Sentinel Stroke National Audit Programme (SSNAP)

Sentinel Stroke National Audit Programme (SSNAP) Help notes for acute organisational audit 2016 Clinical Standards, Royal College of Physicians, London. On behalf of the Intercollegiate Stroke Working Party. SSNAP acute organisational audit help notes 2016 i

Introduction The Royal College of Physicians Clinical Effectiveness and Evaluation Unit in the Clinical Standards Department first conducted the National Sentinel Stroke Audit in 1998 and 1999, and demonstrated that although there were widespread variations in standards across the country, much was being done at local level to change services. Improvements were therefore demonstrated in the second round (Rudd et al 2001). The new continuous SSNAP audit has high case ascertainment and frequent reports, the organisational audit provides the organisational context. The questions are well understood and comparable with the 2012 and 2014 audit. The audit is based on standards agreed by the representatives of the Colleges and professional associations of the disciplines involved in the management of stroke (see list of current members of the Intercollegiate Stroke Working Party in Appendix I). It covers the organisation of the stroke service. Aims of the SSNAP acute organisational audit 2016 1. To audit against the National Clinical Guideline and NICE Guideline for Stroke. 2. To enable trusts to benchmark the quality of their stroke services nationally and regionally. 3. To measure the extent to which the recommendations made in the 2014 SSNAP Organisational Audit have been implemented. 4. To measure the rate of changes in stroke service organisation since the implementation of the National Stroke Strategy and the publication of the National Audit Office Report. Planning the SSNAP acute organisational audit 2016 This is a multidisciplinary audit. Involving all the disciplines at the planning stage of the audit will help with subsequent stages of the audit, particularly when it comes to taking action on the results. Definition of a site Historically some larger trusts with several disparate sites may have registered each site separately to identify the differences between them. A site may include several hospitals and some include more than one trust. The term site is used throughout the proforma and questions relate to services across the site as constituted by the registration form and name of the site. They will receive individualised reports indicating their trust name and the site name. Where there is collaboration between trusts the name of the collaborating trust will also appear on the report. We are aware of ongoing reconfiguration of services across geographical areas and this audit has been devised to take account of a dynamic process. The survey will reflect this in the formulation of questions to obtain information about what stroke services are available for the population served by the acute trusts only. However, the provision of beds and staffing in the community setting has been undertaken in a separate postacute audit carried out by SSNAP in 2015 with national results being made public in December 2015. The audit tool The organisational audit data will be collected via a web based form on the internet to provide good quality data, and to speed up the analysis and reporting. There will be data validation checks to the system. Data sources The organisational audit uses hospital admissions data and management information. It requires the auditor to have access to information regarding the organisation of stroke services and it should reflect the organisation of the service on 1 July 2016. SSNAP acute organisational audit help notes 2016 2

Data collection time frame 13 June 08 July 2016 Data collection will take place between 13 June and 8 July 2016. A checking week will take place between 11 15 July 2016; sites must lock and export their data by the 8 July deadline. Once data are exported centrally on 15 July for analysis, it will not be possible to change answers. tify the helpdesk immediately if you anticipate any potential delays by email: ssnap@rcplondon.ac.uk or telephone: 020 3075 1500/1522. Auditors As previously, data will be collected by local trust or health board staff. The proforma should be completed by anyone in a position senior enough to have access to the information. This would normally be a clinical manager or senior member of the clinical staff. In order to promote the reliability of the results anyone completing the audit proforma should have access to the Help Booklet and the advice on screen accessed via the Help Button in the online version. The discipline and identity of the auditor will be known due to webtool registration. Data quality Clinical involvement and supervision Each trust will have a designated lead clinician who will have overall responsibility with the audit department for the data quality from their trust. Data analysis and reporting As for the previous rounds of the audit, data analysis would be carried out with full statistical support at the Clinical Effectiveness and Evaluation Unit of the Royal College of Physicians. The organisational report with comparative results will be sent to all participating trusts by end 2016. For further information please contact the SSNAP Helpdesk, Clinical Standards Department, Tel: 020 3075 1500/1522 The Royal College of Physicians, Email : ssnap@rcplondon.ac.uk 11 St Andrews Place Fax : 020 7487 3988 Regent s Park London, NW1 4LE SSNAP acute organisational audit help notes 2016 3

BASIC ORGANISATIONAL INFORMATION Once the questions in this section have been answered on the web tool, only certain questions will apply in the main body of the audit. Question A1 Data Item Data Definition Audit Help tes How many hospitals are covered by this form? Some sites may have more than one acute hospital. Please select from the dropdown list the hospital(s) that is covered by this form. NB in this question we are asking about acute hospitals which directly admit stroke patients or which routinely admit them within 7 days. SSNAP acute organisational audit help notes 2016 4

