and looked at results, 3/4 had CT=75%, 2/4 swallow screen=50%, 2/4 ASU=50%, 3/4 Aspirin=75%. If only 1 received all care that meant only 25% achieved the bundle and the chance of improved outcome. We investigated why each element was not achieved.


http://www.nhmrc.gov.au/nics

http://www.nhmrc.gov.au/nics

http://www.wales.nhs.uk/strokecarebundles

http://www.advancingqualityalliance.nhs.uk

http://www.advancingqualityalliance.nhs.uk


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Baseline data from the SSCA were used to monitor performance. Staff were motivated to improve performance and patient safety. We identified barriers and enablers and developed a project plan to implement the bundles, monitor progress and evaluate change. A small team of people developed this and our stroke audit facilitator entered the data.

We developed a driver diagram and change package (test of change worksheets) using Plan, Do, Study, Act (PDSA) cycles. Repeated use of PDSA cycles helps test and refine ideas, amending and implementing new procedures and systems. It is broken into manageable chunks and small changes are tested, if they don’t work then try something else. It was challenging to find time to study the results of the data and optimise further action and lessons learned. We used test of change work sheets which asked 3 fundamental questions – what are we trying to achieve, how will we know change is improvement, what changes can we make.

Some practical challenges we found included clarity of diagnosis (e.g. what was appropriate administration of aspirin and what was meant by swallow screen), inconsistency of data collection/ completion and variation between two acute hospital sites. To facilitate consistency we added descriptors similar to the SSCA, and supportive guidance. Nurses were asked to document why patients did not meet the bundle, and we emphasised the need for complete data. Each patient admitted with a suspected stroke had a care bundle started. Data were entered into excel and charts formulated for feedback. Health Improvement could provide run charts but they only fed back whether the bundle was met or not. It was important to gather reasons why the bundle was not met in order to make improvement.

Time to collect and collate data, enter and report it was underestimated. The complexity involved around stroke was also underestimated and perhaps made it too complex - care bundles should be kept simple. Positives outcomes were: better engagement with staff on the ground, identification of specific issues due to the richness of data on why care bundles were not met and for each element of it. This provided supporting evidence to action and feedback to staff.

The 2010 SSCA National Report contained a bundle analysis based on the percentage that achieved admission to ASU but also swallow test, CT and aspirin within NHS QIS standards comparing this to late admission to ASU or not admitted to ASU at all, see page 7 of the SSCA National Report (http://www.strokeaudit.scot.nhs.uk/Downloads/2011_Report/SSCA-report-2011-web-version_new.pdf). This showed that in many areas there was room for improvement in delivery of bundles of care.

This analysis was redone for NHS Fife for 6 months of 2011 (chart 14) and it demonstrated a minor improvement in the numbers of patients receiving all elements of the care bundle. We have persevered and still believe ultimately that care bundles will improve patient safety and outcome as well as improving our performance.

http://www.strokeaudit.scot.nhs.uk/Downloads/2011_Report/SSCA-report-2011-web-version_new.pdf

http://www.strokeaudit.scot.nhs.uk/Downloads/2011_Report/SSCA-report-2011-web-version_new.pdf


38

Chart 14 NHS Fife - ‘Bundle’ (swallow screen, scan & aspirin) analysis for patients eligible for HEAT target and admitted to a Stroke Unit within 1 day, 2010 data and provisionalp 2011 data (Jan-Jun)

31% 35%

51%60%

43% 47%

69% 65%

49%40%

57% 53%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

QMH 2010 QMH 2011p VHK 2010 VHK 2011p Fife 2010 Fife 2011

bundle not met

bundle met

QMH (Queen Margaret Hospital); VHK (Victoria Hospital Kirkcaldy)

Perc

enta

ge

† Confidence intervals calculated using method described in: ALTMAN et al (2000) Statistics with confidence 2nd edition chapter 6 pp 46-47. ISBN 0727913751.

p Provisional - subject to change as a result of routine monthly data processing.

For further information relating to the work in NHS Fife please contact [email protected]

7.2 NHS Lothian (Dr Andrew Farrall, Consultant Neuroscientist, Radiology)

Brain imaging for acute stroke patients – why the urgency?There is a good evidence base for rapid access to brain imaging for acute stroke patients, but few Scottish hospitals currently achieve national performance standards. Delays to brain imaging arise primarily from complexities in the patient pathway between arrival at hospital and commencing scanning. Joint working by stroke services and imaging departments can achieve considerable improvements in patient care.

Acute stroke is a medical emergency. In the past there was little useful medical intervention available but there is now a clear evidence base for immediate assessment for thrombolysis or early antiplatelet drugs in order to optimise outcomes for the stroke patient. Early imaging of the brain is a vital investigation in suspected acute stroke.

NHS Lothian has undertaken an extensive audit of brain imaging in acute stroke in all its acute hospitals and the results are outlined below. The audit’s chief investigator, Andrew Farrall, summarised their results as follows: “When hospitals have looked at barriers to rapid brain imaging in stroke care there have usually been various delays along the care pathway. Targeting those pre-radiology steps which contribute to the brain scanning statistic (admitting patients, identifying them as stroke patients, recognising stroke patients need imaging, ordering the imaging and making radiology aware), may actually realise the greater improvement in the statistic as those steps cause the most delay once the patient reaches hospital”.



39

The audit in Lothian suggests that joint working between radiologists and stroke physicians along with service managers can achieve a great deal by ensuring a clear local pathway and protocol for acute stroke patients, without significant investment of resources.

