SSNAP data: What are the benefits? Tony Rudd

SSNAP data: What are the benefits? Tony Rudd

Without the audit data services would not have improved 2001 2005 2007 2010 2013

What does SSNAP measure? Organisation of care (measures structure) Clinical processes (measures process) Staffing Quality of Stroke Unit (SU) Stroke unit coverage, access to SU, Acute care organisation TIA/neurovascular service Multidisciplinary working Strategic groups Policies Research Leadership Outcomes Acute care processes Door to needle time Time to scan Time to stroke unit Medical, nursing & therapy assessments & screening Therapy intensity Use of Intermittent Pneumatic Compression Thrombectomy processes Complications 30 day Mortality Modified Rankin score at 6 months Bray BD, Ayis S, Campbell J et al (2013) Associations between the organisation of stroke services, process of care, and mortality in England: prospective cohort study BMJ 346:f2827

Why bother? Its tedious Its time wasting and time better spent looking after patients It doesn t tell me anything I don t know The data don t reflect my service The results are wrong It doesn t tell me what I need to know Why measure performance when I know it isn t good. I ll start when I have made some changes They will only use these data to beat me with

Why bother? Benefits for individual clinicians and their teams Benefits for patients Benefits for the public Benefits for people paying for the care and the politicians Benefits for understanding how stroke care should be provided do the trials translate into real life?

How does it help the individual clinician and team? Until you measure performance objectively you will not really know how you are performing and where to target improvement e.g. door to needle times, time to stroke unit Introducing a healthy element of competition between clinicians, teams, hospitals and maybe even countries Useful data for persuading managers/politicians that resources are needed

Brain Scanning January to March 2015

Physiotherapy July September 2013 January March 2015 Physiotherapy: Domain 6 A (85+) B (75-84) C (70-74) D (60-69) E (<60) Insufficient records Source: SSNAP July-Sep 2013 (Patient Centred)

Team-centred performance table Routinely Admitting Teams Number of patients Overall Performance Team Centred Data Team Name Admit Disch SSNAP Level CA AC Combined KI Level D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 Scan SU Throm Spec Asst OT PT SALT MDT Std Disch Disch Proc TC KI Level Pinderfields Hospital 230 234 D A A D C C D D C C E D B B D Hull Royal Infirmary 212 225 C A B B A C C B A B C D B B B Scunthorpe General Hospital 139 158 A A A A A B D A A A B C A A A York Hospital 212 214 C A B C D C C B A B E C A C C Chesterfield Royal 123 130 C A A C C C D D B B E C A A C Leeds General Infirmary 243 238 D A B D C D C D C D B D B D D Calderdale Royal Hospital 126 150 D A C C D C C C C D C B C B C Rotherham Hospital 106 97 C A B C A C D C A B D D A C C Royal Hallamshire Hospital 245 248 D A B D B B E D C C E D B D D Doncaster Royal Infirmary 140 145 B A A B B C C C A A A B A C B Harrogate District Hospital 87 81 C A A C D B D C B B D B B C C Bradford Royal Infirmary 136 160 D A B D C D D E C B D D A B D Barnsley Hospital 130 130 C A A C B C D C A A D C A D C Source: SSNAP October-December 2015 Team-centred performance table for Yorkshire and The Humber SCN

Case studies on action resulting from audit All new stroke now go directly to the scanner. We used SSNAP data to identify where we have not met a target, and are now delivering care in a much more timely way We have used SSNAP data to drive improvements in thrombolysis rates The PowerPoint slides are shown to therapists, nurses and doctors we then create action plans

National SSNAP score over time Jul - Sep 2013 Oct - Dec 2013 Jan - Mar 2014 Apr - Jun 2014 Jul - Sep 2014 Oct Dec 2014 Jan Mar 2015 A - no teams A - no teams A - no teams A - 6 teams (3%) B - 8 teams (4%) B - 5 teams (3%) B - 14 teams (7%) B - 17 teams (8%) C - 19 teams (11%) C - 26 teams (13%) C - 20 teams (10%) C - 38 teams (19%) D - 74 teams (42%) D - 93 teams (47%) D - 104 teams (53%) D - 97 teams (48%) E - 77 teams (43%) E - 74 teams (37%) E - 60 teams (30%) E - 46 teams (23%) A - 13 teams (6%) A - 16 teams (8%) A - 11 teams (5%) B - 24 teams (12%) B - 27 teams (13%) B - 36 teams (18%) C - 32 teams (16%) C - 43 teams (21%) C - 39 teams (19%) D - 100 teams (50%) D - 89 teams (44%) D - 92 teams (46%) E - 32 teams (16%) E - 29 teams (14%) E - 24 teams (12%)

