Scottish Stroke Care Audit Driving Improvement in Practice Iona Lancaster Anne Davidson
Scottish Stroke Care Standards 90% of all patients admitted to hospital with a diagnosis of stroke are admitted to the stroke unit on the day of admission, or the day following presentation at hospital, and remain in specialist stroke care until in-hospital stroke-related needs are met. (By day 1) 90% of patients have CT/ MRI imaging within 24 hours of admission. 90% of patients are screened by a standardised assessment method to identify any difficulty swallowing safely due to low conscious level and/ or the presence of signs of dysphagia on the day of admission before the patient is given any food/ drink or oral medication. The result of the screen/ test should be clearly documented in the patients notes. (By day 0) Aspirin is given on the day of admission or the following day for all patients in whom a haemorrhagic stroke, or other contraindication, as specified in the national audit, has been excluded. (By day 1) 80% of new patients with a stroke or TIA are seen within 4 days of receipt of referral to the neurovascular clinic. The MCN monitors the delay between arrival at the first hospital and administration of the bolus of recombinant plasminogen activator. 80% of patients receive the bolus within one hour of arrival.
SSCA Changing Culture Key in promoting the integration of audit findings into practice Key in prompting the development of a new stroke patient pathway for PRI Helped to change attitudes to stroke patients - patients with a stroke are now seen as a medical emergency Promoted increased staff knowledge in stroke. Setting up of a Stroke Pathway Quality Improvement Group Setting up exception reporting
Exception reporting Monthly (could be done daily or weekly) Looks at where we have failed to meet the standards Team pull medical, nursing and AHP records and look for the specific reason the patient/s failed e.g. This patient was on 75mg of aspirin pre admission, they were written up to have 300mg as stated in the standard however this was then withheld. The patient had also been thrombolysed. Dr Nair has followed this up with the member of medical staff involved. 2 patients failed to receive their thrombolysis within 1 hour and the reason for missing the target in both cases was a delay between CT and thrombolysis. Both these patients were admitted in the OOH period. Monthly report written and any instances where the pathway was not followed are addressed with individual staff members. Over time we have been able to identified the key issues and start to address them.
Role of the Acute Medical Unit AMU key to stroke Care in PRI Stroke was not a priority Exception reporting had identified the key issues in the AMU (stroke pathway not followed and stroke low priority) Needed an easy and quick way to ensure care was appropriate Team identified that they wanted an easy, see at a glance checklist of what had been done and more importantly what still needed to be done. Team developed a checklist Amended over and over
Creation Of Checklist
What has the Checklist Achieved? Helps staff focus on priorities Ability to answer queries regarding what was still to be done Assisting audit Focus on essential care bundle for Stroke patients Handover to Stroke Unit more effective
Improvements For Patients Safer care, evidenced based practise Patients are prioritised Quality assurance in care delivery Nurses knowledge of stroke care improved Nurses feeling empowered Transfer to Stroke Unit promptly Reduced time of patient unnecessarily remaining NBM
Stroke Patients Today In The AMU Staff actively promote appropriate treatment of patients thus ensuring : CT scanning occurs on day of admission swallow screen and neurological observations are prioritorised on admission and aspirin is appropriately prescribed Blood glucose monitoring undertaken Improvement in communication with Stroke Unit regarding in-patients and pending transfers Stroke unit actively pull patients into unit Feedback from the Stroke Unit which identifies staff who failed to follow the stroke patient pathway appropriately Regular stroke education for nursing staff
Feedback Staff feel they now have the confidence to safely look after a patient with a stroke Support from project lead in stroke care Statistics showing steady improvement
Future Ever evolving in correlation with national guidelines Continue to look at individual patients who fail to meet standards Open to criticism Patient feedback
Admission To The Stroke Unit By Day 1 Admission to the stroke unit by day 1 100 80 67 79 81 88 Percentage 60 40 20 7 0 2009 2010 2011 2012 2013 Year Percentage
Swallow Screening Swallow screening 100 80 70 78 87 90 85 Percentage 60 40 20 0 2009 2010 2011 2012 2013 Year Percentage
Brain Imaging 100 80 Brain Imaging 83 94 95 Percentage 60 40 20 0 47 49 2009 2010 2011 2012 2013 Year Percentage
Aspirin Aspirin Percentage 100 90 80 70 60 50 40 30 20 10 0 88 92 89 69 58 2009 2010 2011 2012 2013 Year Percentage
Outpatient Examination 100 90 80 70 % 60 50 40 30 20 10 0 64 77 77 69 78 75 72 75 79 60 69 64 100 92 100 2012 2013 Latest 12 months May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 % Outpatients Examination <= 4 days Quarterly Stroke Standard (Jan 2013)
Thrombolysis 100 90 80 70 % 60 50 40 30 20 10 0 52 41 40 0 0 0 50 0 60 50 33 33 50 0 0 2012 2013 Latest 12 months May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 % Thrombolysed <= 60 mins Quarterly Stroke Standard (Jan 2013)