Acute Organisational Proforma SECTION ONE: ACUTE PRESENTATION Question 1.1 1.1(a) Data Item Data Definition Audit Help tes Which of the following options best describes the service at your site for patients during the first 72 hours after stroke? (i) We treat all of these patients (ii) We treat some of these patients (iii) We treat none of these patients If 1.1(iii) is chosen: Please select the name and RCP site code of the main hospital treating your patients for the first 72 hours This question has been included to take account of formal regional arrangements by which ALL patients are treated at another site for the first 72 hours before being repatriated for post 72 hour care. This is a very specific category of hospitals. If 1.1(iii) is chosen, you are asked to select the MAIN hospital treating your patients for the first 72 hours. NB Your RCP site code (for the organisational audit) will differ from your SSNAP team code (for the clinical audit). If 1.1(iii) is chosen, you will not be able to answer any questions related to pre 72 hour care i.e. the remainder of Section 1 (Q1.2 1.9), Section 2A (Q2.2 2.8) and Section 2C (Q2.14 2.20). This question should be answered on the basis of what happens generally, not what happens in exceptional examples. Please select one option only. Option (i) will be chosen by the majority of hospitals. Option (ii) will be chosen only by hospitals which have formal arrangements by which they treat patients for the first 72 hours some of the time e.g. on a rotational basis. Option (iii) will be chosen only by hospitals which have formal arrangements by which they do not treat patients during the first 72 hours e.g. London SUs. If more than one hospital provides care for your patients for the first 72 hours, please select the site from which the majority of patients are repatriated. Please call the SSNAP helpdesk if you have queries about how to answer this question. SSNAP acute organisational audit help notes 2016 5

1.2 Data Item Data Definition Audit Help tes Telemedicine Does the stroke service use telemedicine to allow remote access for the management of acute stroke care? If yes, which of the following do you use: Telemedicine is a system of remote patient assessment including review of brain imaging. It may include webcam but should always include clinician to clinician discussion to enable acute management of stroke patients by specialists not on site. Select 1.2(a) (i) and/or (ii) as appropriate. 1.2(a) (i) Remote viewing for brain imaging To review electronic version of scans. E.g. PACS images remotely. Tick all that apply. (ii) Video enabled clinical assessment To review patient condition and assessment via video link. 1.2(b) Do you operate a telemedicine rota with other hospitals? To include formal arrangements for transmitting images with clinicians at other hospitals; with regular training, reviews, audit and feedback. 1.2(c) Which of the following groups of patients are assessed using telemedicine? (i) Only patients potentially eligible for thrombolysis To establish which category of patients are assessed (either by review of electronic version of scans or view of patient condition and assessment via video) using telemedicine. Please select one option only. (ii) Some patients (regardless of eligibility for thrombolysis) (iii) All patients (who require assessment during times when telemedicine is in use) SSNAP acute organisational audit help notes 2016 6

1.3 1.4 Data Item Data Definition Audit Help tes Thrombolysis in your Hospital(s) What level of coverage does your site s thrombolysis service offer its stroke patients (i.e. by all hospitals covered by this site)? How many consultant level doctors from your trust are there on an on call thrombolysis rota? This is the longest possible duration of provision of service across all hospitals within your site if stroke patients can be admitted accordingly. The on call thrombolysis rota is not limited to a rota for your trust alone. If appropriate, it should refer to larger regional rotas of which consultant level doctors from your trust are a part. Please answer within a range of 0 24 hours. Only whole numbers are permitted If more than 20 consultant level doctors on the call thrombolysis rota please answer according to the 20 most frequently on the rota and include a comment indicating the precise number. 1.4(a) Which speciality is this consultant? Each column represents one consultant level doctor. Please select speciality of each consultant by row, making sure that the number of columns completed matches the number of consultants entered in 1.4. 1.5 Thrombolysis in other hospital(s) Does your hospital have a formal bypass arrangement with the local ambulance service to take stroke patients to a hospital where a thrombolysis service is available (during those times when you do not provide thrombolysis)? This refers to the presence of a contract between the ambulance trust and the relevant acute trusts in order for thrombolysis to be administered within the correct timeframe. This question is not applicable if your site provides a 7 day 24 hour thrombolysis service as answered in Q1.3. i.e. if 24 is answered for Q1.3 (i), (ii) and (iii). SSNAP acute organisational audit help notes 2016 7

1.6 Data Item Data Definition Audit Help tes Do you have an agreement with (an)other site(s) to provide thrombolysis for your patients (during the hours when your site does not provide it)? This refers to the presence of a contract between the relevant acute trusts in order of thrombolysis to be available 24 7 if it is not already. Answer no if your site provides a 7 day 24 hour thrombolysis service. If no questions 1.6(a) to 1.6(d) are not applicable. 1.6(a) 1.6(b) How many sites do you have an agreement with? Please give the name and RCP codes of each of these sites Please answer within a range of 1 6. Select the site name from the dropdown list 1.6(c) Does your site have a joint on call medical rota for thrombolysis with this/these site(s)? The joint on call medical rota for thrombolysis is not limited to a rota for your trust alone. If appropriate, it should refer to larger regional rotas of which consultant level doctors from your trust are a part. 1.6(d) What level of thrombolysis coverage is provided by your site in combination with the other site(s) for your stroke patients? This is the longest possible duration of provision of service across all hospitals if stroke patients can be admitted accordingly. Please answer within a range of 0 24 hours. Only whole numbers are permitted. If your thrombolysis service is available to stroke patients 12 hours a day and the other 12 hours are covered by agreements with other sites please enter 24, 24, 24. If your site offers 8 hours coverage a day, and an agreement with another site with coverage for an additional 12 hours a day, please enter 20, 20, and 20. Values entered can only be equal to or more than question 1.3. SSNAP acute organisational audit help notes 2016 8