NHS Lothian audited stroke patients for scanning on the day of admission in all their acute hospitals (Royal Infirmary of Edinburgh – RIE; Western General Hospital (WGH); and St. John’s Hospital (SJH)).

There are several steps from admission through to obtaining a clinically useful result from a brain scan. These steps include:

1 Admitting the patient

2 Identifying the patient as a stroke patient

3 Recognising the stroke patient needs imaging

4 Ordering the imaging & making Radiology aware

5 Transferring the stroke patient to Radiology

6 Starting brain scanning

7 Interpreting & reporting the brain scan result

The performance goal for brain imaging in acute stroke compares the date of step 1 to the date of step 6. Steps 1 through to 4 are mostly outwith the control of a Radiology department, and responsibility for step 5 may or may not rest with a Radiology department. Steps 6 and 7 are the responsibility of Radiology.

NHS Lothian audited brain imaging in all acute stroke patients for May 2011 and May 2010 to see where along the pathway the statistic could be improved. In NHS Lothian, the date and time of ordering imaging is captured in the electronic patient record, which makes it straightforward to split up the pathway into pre-Radiology contributions (steps 1 through to 4) and Radiology contributions (steps 5 & 6).

The table below summarises the audit’s findings for May 2011. In the middle column is the SSCA brain imaging statistic for percentage of stroke patients scanned on the same date as admission (all below the 80% goal). The right column lists what percentage was scanned on the same date as the scan order was placed.

Table 8: NHS Lothian audit of brain imaging of all acute stroke patients: May 2011

Hospital Percentage scanned on same day as admission

Percentage scanned on same day as scan ordered

Royal Infirmary of Edinburgh (RIE) 69% 92%Western General Hospital (WGH) 62% 74%St John’s Hospital (SJH) 58% 100%

The key observation is that in the RIE and SJH Radiology departments, response was very effective once the departments were made aware that there was a stroke patient to scan. At the WGH, a closer look at those patients not scanned on the same day, revealed that the responsible clinician had decided to postpone imaging to the next day in 20%; had those 20% been scanned on the same date as admission, the WGH statistics above would have been 82% and 94% respectively. The results were slightly improved compared to May 2010.

For further information relating to the work in NHS Lothian please contact [email protected]



40

7.3 NHS Western Isles (Dr Mark Barber, Consultant Geriatrician,

NHS Lanarkshire and Pat Welsh, MCN Manager [retired])

In April 2011 NHS Western Isles stroke MCN contacted the Scottish Centre for Telehealth and Telecare (SCTT), to explore a possible telehealth solution for accessing specialist medical rehabilitation stroke services. NHS Western Isles had no stroke or rehabilitation specialists of its own. NHS Lanarkshire was approached, as they had previous experience in providing acute telestroke services and were interested in this new proposal.

Following initial scoping and discussion with the Western Isles Medical Director, it was agreed that a service providing specialist stroke tele-rehabilitation and clinical leadership from Dr Mark Barber in NHS Lanarkshire to the Stroke Unit in the Western Isles Hospital, for a six month trial period, would be established. This would be jointly funded through the Scottish Telestroke Programme, SCTT (NHS 24) and NHS Western Isles. This pilot began in January 2012. An evaluation is underway to provide the requisite data to establish how to, or whether to, continue with the service. This evaluation will also identify any revenue costs, which would require to be covered in a future service level agreement between NHS Western Isles and NHS Lanarkshire.

Dr Barber video links every Wednesday morning with the Stroke Multi-disciplinary Team. He can review electronic versions of the case records, review imaging on the national radiology system and be involved in goal setting with the team. He has also, on occasion, discussed progress and plans with patients’ carers.

Picture below shows Stroke Unit staff in the room where the videolink with Dr Barber takes place

For further information relating to the work in NHS Western Isles please contact [email protected] or [email protected] (Joan Frieslik, Ward Manager, Stroke Unit, Western Isles Hospital)





41

8 Use of SSCA data in researchAs noted in section 2.1 the Research Subgroup of the SSCA Steering Committee continues to oversee the use of SSCA data in research. The datasets are primarily available for researchers based in Scotland who have contributed to the Audit, but open to other researchers also.

This section of the report briefly outlines work undertaken by Dr Sarah Wild comparing SMR01 (Scottish Morbidity Record) and SSCA data, CHSS Fellow Melanie Turner’s work to date using the SSCA dataset and an overview of the work of the Scottish Stroke Research Network.

Information about the SSCA Research Subgroup and forms for requesting data are available on the SSCA website (http://www.strokeaudit.scot.nhs.uk/Research.html).

8.1 Comparison of routine hospital admissions data with SSCA data – an overview (Dr Sarah Wild, Reader in Epidemiology and Public Health, University of Edinburgh and Honorary Consultant in Public Health, NHS Lothian and Caroll Brown, Senior Information Analyst, ISD)

Scottish Morbidity Records collect information about certain activities within NHS Scotland. SMR01 forms an episode-based record for all non-psychiatric, non-obstetric acute hospital admissions in Scotland. A record is formed when a patient is discharged from hospital, changes consultant or is transferred to another hospital or department. The tenth-revision of the International Classification of Diseases (ICD-10) is used to assign codes to diagnoses. Approximately one million records are created each year by clerical staff using clinical information to assign a primary and up to five secondary diagnoses. The data are widely used within the NHS and the Scottish Government.

