AGENDA ITEM 2.4 19 th February 2013 CARDIFF AND VALE UHB STROKE SERVICE Executive Lead: Director of Therapies and Health Science Author: Director of Therapies and Health Science Contact Details for further information: Dr Richard Evans, Divisional Director for Medicine. Telephone 029 2074 2206 SITUATION This report is being presented to the Quality and Safety Committee following a presentation of the RCP Acute Stroke Audit (2012) results and further discussions at the February UHB Board meeting. The Royal College of Physicians (RCP) 2012 organisation self-reported audit was undertaken on the 2nd July 2012, and reported at the end of November 2012. The audit includes all acute stroke provider organisations in England, Northern Ireland and Wales and was a self- assessment audit against criteria set out by the RCP. The report contains 8 domains, and enables comparisons by county and regions. Further information can be found at: http://www.rcplondon.ac.uk/sites/default/files/documents/ssnap-acute-organisationalaudit-2012-generic_report.pdf The Wales report can be viewed at: http://www.rcplondon.ac.uk/sites/default/files/documents/ssnap-acute-organisationalaudit-supplementary-report-for-wales.pdf The audit report for Cardiff and Vale UHB was disappointing, with a score of 63.8 (<2 point improvement from the 2010 audit), placing us 12/14 in Wales, and in the lower quartile of all participants. Not all LHBs have interpreted definitions in the same way, creating variance in consistency of completion of the audit. Welsh Government has further expectations for stroke services meeting 95% compliance with Acute Intelligent targets and actions plans for the "Together for Health" Stroke Delivery Plan was published in December 2012 : http://wales.gov.uk/topics/health/publications/health/reports/plan/?lang=en by the end of March 2013, with quarterly reporting to WG. As well as a poorer than expected performance in the RCP audit, the service is also struggling to meet its Tier 1 acute stroke bundle target and further scrutiny is required of the mortality data to give assurance. The stroke service has received 2 Coroner rule 43 notices, one in 2010 and one in 2012. Cardiff and Vale UHB Stroke Service Page 1 of 6 Quality and Safety Committee
Acute stroke services sit largely within the Medicine Division, though there are significant parts of the pathway within Primary Community and Intermediate Care Division, with other staff in Clinical Diagnostics and Therapeutics and Mental Health Divisions, Social Workers from Cardiff Local Authority, and 3 rd Sector Stroke Association staff. BACKGROUND RCP Audit The RCP audit was the first report under the new SSNAP, building on the 7 previous biennial rounds of the national sentinel stroke organisational audit. The UHB has a stroke service improvement group which develops and monitors stroke service plans and performance of the Tier 1 intelligent targets. Acute Stroke Intelligent Target Performance The first 24 hours has consistently been the hardest domain to sustain improvement. Ring-fencing of stroke beds was supported in September 2012; however this has not been possible due to UHB wide unscheduled care constraints. If patients do not receive care on the acute stroke unit, care is compromised. There are additional intelligent targets for rehabilitation which are collected, but not part of Tier 1 reporting. Mortality data The CHKS mortality data presented in the performance report to the UHB Board in February demonstrated an increase in mortality for the dates June 12 compared with June 11. However, this data is not consistent with prospective mortality data collected by the stroke team Stroke Delivery Plan 2013-14There is a requirement for each LHB to develop a stroke delivery plan to meet the exceptions of this plan. Rule 43 The 2010 Rule 43 related to an expired date licensed drug used as part of a clinical trial. The 2012 Rule 43 related to primary care assessment of new neurological symptoms in an anti-coagulated patient ASSESSMENT Cardiff and Vale UHB has implemented many service improvements during in the last two years and improved stroke outcomes for patients. The data in the RCP report does not reflect the rate of change in thrombolysis, clot retrieval, professional engagement and the cooperation between many different professional groups that has been developed. It does however capture the organisational issues that need addressing, including constraints in accessing the acute stroke unit. RCP Audit Result Cardiff and Vale UHB Stroke Service Page 2 of 6 Quality and Safety Committee