1.7 Data Item Data Definition Audit Help tes Interventional Neuroradiology Does your site use intra arterial treatment (e.g. thrombectomy) to treat patients with acute stroke? Only select yes if you provide intra arterial treatment (e.g. thrombectomy) at your hospital(s) i.e. those primary admitting hospitals accounted for in A1. Select one option only. If 1.7 (iii) answered go to Section 2. 1.7(a) (i) Yes, at our site (ii) Yes, by referral to another site (iii) If by referral, do you thrombolyse some of these patients first? Select yes, by referral. only if patients are referred to a hospital outside of those accounted for in A1. If yes, by referrals is chosen the subsequent questions (Q1.7 (b) (d)) will be greyed out. The responses of the site to which your patients are referred will be used in your report. If by referral to another site, select the site name from the dropdown list. (this is not the same as the SSNAP code). If the site that you refer your patients to for thrombectomy does not participate in SSNAP e.g. The Walton Centre or the Queens Medical Centre, ttingham please select the check box given and add the name of the site to the comments (C)button. 1.7(b) If you carry out intra arterial treatment at your site, do you then refer them to another site once the treatment has taken place? 1.7(b)i If yes, enter site name/code below. The site code is not the same as the SSNAP Team code. Please select the site name from the dropdown list. (this is not the same as the SSNAP code) 1.7(c) What hours is the service available (either at your site and/or by referral?) This is the longest possible duration of provision of service across all hospitals if stroke patients can be admitted accordingly. The number of hours entered should reflect both on site and off site coverage, either individually or as a combination. If this service is available to stroke patients 12 hours a day Monday Sunday enter, 12, 12, 12. If it's available 24 hours a day Monday Friday, but only available 8 hours on Saturday and no hours on Sunday please enter 24, 8, 0. Range 0 24 hours. SSNAP acute organisational audit help notes 2016 9

1.8 Data Item Data Definition Audit Help tes How many consultant level doctors from your site carry out interventional neuroradiology (thrombectomy)? These are the doctors who perform thrombectomy but work primarily at your site only. This should not include doctors who work primarily at other sites; each doctor should only be counted at one site. Include doctors who have performed 1 or more thrombectomy procedures in the last 12 months. Either independently or under supervision. 1.8(a) For each of these consultants, please state their specialty. Please answer within a range of 1 10. If more than 10 consultant level doctors please answer according to the 10 most frequently performing thrombectomy and include a comment indicating the precise number. 1.9 How many acute stroke patients presenting to your site were treated either on site or by referral off site intra arterially between April 1, 2015 and March 31, 2016? Each column represents one consultant. Please select speciality of each consultant by row, making sure that the number of columns completed matches the number of consultants entered in 1.8. Please answer within a range of 1 2000 1.9(a) Of these patients, how many were treated: (i) At your site (ii) By referral off site Amounts entered for 1.9(a)i and 1.9(a)ii either as a combination or individually cannot exceed 1.9. Please answer within a range of 1 2000. SSNAP acute organisational audit help notes 2016 10

SECTION TWO STROKE UNITS Question Data Item Data Definition Audit Help tes 2.1 Details of hospitals Stroke unit beds solely for patients in first 72 hours after stroke Type 1 bed Stroke unit beds solely for patients beyond 72 hours after stroke Type 2 beds Stroke unit beds used for both pre and post 72 hour care Type 3 beds Please give details for each of the acute hospitals entered for A1. See definition of acute hospitals in A1. SECTION 2A: STROKE UNITS Beds for patients in first 72 hours after stroke (Type 1 beds). Care on stroke unit beds used solely for patients in the first 72 hours after stroke (please answer based on ALL beds noted in 2.1 (c). 2.2 How many of these beds have continuous physiological monitoring (ECG, oximetry, blood pressure)? 2.3 How many stroke consultant ward rounds are conducted on your acute stroke ward per week? Stroke specialist consultant A consultant with specialist skills in stroke. A stroke specialist has expertise in all 3 principal areas of stroke management (Prevention, Acute Stroke, Stroke Rehabilitation). This question reflects the NHS England 7 day working standard for acute care. If monitors are not fixed, consider how many beds respond according to the number of beds which can have concurrent use of mobile monitors. Ensure the figure entered is not more than total for 2.1(c). This question should reflect the number of times a week a specialist stroke consultant ward round is carried out directly review stroke patients. If you have 2 consultant led ward rounds 7 days a week please enter 14. If there is more than one location for these beds, please give an estimated average e.g. if there are 20 beds overall and 10 have ward rounds 7 times a week and the other 10 have ward rounds 5 times a week, you should put 6. If you have permutations outside of this please contact the SSNAP helpdesk Please answer within a range of 1 21. SSNAP acute organisational audit help notes 2016 11