Data Quality Assurance Assessments are performed periodically and suggest that 88% of the sample of records had the correct codes. However I64 (the ICD-10 code used for stroke, not specified as haemorrhage or infarction) was one of the four codes that was most commonly incorrectly coded. Co-morbidities such as diabetes are under-recorded and there are major variations between hospitals in coding quality. It is recognised that both clinical staff and coders could improve data quality.

The SSCA collects data from all hospitals managing acute stroke in Scotland to support and improve quality of stroke care. This information has been used to make comparisons with the SMR01 data on emergency admissions for stroke as the primary diagnosis (ICD-10 codes I61 [intra-cerebral haemorrhage], I63 [cerebral infarction] and I64). This comparison has been done twice using data from both sources linked by ISD NSS for 2000-2005 and 2006-2009. Records were considered to be matched when the dates of admission in an individual person from the two data sources were within two days of each other. The findings are summarised in figure 1 below.



42

Figure 1 Distribution of stroke records for Scotland between the SSCA and SMR01

2000-2005

SSCA

5,764

22%

SMR01

7,795

29%

Both

12,859

49%

2006-2009

SSCA

8,318

23%

SMR01

9,902

26%

Both

18,089

51%

The distribution of records among the three categories for people under 65 years of age (n=8,522 for 2006-2009) was very similar to the pattern observed for all ages.

There was variation between hospitals with proportions of records ranging from 3-48% for the SSCA only, 27-74% for the proportion appearing in both sources and 8-70% of mentions occurring in SMR01 alone across both time periods. Differences by Health Board are summarised in chart 15.


43

Chart 15 Percentage of total by datasource 2006 - 2009

0

10

20

30

40

50

60

70

80

% Matched

% SSCAS

% SMR

Ayr

shire

& A

rran

Bor

ders

Dum

frie

s&

Gal

low

ay

Fife

For

th V

alle

y

Gra

mpi

an

Gre

ater

Gla

sgow

& C

lyde

Hig

hlan

d

Loth

ian

Ork

ney

She

tland

Tays

ide

Wes

tern

Isle

s

Sco

tland

Perc

enta

ge

Note: The data presented in chart 15 excludes NHS Lanarkshire as data was not collected in SSCAS.

In summary, the proportion of strokes recorded on both the SSCA and SMR01 has increased slightly between 2000-5 and 2006-9. However, numbers of cases are still slightly lower in the SSCA (26,407 in 2006-9) than in SMR01 (29,291 in 2006-9). It is possible that some of the strokes identified in the SSCA may have been associated with coding of stroke as a secondary cause of admission in SMR01. It is not possible to tell which is the most reliable data source from these comparisons and further validation using record review is required to check the completeness and accuracy of both data sources (see Melanie Turner’s report of work in NHS Grampian, section 8.2).

For further information relating to this work please contact [email protected] or [email protected].

8.2 Comparison of routine hospital admissions data with SSCA data in NHS Grampian (Melanie Turner, Research Fellow, Division of Applied Health Sciences, University of Aberdeen)

Previous work carried out by Dr Sarah Wild (section 8.1) showed variations between strokes recorded in the SMR01 and the SSCA.

The correlation between stroke diagnosis in SMR01 and the SSCA for data recorded for Aberdeen Royal Infirmary was investigated to establish possible reasons for the variations.

Data were obtained from Health Intelligence in Grampian for all SMR01 entries where an ICD10 code of I61, I63, I64 or G45 was entered as the main condition between 01.01.2010 and 31.10.10. Data were obtained from the audit co-ordinator for all entries on the SSCAS in Aberdeen for the same time period. Caldicott Guardian approval was obtained and all data were managed according to standard data protection protocols.





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Initial matching confirmed 60.6% of the total were recorded in both the SSCA and SMR01, while 31.6% were only in the SSCA and 7.8% only in SMR01.

Case-note review was then carried out. Of the entries only on SMR01, some had already been entered in the SSCA then discounted and excluded because they did not have a stroke, and one entry was double counting of a ward transfer. Of the remaining entries, 29 were confirmed to have had a stroke diagnosis and should have been in the SSCA and the remaining 19 which had been coded with stroke as the main diagnosis had another diagnosis following case note review. The possible reasons for stroke diagnosis not being picked up by the SSCA included the death of a patient soon after hospital admission; the patient had been discharged quickly, or transferred to a hospital out-with the area.

Of the entries only in the SSCA, reasons for not appearing in SMR01 include, being coded as G45 (TIA) in SMR01, being missed due to different admission hospitals, or having stroke as a secondary diagnosis code or no mention of stroke in the admission codes. For a high number of entries the most common main and other diagnosis codes were fractures; other cerebrovascular diseases; other non-traumatic intracranial haemorrhage; pneumonitis due to solids and liquids; syncope and collapse; dizziness and giddiness; headache; other paralytic symptoms; and unspecified injury to head.

The results from this study suggest that the SSCA more accurately represents the number of strokes occurring in Aberdeen than SMR01 for the period 01.01.2010 to 31.10.10, 95.6% versus 78.2%. Both datasets however still did not accurately represent all patients who had suffered a stroke.

The results from this analysis are different from those previously carried out. Possible reasons for this include the inclusion of G45 codes in this analysis, individual case note review to confirm diagnosis and more detailed information on secondary diagnosis codes and hospital admission codes. The SSCA coding may have improved due to training and increased experience of audit staff.