The summary domain scores were: DOMAIN SCORE AREAS TO IMPROVE 1: Acute care 50/100 Ward rounds 7 days/week Continuous physiological monitoring Access to stroke unit 2: Organisation 10/100 Early supported discharge multidisciplinary of care service, with access within 48 hours to specialist staff All stoke patients in acute stroke unit, not on outlying wards Sufficient stroke beds to enable all stroke patients to be treated in acute stroke unit Specialist stroke/neurology community team for 3: Specialist Roles 4: Interdisciplinary services( stroke unit) 5:TIA/Neuorvasc ular service 6: Quality Improvement, training and research 7:Team meetings 79.2/100 8: Communication with patients and carers TOTAL SCORE 63.8/100 longer term management 60/100 Ward rounds 7 days/week Specialist therapists /nurses need to be band 7 or above on acute stroke unit Patients should not wait for a physiotherapist to move patients out of bed 55/100 Qualified staff per 10 stoke beds below median for: Clinical Psychology, dietetics, Occupational Therapy, Physiotherapy, Speech and Language Therapy, Pharmacy 6 or 7 day working needed for OT, Physiotherapy and Speech and Language therapy 87/5/100 Usual waiting time for carotid image for high risk TIA patients required same or next day 7 days a week 75/100 Need to funding for nurses and therapists for more than 10 external study days p.a. Need team meetings to be more than twice/week consistently Need social worker to be present at meetings 93.8/100 Outpatient consultations need to make management plans available in writing The stroke service improvement group are developing an action plan to identify all areas where improvements are needed. Medicine is the lead Division for stroke, but will also require support from PCIC and Clinical Diagnostics and Therapeutics as well as the planning team to include actions as part of the 2013-14 operational plans. If developments in the stroke service are not prioritised and implemented by 2014 it is likely that the SSNAP audit result will remain in the lower quartile. Acute Stroke Intelligent Target Performance Cardiff and Vale UHB Stroke Service Page 3 of 6 Quality and Safety Committee
December 2012 Intervention Total No. of patients within the care bundle in this period first 3 hours first 24 hours first 3 days first 7 days Of the total number of patients within the care bundle, number that were compliant with every element this period 38 38 100% 38 27 71% 38 37 97% 38 37 97% % Compliance There will be an RCP audit of stroke rehabilitation services during 2013, which potentially could show similar performance to the acute service, unless changes are made to improve the implementation of the agreed pathway, development of Early Supported Discharge (ESD) and staffing shortfalls addressed. Mortality Data The data demonstrate an increase in mortality by 4% from June 2011 and have highlighted specific peaks in data at three separate points during the year. The Director for I&I has met with the stroke team to scrutinise the data and undertake further analysis (further update will be provided in the Performance reporting current month mortality data). It is felt that a combination of factors have contributed to skew the data, which includes a coding backlog. Nevertheless, to seek assurance an audit is taking place of all case records of patients who died during this period. The mortality rate for June 2012 is considered to be within the range expected for European comparators. It should also be noted that stroke services which provide thrombolysis will have an increased rate of mortality within 30 days, compared with those which have lower levels of thrombolysis where the mortality rate is higher post 30 days. All stroke deaths will be discussed at a monthly stroke mortality review lead by the clinical lead for stroke, commencing February 2013. Cardiff and Vale UHB Stroke Service Page 4 of 6 Quality and Safety Committee
Stroke Delivery Plan 2013-14 Medicine Division are working with the Stoke clinical lead to develop the stroke delivery plan by end of March 2013. There is an expectation that this plan will be adopted by the Board and made publicly available on the UHB web site, along with quarterly updates. During February Medicine Division are focussing on access to the acute stroke unit, to revise the operation plan and implement changes to improve this element of the pathway. Other aspects for improvement will be included in the delivery plan. Rule 43 There is no connection between the 2 Rule 43 notices. Following the 2012 ruling, training has taken place with the practice involved and other GPs to reinforce the primary care actions required with neurological symptoms of anti coagulated patients. A presentation was given at the medical unit round on 1 February 2012, and shared with PCIC division highlighting key messages and actions for primary and secondary care. RECOMMENDATION The Quality and Safety Committee is asked to: NOTE the results of the SSNAP audit, and the underlying reasons for the audit scores. NOTE the plans in place to implement improvements and the leadership from the Medicine Division to effect change BE ASSURED that mortality reviews are taking place and rule 43 recommendations have been actioned. RECEIVE the 2013-14 stroke delivery plan at the next Quality and Safety Committee. Cardiff and Vale UHB Stroke Service Page 5 of 6 Quality and Safety Committee
Financial Impact Quality, Safety and Experience Standards for Health Services Risks and Assurance Equality and diversity This report has no financial implications Intelligent targets are monitored monthly and on-going patient experience is undertaken. Mortality rate required ongoing scrutiny to give assurance. Further concern relates to the acute stroke unit access, staffing resource and lack of Early supported discharge. Standard 7: Safe and Clinically Effective care. Reputational risk as audit reflects poorly compared to the quality of care received by the vast majority of patients. Tier 1 monitoring and ongoing mortality review provides assurance framework. Service meets equality and diversity requirements. Cardiff and Vale UHB Stroke Service Page 6 of 6 Quality and Safety Committee