Data Item Data Definition Audit Help tes 2.4 Is there immediate access to scanning for urgent stroke patients (as defined in the NICE The NICE clinical guidelines recommend that brain scanning should be performed immediately for people with acute stroke if any of the following apply: Guidelines) on these beds? Indications for thrombolysis or early anticoagulation treatment An anticoagulant treatment A known bleeding tendency A depressed level of consciousness (Glasgow Coma Score below 13) Unexplained progressive or fluctuating symptoms Papilloedema, neck stiffness or fever Severe headache at onset of symptoms 2.5 How many of the following nursing staff are there usually on duty at 10AM for these beds? Registered nurses Care assistants 2.6 How many nurses are there usually on duty at 10AM for these beds who are trained in the following? Swallow screening Stroke assessment and management This question refers to the number of individuals on the ward at 10am. Registered nurses are those defined as registered with the NMC as Registered Nurses (Adult). Care assistant includes the terms health care support worker, nursing auxiliary, or generic worker. Swallow screening refers to a formal swallow screen (performed by any member of the team). Presence or absence of the gag reflex is not sufficient as it is proven to be of little prognostic value for the ability to swallow. A nurse trained in stroke management would have stroke specific management experience i.e. can check for deterioration of symptoms and take necessary Please enter 0 if no nursing staff on duty. However, the total number of nursing staff (registered nurses and/or care assistants) must be more than 0 for each time period. As this question refers to individuals, only whole numbers are permitted. Only the nursing staff for the beds which are solely used for patients in the first 72 hours after stroke (i.e. the total entered for 2.1(c)) Please do not double count any nurses/care assistants listed in 2.10 and 2.17 Please enter 0 if no nursing staff with this specific training are on duty at 10am. As this question refers to individuals, only whole numbers are permitted. Only the nursing staff for the beds which are solely used for patients in the first 72 hours after stroke (i.e. SSNAP acute organisational audit help notes 2016 12

2.7 How many of the following nursing staff are there usually on duty at 10PM for these beds? Registered nurses Care assistants Data Item Data Definition Audit Help tes 2.8 What is the total establishment of whole time equivalents (WTEs) of the following bands of nurses for your Type 1 beds (beds solely for patients in the first 72 hours after stroke)? steps. Perhaps s(he) is trained in transfers. This question refers to the number of individuals on the ward at 10pm. WTEs Whole Time Equivalent An WTE of 1.0 means that the person is equivalent to a full time worker, while an WTE of 0.5 signals that the worker is half time etc. the total entered for 2.1(c)) Please do not double count any nurses listed in 2.11 and 2.18 Enter 0 if no staff of that grade. However, the total number of nursing staff (registered nurses and/or care assistants) must be more than 0 for each time period. Only the nursing staff for the beds which are solely used for patients in the first 72 hours after stroke (i.e. the total entered for 2.1(c)) As this question refers to individuals, only whole numbers are permitted. Please do not double count any nurses/care assistants listed in 2.12 and 2.19 Answer required for all Bands (1 8c) Enter 0 if no establishment. SECTION 2B: STROKE UNITS Beds for patients beyond 72 hours after stroke (Type 2 beds) Care on stroke unit beds used solely for patients beyond 72 hours after stroke (please answer based on ALL beds noted in 2.1 (d). 2.9 How many days per week is there a stroke specialist consultant ward round for these beds? Stroke specialist consultant A consultant with specialist skills in stroke. A stroke specialist has expertise in all 3 principal areas of stroke management (Prevention, Acute Stroke, Stroke Rehabilitation). If there is more than one location for these beds, please give an estimated average e.g. if there are 20 beds overall and 10 have ward rounds 7 times a week and the other 10 have ward rounds 5 times a week, you should put 6. If you have permutations outside of this please contact the SSNAP helpdesk. Please answer within a range of 1 7. SSNAP acute organisational audit help notes 2016 13

Data Item Data Definition Audit Help tes 2.10 How many of the following nursing staff are there usually on duty at 10AM for these beds? This question refers to the number of individuals on the ward at 10am. Registered nurses are those defined as registered with the NMC as Registered Nurses (Adult) Qualified nurses Care assistant includes the terms health care support Care assistants worker, nursing auxiliary, or generic worker. Please enter 0 if no nursing staff on duty at 10pm. However, the total number of nursing staff (registered nurses and/or care assistants) must be more than 0 for each time period. As this question refers to individuals, only whole numbers are permitted. 2.11 How many nurses are there usually on duty for these beds at 10AM who are trained in the following? Swallow screening Stroke assessment and management Swallow screening refers to a formal swallow screen (performed by any member of the team). Presence or absence of the gag reflex is not sufficient as it is proven to be of little prognostic value for the ability to swallow. A nurse trained in stroke management would have stroke specific management experience i.e. can check for deterioration of symptoms and take necessary steps. Perhaps s(he) is trained in transfers. Only the nursing staff for the beds which are solely used for patients beyond the first 72 hours after stroke (i.e. the total entered for 2.1(d)/ do not double count any nurses/care assistants listed in 2.5 and 2.17) Please enter 0 if no nursing staff with this specific training are on duty at 10am. As this question refers to individuals, only whole numbers are permitted. Only the nursing staff for the beds which are solely used for patients beyond the first 72 hours after stroke (i.e. the total entered for 2.1(d)).Please do not double count any nurses/care assistants listed in 2.6 and 2.18. 2.12 How many of the following nursing staff are there usually on duty at 10PM for these beds? This question refers to the number of individuals on the ward at 10pm. Please enter 0 if no nursing staff on duty at 10pm. However, the total number of nursing staff (registered nurses and/or care assistants) must be more than 0 for each time period. As this question refers to individuals, only whole SSNAP acute organisational audit help notes 2016 14