It is important that this work should be further investigated in other areas of Scotland to see if similar results would be obtained. This would allow greater validation of the SSCA dataset and show its robustness in comparison to SMR01 and demonstrate which data source most accurately represents the number of strokes occurring in Scotland. This would be beneficial in order to determine the provision of adequate patient care, stroke services and resources.

Using routine data to answer important questions about the optimal care of stroke and TIA patients in Scotland?

The process of linking and anonymising the SSCA dataset to inpatient (SMR01) and death certification data within ISD is ongoing.

Important research questions will be answered once the data have been linked, these include

- Further validation of the SSCA data against SMR01 diagnosis of stroke from 2010 onwards;

- Investigation of the benefits of Stroke Unit care – does it affect outcomes and impact on long term survival of patients looking at 30 day and 6 month case fatality?;

- Impact and outcomes (death, 30 day and 6 month mortality) following thrombolysis treatment; and

- The stroke and cardiovascular event rate following outpatient clinic attendance.

For further information relating to this work please contact [email protected].



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8.3 Scottish Stroke Research Network (Professor Matthew Walters, Clinical Pharmacology, Research Institute of Cardiovascular and Medical Sciences, University of Glasgow)

The NHS Research Scotland (NSR) Scottish Stroke Research Network (SSRN) aims to expand stroke research in Scotland whilst ensuring it is of high quality, timely and better tailored to the needs of the people of Scotland. The network is funded by the Chief Scientist Office and works effectively with partner networks across the UK.

The SSRN supports eligibly-funded clinical trials and other well-designed studies, all of which are assessed by an expert committee prior to adoption. Our portfolio spans a broad range of high quality academic and commercial research activity covering all aspects of cerebrovascular disease including prevention, acute treatment and rehabilitation.

We support very large clinical trials such as IST3 (Third International Stroke Trial (Thrombolysis) - http://www.dcn.ed.ac.uk/ist3/) and CLOTS (Clots in Legs Or sTockings after Stroke - http://www.dcn.ed.ac.uk/clots/), which have potential to improve the treatment of stroke patients on a global scale. Our portfolio also includes cutting-edge translational work such as PISCES (Pilot Investigation of Stem Cells in Stroke - http://ctru.leeds.ac.uk/pisces), the first clinical trial of stem cell therapy in stroke.

The network is highly active and fully engaged with the stroke research community: as of March 2011 the SSRN had exceeded its aspirational recruitment targets for all studies. The total recruitment of Scottish patients into SSRN trials was 1,422, equivalent to approximately 12% of all patients admitted to hospital in Scotland with stroke.

The SSRN aims to build on this success in 2012, and further cement Scotland’s reputation as a global leader in stroke research.

For further information relating to this work please contact [email protected].

http://www.dcn.ed.ac.uk/ist3/

http://www.dcn.ed.ac.uk/clots/

http://www.dcn.ed.ac.uk/clots/

http://ctru.leeds.ac.uk/pisces



46

List of References1. The Scottish Government, Better Heart Disease and Stroke Care Action Plan. Edinburgh,

Scotland: 2009. http://www.scotland.gov.uk/Publications/2009/06/29102453/0

2 Scottish Intercollegiate Guidelines Network (SIGN). Management of Patients with Stroke or TIA: Assessment, investigation, immediate management and secondary prevention. Edinburgh, Scotland: SIGN (No. 108); 2008. http://www.sign.ac.uk/guidelines/fulltext/108/index.html

3. The Healthcare Quality Strategy for NHS Scotland, Scottish Government, May 2010

4. http://scotland.gov.uk/Topics/Health/NHS-Scotland/NHSQuality/qualityambitions

http://www.scotland.gov.uk/Publications/2009/06/29102453/0

http://www.sign.ac.uk/guidelines/fulltext/108/index.html

http://www.sign.ac.uk/guidelines/fulltext/108/index.html

http://scotland.gov.uk/Topics/Health/NHS-Scotland/NHSQuality/qualityambitions


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Appendix A: Managed Clinical NetworksFollowing publication of the 2011 SSCA National Report Hazel Dodds (SSCA Clinical Coordinator, ISD) and Katrina Brennan (National Action Plan Coordinator, Scottish Government) visited all Health Boards in Scotland to meet with stroke clinical teams, stroke MCNs, radiologists, senior managers/ executives, planners and other relevant personnel with input to stroke care locally. The meetings were held between October 2011 and June 2012 therefore the Boards reviewed early may have progressed some of the issues highlighted below.

The meetings were well attended in all Boards. There was evidence of improvements in practice in most areas and many actions were being taken forward to further improve the delivery of stroke care locally and ultimately improve performance against the stroke admission HEAT target and NHS QIS standards.

There were key achievements that were replicated across most Boards: ● Improved admission to Stroke Unit by the day following admission; ● Stroke teams providing ‘outreach’ service to ensure that all stroke patients in the hospital

have the best pathway and have the key elements of care coordinated even when they are not able to be admitted to the Stroke Unit;

● All areas have immediate scanning available 24/7 for patients eligible for thrombolysis (other than Orkney who have no CT scanner and will be dependent on timing of airlift to Aberdeen); and

● Pre-alert by Scottish Ambulance Service when stroke patient en route to A&E.