Data Item Data Definition Audit Help tes numbers are permitted. 2.13 What is the total establishment of whole time equivalents (WTEs) of the follow band of nurses for Type 2 beds? (beds solely for patients beyond 72 after stroke) WTEs Whole Time Equivalent An WTE of 1.0 means that the person is equivalent to a full time worker, while an WTE of 0.5 signals that the worker is half time etc. Only the nursing staff for the beds which are solely used for patients beyond the first 72 hours after stroke (i.e. the total entered for 2.1(d)). Please do not double count any nurses listed in 2.7 and 2.19. Answer required for all Bands (1 8c) Enter 0 if no establishment. SECTION 2C: STROKE UNITS Beds for both pre and post 72 hour care (Type 3 beds) Care on stroke unit beds which are used for both pre and post 72 hour care (please answer based on ALL beds noted in 2.1(e). 2.14 How many of these beds have continuous physiological monitoring (ECG, oximetry, blood pressure)? If monitors are not fixed, consider how many beds respond according to the number of beds which can have concurrent use of mobile monitors. Ensure the figure entered is not more than total for 2.1(e). 2.15 How many stroke consultant ward rounds are conducted on your acute stroke ward per week? Stroke specialist consultant A consultant with specialist skills in stroke. A stroke specialist has expertise in all 3 principal areas of stroke management (Prevention, Acute Stroke, Stroke Rehabilitation). This question reflects the NHS England 7 day working standard for acute care. This question should reflect the number of times a week a specialist stroke consultant ward round is carried out directly review stroke patients. If you have 2 consultant led ward rounds 7 days a week please enter 14. If there is more than one location for these beds, please give an estimated average e.g. if there are 20 beds overall and 10 have ward rounds 7 times a week and the other 10 have ward rounds 5 times a week, you should put 6. If you have permutations outside of this please contact the SSNAP helpdesk. Please answer within a range of 1 21. SSNAP acute organisational audit help notes 2016 15

Data Item Data Definition Audit Help tes 2.16 Is there immediate access to scanning for urgent stroke patients (as defined in the NICE Guidelines) on these beds? The NICE clinical guidelines recommend that brain scanning should be performed immediately for people with acute stroke if any of the following apply: Indications for thrombolysis or early anticoagulation treatment An anticoagulant treatment A known bleeding tendency A depressed level of consciousness (Glasgow Coma Score below 13) Unexplained progressive or fluctuating symptoms Papilloedema, neck stiffness or fever Severe headache at onset of symptoms 2.17 Type 3 beds (beds used for pre and post 72 hours only). How many of the following nursing staff are there usually on duty at 10AM for these beds? This question refers to the number of individuals on the ward at 10am. Registered nurses Care assistants Registered nurses are those defined as registered with the NMC as Registered Nurses (Adult) Care assistant includes the terms health care support worker, nursing auxiliary, or generic worker. Please do not double count any nurses listed in 2.5 or 2.10 if the nurses are across both types of bed, please estimate. Please enter 0 if no nursing staff on duty at 10am. However, the total number of nursing staff (registered nurses and/or care assistants) must be more than 0 for each time period As this question refers to individuals, only whole numbers are permitted. 2.18 How many nurses are there usually on duty at 10AM for these beds who are trained in the following? Swallow screening Stroke assessment and management This question refers to the number of individuals on the ward at 10am. Swallow screening refers to a formal swallow screen (performed by any member of the team). Presence or absence of the gag reflex is not sufficient as it is proven to be of little prognostic value for the ability to swallow. Please do not double count any nurses listed in 2.6 or 2.11. Enter 0 if no nursing staff with this specific training are on duty at 10am, As this question refers to individuals, only whole numbers are permitted. SSNAP acute organisational audit help notes 2016 16

Data Item Data Definition Audit Help tes A nurse trained in stroke management would have stroke specific management experience i.e. can check for deterioration of symptoms and take necessary steps. Perhaps s(he) is trained in transfers. 2.19 How many of the following nursing staff are there usually on duty at 10PM for these beds? Registered nurses Care assistants 2.20 What is the total establishment of whole time equivalents (WTEs) of the follow band of nurses for Type 3 beds? (beds for both pre and post 72 hour care) This question refers to the number of individuals on the ward at 10pm. Registered nurses are those defined as registered with the NMC as Registered Nurses (Adult) Care assistant includes the terms health care support worker, nursing auxiliary, or generic worker. WTEs Whole Time Equivalent An WTE of 1.0 means that the person is equivalent to a full time worker, while an WTE of 0.5 signals that the worker is half time etc. Enter 0 if no staff of that grade. Please enter 0 if no nursing staff on duty at 10pm. However, the total number of nursing staff (registered nurses and/or care assistants) must be more than 0 for each time period As this question refers to individuals, only whole numbers are permitted. N.B Please do not double count any nurses/care assistants lists in 2.7 or 2.12. Enter 0 if no establishment. SSNAP acute organisational audit help notes 2016 17

SECTION THREE: SERVICES AND STAFF ACROSS ALL STROKE UNIT BEDS Question Data Item Data Definition Audit Help tes 3.1 Does your stroke unit have access to the following within 5 days of referral: a. Social work expertise b. Orthotics c. Orthoptics d. Podiatry/foot health This refers to 5 consecutive days (i.e. not working days). Auditors should check with clinicians and/or the Social Work department to clarify local arrangements. SSNAP acute organisational audit help notes 2016 18

Data Item Data Definition Audit Help tes 3.2 What is the total establishment of whole time equivalents (WTEs) of the following qualified professionals and support workers for all your stroke unit beds? (Enter 0 if no establishment). Clinical Psychology a person with a postgraduate qualification in clinical psychology trained in assessment and treatment of neurological impairments. Dietetics A senior dietician with at least 2 years experience. Occupational Therapy The occupational therapy stroke service is under the overall supervision of an occupational therapist experienced in stroke rehabilitation supervising provision of the occupational therapy stroke service. Suggested guideline: five years experience of which two will include stroke rehabilitation with evidence of continued professional development relating to stroke." Physiotherapy Senior physiotherapist experienced in stroke rehabilitation or with access to specialist supervision as per CSP guidance Speech & Language Therapy specialist in acquired neurological communication and swallowing difficulties or with access to specialist supervision. Pharmacy a person who is qualified as a pharmacist. Nursing staff (bands 7 8c) Qualified nurses are those defined as registered with the NMC as Registered Nurses (Adult) and specified by band. Enter total for both individual numbers and the WTE for the total establishment of these professionals and support staff. Total establishment being all roles fully staffed, including those currently unfilled. WTE can be up to 3 decimal points but if number of individuals 0 then WTE must also be 0. If professionals and support workers are generic i.e. cover non stroke beds as well, please calculate proportion of time spent on stroke beds. E.g. WTE hours for a nurse overseeing a ward of 30 beds 10 of which are designated for stroke patients would be 1/3. Similarly, if professionals and support workers have allocated hours to spend solely with stroke patients, please indicate WTE hours as a proportion of total hours worked. Only tick the 6 day working or 7 day working if these professionals treat stroke patients in relation to stroke management at weekends on the stroke unit. Enter 0 if no establishment. SSNAP acute organisational audit help notes 2016 19

3.3 Data Item Data Definition Audit Help tes Junior Doctor Sessions How many sessions of junior doctor time are there per week in total for all stroke unit beds? a. Specialty trainee 3(ST3)/registrar grade or above b. Foundation years/core training/st1/st2 or below c. n training grade junior doctor 1 session represents half a day. These could also be known as Physician Assistants. Please answer within a range of 0.99. Whole numbers only. 3.4 3.4(a) Do you have Physician Associates as part of your clinical team? If yes: How many whole time equivalents (WTEs) do these Physicians Associates work across your stroke service? WTEs Whole Time Equivalents Physician associates (formerly known as Physician assistants) support doctors in the diagnosis and management of patients. They are trained to perform a number of roles including: taking medical histories performing examinations diagnosing illnesses analysing test results developing management plans. They work under the direct supervision of a doctor. See the NHS careers link below for further details. http://www.nhscareers.nhs.uk/explore bycareer/doctors/careers in medicine/physician associate/. Please answer within a range of 0 99 and can be up to 3 decimal places. SSNAP acute organisational audit help notes 2016 20

3.5 Data Item Data Definition Audit Help tes Venous thromboembolism prevention What is your first line treatment for preventing venous thromboembolism for patients with reduced morbidity? If your site uses more than one treatment, select that which is most frequently used. Select one option only. 3.6 Are you commissioned (or in Wales, expected) to carry out 6 month reviews? The review of stroke patients six months after their stroke. 6 month review A review of a stroke patient s progress 6 months after their stroke. This review provides the opportunity to assess whether a patient's needs have been met, assess the need for further support and set future goals for on going rehabilitation if appropriate. By collecting this information about patient outcomes at six months we can look at: changes in disability compared to discharge, where they have been discharged to (home or care home, place of residence) unmet needs mood and cognition, in particular identification of these areas which were silent symptoms when the patient presented acutely changes in whether the patient is in atrial fibrillation (AF) and on treatment (anticoagulation) to reduce the risk of having a further stroke. SSNAP acute organisational audit help notes 2016 21

3.7 Data Item Data Definition Audit Help tes Are the patients that you discharge given a 6 month review? Do stroke patients who are discharged from your site (please include all hospitals) receive a formal 6 month review? Formal 6 months reviews can take place between 4 8 months following stroke onset (6 months being the average). Select one option only. 3.7 (a) If all or some, who carries these out? Tick all that apply 3.7(a)i How many other services carry out reviews on the patients that you discharge? These are the services patients are referred to upon discharge from your site. Only applies if other services is ticked in 3.7a. Please enter a whole number between 1 50. SSNAP acute organisational audit help notes 2016 22

Data Item Data Definition Audit Help tes 3.7 (c) What other types of services carry out a 6 month review of patients that you discharge? (i) Other inpatient service (e.g. Community hospital) (ii) Outpatient clinic (iii) Early Supported Discharge (ESD) team (iv) Community Rehabilitation Team (CRT) (v) 6 month review Other inpatient services: Bed based services for patients who continue to need inpatient (hospital) care and consultant access but this no longer needs to be at an acute level (they are no longer based on a HASU or SU and require rehabilitation support only) e.g. community hospitals. Outpatient care: Is any health care service provided to a patient who is not admitted to a bed based facility. Outpatient care may be provided in a clinic or hospital outpatient department and appointments are normally necessary. Early Supported Discharge (ESD): Refers to a multidisciplinary team which provides rehabilitation and support at the patients home at the same intensity as patients would receive when in hospital. Community Rehabilitation Team: A community rehabilitation team which treats stroke patients at their own home Tick all that apply. If you have an integrated team then still tick all that apply (i.e. if you have an ESD and Community rehabilitation team integrated service then tick both ESD and Community rehabilitation team) service (stand alone following inpatient care or transfer from ESD. team) 6 month assessment provider: Providers who carry out a 6 (vi) Family and carer support service (e.g. month outcome reviews of patients only. Stroke Association) Family and carer support service e.g. Stroke Association: A (vii) Other service which is commissioned to provide on going support to families and carers of stroke survivors. SSNAP acute organisational audit help notes 2016 23