There were some common barriers noted by Boards that prevented them from improving their practice and ultimately their performance:

● CT imaging on day of admission remains an issue in most Boards for a variety of reasons, e.g. delays in referral process, allocation of specific inflexible CT slots, availability of scanner etc. Stroke clinical teams are now working with radiology colleagues to identify delays and improve the patient pathway to CT imaging. There was a national meeting held on 17th May 2012 to discuss this issue. A review of NHS QIS standards is underway and this standard may change to be measured in hours rather than day of admission;

● Use of Clopidogrel instead of Aspirin in the acute management of stroke was increasing. This has been discussed at all Board meetings in relation to the current evidence which continues to support the use of Aspirin in the acute phase of stroke with Clopidogrel prescribed at 14 days; and

● Person dependent services (e.g. assessment of patients by stroke clinicians, coordinating admission to the Stroke Unit, swallow screening in other wards, running of outpatient clinics etc.) were an issue in some Boards. When an identified person was absent specific roles/ tasks were not completed. Boards are now looking to ensure that all responsibilities have back up.

Hazel and Katrina have summarised (by Board) some of the key achievements and issues raised at the Board meetings.


48

NHS AYRSHIRE AND ARRAN Key achievement(s):

● Direct admission from A&E to Hyperacute Stroke Unit (meeting HEAT target routinely) for rapid assessment by the stroke team for all patients with stroke as their most likely diagnosis;

● Thrombolysis now delivered at both hospital sites (Mon-Fri 9-5) and are progressing to cover out of hours period also. It was anticipated that an extended service would commence at Ayr Hospital in January 2012; and

● Consistently exceed the required standard in relation to TIA patients from referral to being seen in a neurovascular clinic.

Key issues: ● Lower number than anticipated being thrombolysed – despite FAST campaign many

patients were still delaying contacting their GP or waiting for a home visit before being referred later in the day therefore out with the time window for thrombolysis. Work is ongoing with GP practices and the general public to highlight the need for fast referral to hospital;

● Need to maximise the telehealth link between the two hospitals in NHS Ayrshire & Arran; and

● CT brain scanning on day of admission remains a challenge and one which the MCN are working closely on with radiology colleagues to try and improve the pathway including ordering the CT timeously and appropriately.

NHS BORDERSKey achievement(s):

● Stroke care pathway reviewed during LEAN project and revised pathway agreed that has resulted in improved access to the Integrated Stroke Unit, though there are still some issues with consistency;

● Development of exception reporting and escalation policy for HEAT target breeches with the support of the Chief Executive;

● Rolling programme of education in relation to swallow screen has had an impact with the data showing that patients not getting to the Stroke Unit were also being screened; and

● Consistently achieve the required standard in relation to TIA patients from referral to being seen in a neurovascular clinic.

Key issue(s): ● Unable to provide direct admission to the Integrated Stroke Unit due to medical cover; ● Issue with person dependent service, e.g. Stroke Coordinator role. The Board are looking

at how this can be covered by other members of the stroke clinical team; and ● Lower number than anticipated being thrombolysed – Borders provide thrombolysis 9-5

but only when Stroke Physician is available. Out of hours use Lothian hub but this does not cover in hours when Stroke Physician is not available.


49

NHS DUMFRIES AND GALLOWAY (D&G)Key achievement(s):

● Consistently exceeding Stroke Admission HEAT target with significant improvement since last year. This is due to a number of changes, e.g. flow of patients from the Medical Admissions Unit (MAU) to the Stroke Unit more timely with immediate triage by stroke team within hours and daily visit to MAU by Stroke Specialist Nurse;

● Improvements in swallow screening at Dumfries & Galloway Royal Infirmary due to increased training, introduction of swallow screen labelling system and active exception reporting with feedback provided to ward staff. (There remain inconsistencies at Galloway Community Hospital which are being reviewed by the MCN); and

● CT scanning better than national average and significant improvement since last year.

Key issue(s): ● Variances noted in relation to prescribing of Aspirin which does not correlate with CT

scanning data; and ● Education of staff (minimum of STARS) in ward at Galloway Community Hospital in order

to meet the HEAT target criteria for an area with ‘designated stroke beds’.

NHS FIFEKey achievement(s):

● The HEAT target was consistently achieved prior to the move from QMH to RVH, since the move performance has been affected due to the new pathway being established. The performance however is now improving again and a well-defined pathway is in place; and

● Better performance than the national average in relation to CT scanning. Radiology working with the stroke team to facilitate early scanning and prioritising stroke patients by extending the availability of scanning beyond 5 pm.

Key issue ● Despite good pathway documents relating to swallow screen, performance remains

inconsistent, agreed to explore other processes to improve performance; and ● Out patient referral processes are not efficient, it was noted that the MCN need to raise

awareness with GPs of all clinics available to maximise appropriate use of TIA slots.

NHS FORTH VALLEY (FV)Key achievement(s):

● Admission to Stroke Unit has improved since moving to the new Forth Valley Royal Hospital in July 2011. At the time of the meeting in December, it was noted that there had been no instances when a stroke patient could not be admitted direct from the Combined Assessment Unit to the Stroke Unit; and

● Regularly achieve the required standard in relation TIA patients from referral to being seen in a neurovascular clinic.