SECTION FOUR: OTHER STROKE CARE MODELS Question 4.1 4.1(a) Data Item Data Definition Audit Help tes Specialist Early Supported Discharge Team Do you have access to at least one stroke/neurology specific early supported discharge multidisciplinary team? If yes: How many Specialist Early Supported Discharge (ESD) teams does your site have access to? Early supported discharge team refers to a multidisciplinary team which provides rehabilitation and support in a community setting with the aim of reducing the duration of hospital care for stroke patients. A stroke/neurology specific team is one which treats stroke patients either solely or in addition to general neurology patients. This question should not include nonstroke/neurology specific teams. Only include ESD teams that see 10 or more patients per year. If no, questions 4.1(a), 4.1(b) and 4.1(c) are not applicable. Must be a whole number. Please answer between range of 0 9. 4.1(b) 4.1(c) Please give the name and contact details for each of these teams. What percentage of your patients have access to at least one of these teams if needed? If patients that are discharged from your site receive 6 month reviews at the named ESD teams then answer yes. Answer no if the service does not carry 6 months reviews on stroke patients after they are discharged from your service. This is to identify where there is variable geographic access to the team. If it s an integrated team, tick yes if it provides 6 month reviews. If participating SSNAP team select the team from the dropdown list provided. If not, tick the check box indicated and give name of team in free text field. Please provide a percentage between 1 and 100 SSNAP acute organisational audit help notes 2016 24

4.2 4.2(a) Data Item Data Definition Audit Help tes Specialist Community Rehabilitation Team Do you have access to at least one stroke/neurology specific community rehabilitation team for longer term management? If yes: How many specialist Community Rehabilitation teams does your site have access to? A community rehabilitation team is a team working in the community delivering rehabilitation services within a patient s home. A stroke/neurology specific team is one which treats stroke patients either solely or in addition to general neurology patients. Only include community rehabilitation teams that see 10 or more patients per year If no, questions 4.2(a), 4.2(b) and 4.2(c) are not applicable. Must be a whole number. Please answer between range of 0 9. 4.2(b) 4.2(c) Please give the name and contact details for each of these teams. What percentage of your patients have access to at least one of these teams if needed? If patients that are discharged from your site receive 6 month reviews at the named community rehabilitation teams then answer yes. Answer no if the service does not carry 6 months reviews on your stroke patients after they are discharged from your service. This is to identify where there is variable geographic access to the team. If it s an integrated team, tick yes if it provides 6 month reviews. If participating SSNAP team select the team from the dropdown list provided. If not, tick the check box indicated and give name of team in free text field. Please provide a percentage between 1 and 100 SSNAP acute organisational audit help notes 2016 25

4.3 n specialist Community Rehabilitation Team Do you have access to at least one non specialist community rehabilitation team for longer term management? A non specialist team treats other patients in addition to stroke and neurology patients. If no, questions 4.3(a) and 4.3(b) are not applicable. 4.3(a) If yes: How many non specialist Community Rehabilitation teams does your site have access to? Only include non specialist community rehabilitation teams that see 10 or more patients per year. Must be a whole number. Please answer between range of 0 9. 4.3(b) 4.3(c) Please give the name and contact details for each of these teams. What percentage of your patients have access to at least one of these teams? If patients that are discharged from your site receive 6 month reviews at the named community rehabilitation teams then answer yes. Answer no if the service does not carry 6 months reviews on your stroke patients after they are discharged from your service. This is to identify where there is variable geographic access to the team. If it s an integrated team, tick yes if it provides 6 month reviews. If participating SSNAP team select the team from the dropdown list provided. If not, tick the check box indicated and give name of team in free text field Please provide a percentage between 1 and 100 SSNAP acute organisational audit help notes 2016 26

SECTION FIVE: TIA / NEUROVASCULAR Question 5.1 Data Item Data Definition Audit Help tes Does your site have a neurovascular clinic? A clinic which provides checks and assessments of nerve function and blood flow to an injured extremity. 5.1(a) 5.1(b) 5.1(c) 5.1(d) If no, who provides this for your patients? How many clinics within a 4 week period? How many new patients were seen during the past 4 weeks? What is the current average waiting time for an appointment from referral? Please select from the dropdown list Please provide a range between 0 300. Please provide a range between 0 999. Check through the appointments for TIA/neurovascular clinic appointments made in the previous month to calculate the delay between referral and appointment for minor stroke/tia. Please provide a range between 0 100. 5.2 Is carotid imaging available at this site? If no selected, 5.4 is not applicable. 5.3 What patients are treated at your site? (i) High risk TIA patients (ABCD2 score 4 or more) (ii) Low risk TIA patients (ABCD2 score less than 4) (iii) High and low risk TIA patients TIA Transient Ischaemic Attack (Amaurosis Fugax to be regarded to be as a TIA) Risk will be assessed using a validated tool (e.g. ABCD 2 where high risk is defined as a score of 4 or more). SSNAP acute organisational audit help notes 2016 27