Key issue(s): ● Small independent audit identified that all patients admitted to the Stroke Unit were being

swallow screened on arrival, however others not admitted to the Stroke Unit were not and this was having an impact on performance. The MCN are reviewing training of staff in the


50

Clinical/ Acute Assessment Units and also documentation in order to improve swallow screening for patient safety and ultimately performance against the standard;

● Issues identified in relation to the early prescribing of Aspirin e.g. first dose prescribed for following morning, raising awareness with hospital at night and out of hours teams. Most patients in Forth Valley were scanned within 24hrs and therefore timely prescribing of Aspirin should not be an issue; and

● Sustainability issue noted regarding neurovascular clinics due to medical cover for the clinics, but the team are aware of this and plans are in place.

NHS GRAMPIANKey achievement(s):

● Consistently admitting patients to the Stroke Unit at Aberdeen Royal Infirmary on same day and by the day following admission, exceeding the requirements of the interim HEAT target;

● Above average rate of thrombolysis at Aberdeen Royal Infirmary – 15% of stroke patients are thrombolysed; and

● Consistently meet and exceed the referral to seen at neurovascular clinic outpatient standard at Aberdeen Royal Infirmary.

Key issue(s): ● Inconsistent pathway for admission of acute stroke patients to Dr Gray’s Hospital, Elgin; ● Lack of evidence in the data of thrombolysis activity at Dr Gray’s, though staff noted that

patients had been thrombolysed on site. Issues in relation to Thrombolysis Governance relating to these patients; and

● Swallow screen poor at Aberdeen Royal Infirmary compared to day of admission data.

NHS GREATER GLASGOW & CLYDE (GG&C)Key achievement(s):

● Since moving the Stroke Unit to the main hospital last year patients are routinely being admitted to the Stroke Unit by the day following admission at the Inverclyde Royal Hospital. Other standards have also improved due to this, e.g. swallow screen and aspirin;

● The Southern General Hospital and the Western Infirmary are consistently exceeding the interim HEAT target for Stroke Unit admission; and

● Access to CT imaging on day of admission is achieved for >75% of patients at the Southern General Hospital and the Western Infirmary which is above the national average.

Key issue(s): ● Inconsistencies across sites in relation to swallow screening, in particular at Royal

Alexandra Hospital (RAH), Paisley where performance continues to be poor with no improvement documented in the past two years. The MCN are aware of this and plan to meet with colleagues in RAH to clarify what the issues are and ensure improvement in the future in particular in relation to patient safety which will also result in improved performance against standards; and

● Use of Clopidogrel instead of Aspirin in the acute management of stroke at Western Infirmary has had an effect on Aspirin performance. It was noted at the meeting that


51

Aspirin was being used acutely in the other hospitals, though again this was not always reflected in the data. The MCN undertook to review Aspirin prescribing in all areas.

NHS HIGHLAND (first visit to NHS Highland was not undertaken until July 2012 after publication of this report due to cancellation)

Key achievement(s): ● Stroke care pathway at Raigmore Hospital reviewed during LEAN project. Revised

pathway initially resulted in improved access to the Integrated Stroke Unit, however there are still issues with consistency. Project Group continue to review the pathway in partnership with the stroke team, A&E, medical receiving unit, radiology department, patients and carers;

● Meet and exceed the thrombolysis rate (per 100,000) despite the geography and rurality of NHS Highland; and

● Consistently meet and exceed the referral to seen at neurovascular clinic outpatient standard at Lorn and Islands Hospital.

Key issue(s): ● Inconsistent swallow screen at Caithness and Belford Hospitals compared to admission

data; ● Performance in relation to CT scanning is inconsistent and below the standard on all sites

and there is a need to examine the pathway for all sites; and ● Early prescribing of Aspirin is inconsistent across all sites and below the required standard.

NHS LANARKSHIRE (first visit to NHS Lanarkshire was not undertaken until June 2012 after publication of this report due to cancellation)

Key achievement(s): ● A robust pathway is in place which supports the HEAT target in the three hospitals. The

target has been met or exceeded since July 2011; ● The TIA outpatient service performs well across the three hospital sites and meets or

exceeds the target every month; and ● Exception reporting against the QIS standards has resulted in improvement in some of the

standards in particular at Hairmyres and Wishaw this year.

Key issue(s): ● Performance in relation to CT scanning is poor in relation to the standard and there is a

need to examine the pathway in particular at Monklands and Wishaw Hospitals; and

● There are inconsistencies with swallow screen at all three sites in particular at Hairmyres.

NHS LOTHIANKey achievement(s):

● Stroke front door checklist has been introduced at the Western General Hospital (WGH) with plans to roll out to all sites. The checklist is used as a prompt in relation to immediate stroke care and also to aid collection of information in relation to the standards. This is not always fully completed and further training is planned to improve it’s use;

● CT imaging audit (see section 7.2) carried out, radiologists and stroke teams working together to improve access to CT imaging for stroke patients; and


52

● The Western General Hospital exceeds the outpatient – referral to seen at neurovascular clinic every month, consistently reaching >90%. This is due to the TIA hotline introduced a couple of years ago.

Key issue(s): ● Slippage in admission to the Stroke Unit at RIE thought to be due to delayed discharges

and bed pressures across the hospital; and ● Inconsistent performance at St John’s Hospital thought to be due to person dependent

service. When the stroke physician or stroke specialist nurse were not available patients were not managed in the same way which is reflected in the performance. This was highlighted in particular in relation to swallow screening.