5.4 Data Item Data Definition Audit Help tes What is the usual waiting time for patients to receive carotid imaging? Only tick one option for each (a) and (b) but one option must be selected. 5.4(a) 5.4(b) For HIGH risk TIA patients For LOW risk TIA patients If 5.3 (ii) is selected will grey out. If 5.3 (i) is selected will grey out. 5.5 Within what timescale can you see, investigate and initiate treatment for ALL your HIGH risk TIA patients? 5.6 Within what timescale can you see, investigate and initiate treatment for ALL your LOW risk TIA patients? It refers to a service for ALL HIGH RISK TIA patients. The patients may or may not be admitted or both. Answer for inpatient or outpatient or both as appropriate. It refers to a service for ALL LOW RISK TIA patients The patients may or may not be admitted or both. Answer for inpatient or outpatient or both as appropriate. Risk will be assessed using a validated tool (e.g. ABCD 2 where high risk is defined as a score of 4 or more). If you have ticked yes for either (a) or (b) you must select a corresponding option below. If you have selected 5.3 (i) or (iii) no cannot be selected for both. Risk will be assessed using a validated tool (e.g. ABCD 2 where low risk is defined as a score of less than 4). If you have ticked yes for either (a) or (b) you must select a corresponding option below. If you have selected 5.3 (ii) or (iii) no cannot be selected for both. SSNAP acute organisational audit help notes 2016 28

5.7 Data Item Data Definition Audit Help tes TIA patients in your site What is the total number of inpatients with confirmed or suspected TIA across all primary admitting hospitals on 1 July 2016? This refers to the number of inpatients with a primary diagnosis of TIA across all the hospitals which were entered for A1, at the time the organisational audit form is completed. Please answer within a range of 0 100. 5.7(a) How many inpatients with confirmed or suspected TIA are in stroke unit beds across all primary admitting hospitals at the time this form is completed? This refers to the number of inpatients with a primary diagnosis of TIA across who are in stroke beds across all the hospitals which were entered for A1, at the time the organisational audit form is completed. Please answer within a range of 0 99. This should not be more than the number given for question 2.1(b). SSNAP acute organisational audit help notes 2016 29

SECTION SIX: SPECIALIST ROLES Question 6.1 Data Item Data Definition Audit Help tes Is there a clinician with specialist knowledge of stroke who is formally recognised as having principal responsibility for stroke services? A physician with specialist skills in stroke. A stroke specialist has expertise in all 3 principal areas of stroke management (Prevention, Acute Stroke, Stroke Rehabilitation). Only one option can be ticked, this individual should be recognised as the overall leader of the stroke service as a whole. 6.1(a) If yes, please select one option (i)doctor (ii) Nurse (iii) Therapist Select one option if Yes 6.2 Do you have at least one accredited specialist registrar in post registered for stroke specialist training? An accredited SpR will be a specialist registrar who is a doctor who is in a post approved for stroke specialty training. 6.3 How many accredited specialist registrar posts to you have at your site? This is the total number of posts at your site, whether they are filled or unfilled. Must be a whole number. Please answer within a range of 0 99. 6.3(a) How many of them are currently filled? Cannot exceed the number in 6.3 Can answer within a range of 0 99. A response is required in all fields; Enter 0 if appropriate. SSNAP acute organisational audit help notes 2016 30

6.4 Data Item Data Definition Audit Help tes Workforce Planning Do you have any unfilled stroke consultant posts? The aim of this section is to match the stroke care you provide to the type of consultant workforce that is, and may in the future, be available in your site. This may improve both national planning for training of future consultant physicians working in stroke medicine and their equitable distribution. These questions will be used to inform a study being undertaken by the British Association of Stroke Physicians (BASP). They will also be used by the Royal College of Physicians Stroke Specialist Group. If no questions 6.4(a) and 6.4(b) are not applicable. 6.4(a) How many programmed activities (PAs) do these posts cover? PA refers to Programmed Activities (or Sessions in Wales) 1 decimal place permitted. Please answer within a range of 1 999. 6.4(b) For how many months have these posts been funded but unfilled? Please answer within a range covering months between 1 120. 6.5 6.5(a) 6.5(b) Existing Posts How many programmed activities (PAs) do you have in total for Stroke Consultant Physicians How many consultants (individuals) are these PAs divided amongst? How many of these PAs are Direct Clinical Care (DCCs) for Stroke? PA refers to Programmed Activities (or Sessions in Wales) Stroke Consultant Physician A physician with specialist skills in stroke. A stroke specialist has expertise in all three principal areas of stroke management (Prevention, Acute Stroke, Stroke Rehabilitation). Direct clinical care (DCCs) refers to direct patient contact and/or management. DCC is work directly related to preventing, diagnosing or treating illness, including emergency work carried out during or arising from on call work. Please answer within a range of 0 99. 2 Decimal places permitted. 6.5(a) 6.5(c) will be grey out if 0. Please answer within a range of 1 99. Please answer within a range of 0 99. SSNAP acute organisational audit help notes 2016 31