NHS ORKNEYKey achievement(s):

● Significant amount of training has been undertaken with the staff in the Assessment and Rehabilitation Ward but also with staff at the front door in the Acute Receiving Unit and in the Acute Ward. This training has contributed in particular to a significant improvement in the number of patients swallow screened on day of admission;

● Though there are no stroke physicians in NHS Orkney, all patients are reviewed by the stroke team in Aberdeen by video or teleconference. This works very well and is seen as extremely beneficial to the patients’ care; and

● Pre-alert system in place and working well with the Scottish Ambulance Service, any patients with clinical diagnosis of stroke, confirmed onset and thought to be eligible for thrombolysis are notified to the Acute Receiving Unit at Balfour Hospital and preparation for airlift is started before the patient arrives at the hospital.

Key issue(s): ● No CT scanner in NHS Orkney therefore all patients requiring scanning need to be airlifted

to Aberdeen, this clearly has an impact on patients that could be eligible for thrombolysis; and

● Evidence of outpatient activity in NHS Orkney, no data is currently collected in the SSCA as the patients are seen in GP practices and reviewed by the Aberdeen stroke team by video link. It would be good to evidence the NHS Orkney TIA pathway by collecting this data.

NHS SHETLANDKey achievement(s):

● Though access to CT imaging was not 24/7 at the time of the meeting in November, there was no evidence of radiographers not being available to carry out a CT head scan in suspected stroke when required;

● All stroke patients are admitted directly to stroke designated beds within the medical unit; and

● Swallow screening has improved in the last year due to training provided by the Stroke Specialist Nurse and revised documentation that supports the Stroke Patient Pathway and ensures that all patients are swallow screened appropriately.


53

Key issue(s): ● It was noted that there can sometimes be a delay in contacting a radiologist to discuss

stroke patients not eligible for thrombolysis, often up to an hour.

NHS TAYSIDEKey achievement(s):

● Since April 2011 NHS Tayside has been consistently meeting and exceeding the HEAT target. There was a dip noted in Perth Royal Infirmary (PRI) in January due to specific bed management issues but they are now exceeding the target again. This has in part been due to the adoption of a ‘pull through’ of patients from admissions wards in both Ninewells and PRI to the Stroke Units and improved communication between staff in both areas;

● Daily/ weekly/ monthly exception reporting in both Ninewells and PRI has contributed to improvements in stroke care and ultimately performance against standards; and

● Access to CT imaging at PRI has improved and has been consistently >70% for most of 2011 which is better than the national average.

Key issue(s): ● There continues to be delays to CT imaging at Ninewells Hospital in part due to delays

in referral but also due to inflexible slots and access to the scanner. The pathway to CT imaging and provision of flexible slots is being actively reviewed by the stroke MCN and clinical teams with issues/ performance discussed at the Stroke Improvement Board and recently escalated to the Medical Director;

● An issue was noted in relation to the transferring of patients between departments for thrombolysis and access to portering in Ninewells. This is being actively reviewed by the stroke MCN and related service managers;

● Patients assessed as FAST positive within Perth and Kinross have a pre-alert to A&E in Perth Royal Infirmary and Ninewells Hospital. All Scottish ambulance staff are aware of the time critical nature of a stroke patient regarding potential thrombolysis. The low numbers of patients being thrombolysed in PRI thought to be due to the rurality of Perth & Kinross and the patients getting to the hospital within the time window. The MCN in consultation with the SAS is reviewing training requirements in relation to FAST and thrombolysis awareness; and

● Referral to neurovascular clinic at Stracathro Hospital has always exceeded the standard of 80% but has dipped in 2011. This has been discussed with the relevant clinician and is thought to be due to availability of clinic slots, this is being reviewed by the MCN.

NHS WESTERN ISLESAs noted previously in this report there was an issue with data collection in the Western Isles in 2011 and when reviewed it was agreed that the data was incomplete and inaccurate in some areas. Due to this, colleagues from ISD and NHS Western Isles agreed that Western Isles inpatient data should not be presented in the 2012 National Report. Outpatient and thrombolysis data have been included.

Key achievement(s): ● Most stroke patients are admitted to the Integrated Stroke Unit though some via the High

Dependency Unit if they have been thrombolysed. The stroke clinical team have initiated contacting A&E on a daily basis to ensure that all patients with stroke as the most likely


54

diagnosis are being admitted to the Integrated Stroke Unit and not elsewhere in the hospital;

● Swallow screen training delivered in all areas and confident that all relevant patients are being swallow screened though there remain some issues with documentation and this continues to be reviewed; and

● Access to CT imaging at Western Isles Hospital was good and in most months above the national average.

Key issue(s): ● Thrombolysis governance protocol not in place. MCN and stroke team are currently

developing a protocol, how/ when patients will be discussed and an appropriate escalation policy;

● Though performance in 2011 in relation to outpatients referral to clinic has been consistently good, there may be sustainability issues in the future due to medical cover. This is currently being reviewed by the MCN; and

● Some issues raised in relation to equitable access to services due to the rurality of NHS Western Isles. The MCN are reviewing where access to services can be enhanced or are investigating extending the use of telemedicine, e.g. in relation to care of stroke patients in the community.


55

Appendix B: Additional InformationAdditional information is available on the SSCA website:

● Aims and methods of the audit. http://www.strokeaudit.scot.nhs.uk/about.htm

● Audit documentation, e.g. data collection forms.

http://www.strokeaudit.scot.nhs.uk/Participants/main.html

● Core dataset definitions. http://www.strokeaudit.scot.nhs.uk/Participants/main.html

● Current Steering Committee members. http://www.strokeaudit.scot.nhs.uk/about/SG_files/SC_List.pdf

● Contact details of Project Team. http://www.strokeaudit.scot.nhs.uk/contact.htm

● Previous Annual Reports. http://www.strokeaudit.scot.nhs.uk/reports.html

● Information on Research relating to SSCA. http://www.strokeaudit.scot.nhs.uk/Research.html

Information on Quality standards.

http://www.strokeaudit.scot.nhs.uk/Quality.html

● Information for Patients and Carers. http://www.strokeaudit.scot.nhs.uk/Patients.html

http://www.strokeaudit.scot.nhs.uk/about.htm



http://www.strokeaudit.scot.nhs.uk/about/SG_files/SC_List.pdf

http://www.strokeaudit.scot.nhs.uk/contact.htm



http://www.strokeaudit.scot.nhs.uk/Quality.html

http://www.strokeaudit.scot.nhs.uk/Patients.html


56

AcknowledgementsThis report could not have been written without the help of a great many people. This includes:

● Patients with stroke who have contributed medical information to the audit. ● Audit, clinical, IT and Managed Clinical Network staff at all units participating in the audit

who ran their local data collection, provided local reports and commented on drafts of this National Report.

● The SSCA Audit Team and ISD Publications Team as part of the Information Services Division of NHS Scotland who co-ordinate and collate the necessary information to produce the report and support the publication of the National Report.

● Members of the Report Writing Sub-Group of the SSCA Steering Committee who have contributed to the writing of and commented on drafts of this report.

● The Scottish Government through the CHD & Stroke Strategy providing funding for the Scottish Stroke Care Audit.

This Annual National Report was prepared by Professor Martin Dennis, Hazel Dodds, Robin Flaig, David Murphy, Jan Cassels, Alan Reekie, Professor Peter Langhorne, Dr Christine McAlpine and Dr Mary-Joan Macleod, with contributions from Health Boards and partner organisations.

Scottish Stroke Care Audit logo designed by Definitive Studio® Graphic Design and Communication.

Contact details: studio 01896 750867

email: [email protected]

website: www.definitivestudio.co.uk

This report is also available as an Easy Access Public Summary, this version of the report can be found on the SSCA website (http://www.strokeaudit.scot.nhs.uk/reports.html).

We are grateful to Chest Heart & Stroke Scotland, the Stroke Association, Speakability, patient/ carer groups and health professionals that provided feedback on the 2011 Public Summary and those involved in reviewing the drafts of the 2012 Public Summary.


www.definitivestudio.co.uk



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ContactsIf you have any general questions about stroke care in your local area please contact your local Stroke Managed Clinical Network.

Health Board Contact Name Phone Number Email Address

Ayrshire & Arran Denise Brown 01563 825818 [email protected]

Borders Sandi Haines 01896831869 [email protected]

Dumfries & Galloway Christine Cartner 01387 244227 [email protected]

Fife Morag Maillie 01592 226841 [email protected]

Forth Valley David Munro 01786 457304 [email protected]

Grampian Lorraine Urquhart 01224 555380 [email protected]

Greater Glasgow & Clyde Camilla Young 0141 314 0220 [email protected]

Highland Christian Goskirk 01408 664078 [email protected]

Lanarkshire Katrina Brennan 01236 707724 [email protected]

Lothian Morag Medwin 0131 537 9208 [email protected]

Orkney Nickie Milne 01856 888023 [email protected]

Tayside Gail Smith 01307 474157 [email protected]

Shetland Kerry Russell 01595 743632 [email protected]

Western Isles Chrisanne Campbell 01851704704 [email protected]

Website http://www.strokeaudit.scot.nhs.uk















Http://www.strokeaudit.scot.nhs.uk


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Any questions about the SSCA should be referred to the Co-ordinating Centre. Please refer questions on:

● this report to Hazel Dodds, Robin Flaig, David Murphy or Alan Reekie; and ● the SSCA computer system to Robin Flaig.

For general questions about the Audit please contact Hazel Dodds, National Clinical Coordinator for the SSCA.

Hazel DoddsClinical Coordinator Gyle Squarephone: 0131 275 7184 1 South Gyle Crescentemail: [email protected] Edinburgh, EH12 9EB

Robin FlaigQuality Assurance Manager University of Edinburghphone: 0131 537 3127 Division of Clinical Neurosciencesemail: [email protected] Bramwell Dott Building, Western General Hospital, Crewe Road, Edinburgh, EH4 2XU

David MurphySenior Information Analyst Gyle Squarephone: 0131 275 6624 1 South Gyle Crescent, email: [email protected] Edinburgh, EH12 9EB

Alan ReekieSenior Information Analyst Gyle Squarephone: 0131 275 6705 1 South Gyle Crescent, email: [email protected] Edinburgh, EH12 9EB

If you have general questions about stroke care in Scotland please contact Professor Martin Dennis, Chair of the Scottish Stroke Care Audit and the National Advisory Committee for Stroke.

Professor Martin DennisClinical Lead University of Edinburghphone: 0131 537 1719 Division of Clinical Neurosciencesemail: [email protected] Bramwell Dott Building, Western General Hospital, Crewe Road, Edinburgh, EH4 2XU







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Stroke Care Audit Team Information Services Division (ISD)Gyle Square 1 South Gyle Crescent Edinburgh, EH12 9EB

Stroke Services in Scottish Hospitals · 2016-08-03 · 2012 National Report - Stroke Services in...

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