Percentage of teams National SSNAP scores over time 100% SSNAP overall score 80% A 60% 40% B C D 20% E 0% Jul-Sep 2013 Oct-Dec 2013 Jan-Mar 2014 Apr-Jun 2014 Jul-Sep 2014 Oct-Dec 2014 Jan-Mar 2015 Reporting Quarter

Other examples of changes in SSNAP results over time Acute Assessments Domain 3: % Eligible patients Thrombolysed as per RCP criteria Domain 4: Stroke Consultant Assessment within 24 hours July Sep 2013 Jan Mar 2015 75% 81.8% 72.8% 76.4% Swallow Screening Within 4 hours for applicable patients 64.6% 68% Domain: 8 72 hour Bundle: If applicable, nurse within 24 hours, AND at least one therapist within 24h AND all relevant therapists within 72h AND rehab goals within 5 days 43.2% 52.4%

Appropriate place of care regardless of age Admission to stroke unit Source: Sentinel/SINAP/SSNAP

Thrombolysis provision over time % of patients who were thrombolysed out of all strokes Year of audit

Compliance (%) against the therapy target* Occupational Therapy April June 2013 April June 2014 April June 2015 53.4% 67.3% 75.3% Physiotherapy April June 2013 April June 2014 April June 2015 49.6% 67.1% 69.5% Speech and Language Therapy April June 2013 April June 2014 April June 2015 22.3% 30.9% 37.8% (based on target of 80% (OT), 85% (PT), or 50% (SALT) of patients being applicable to receive 45 minutes of OT/PT/SALT on 5 days per week)

Using SSNAP data: Atlas of Variation: Rates of AF Treated with Anticoagulation

Collecting and reporting data is only one part of quality improvement Regional Workshops most regions using data to plan reconfiguration of stroke care Slide toolkits bespoke for each hospital every 3 months Publicity and peer reviewed publications Provide transparent information to all Peer review team supporting change NHS Performance indicators and single quality marker

Information for patients and families Patients will get better care if they know what they should be receiving They can be powerful advocates for service improvements

Information for the Public The public are paying for the services and should know what they are getting Required in England as part of transparency agenda Getting the public arguing for change is a lot more powerful than professionals arguing for change Encourage the press to write about stroke

Information for those paying for the services and those responsible for managing the services Help decide overall organisation of care used in every region in England to inform decisions about reconfiguration Ability to make decisions about resources where do they need to invest or disinvest

Ensuring audit data are used in key academic publications: Association of care with good outcomes Stroke unit item Odds of death at 30 days P value Early stroke consultant assessment CT scan within 24 hours Early nurse & therapist assessment Early swallow assessment & nutrition management Early iv fluids and aspirin 0.009 0.49 0.028 <0.001 <0.001 0.5 0.75 1 Bray et al BMJ (2013)

Size of unit and thrombolysis rate and efficiency Door to needle times Number of patients thrombolysed Bray et al Stroke 2013

Time to SALT dysphagia assessment and risk of strokeassociated pneumonia Modelled association adjusted for age, sex, stroke type (ischaemic, primary intracerebral haemorrhage, undetermined), pre-stroke functional level (modified Rankin Score), place of stroke (out of hospital or inpatient) and comorbidity, and NIHSS Bray et al, In press with JNNP

Adjusted hazard ratio of 30-d mortality of patients admitted on weekends, by ratio of registered nurses per ten beds on the weekend. Higher mortality with fewer nurses Bray et al PLoS Med 2015

SSNAP in Northern Ireland: Participation Oct Dec 2015

Stroke Unit Domain No team in Northern Ireland received better than a D score for the stroke unit domain. Averages across participating Northern Ireland teams (Oct Dec 2015): 26% of patients being directly admitted to a stroke unit within 4 hours of clock start 67% of patients spend at least 90% of their stay on stroke unit

Time to stroke unit in hours Median time to stroke unit (in hours) 35:00:00 30:00:00 25:00:00 28 hr 47 mins 25 hr 56 mins 20:00:00 14 hr 36 mins 15:00:00 10:00:00 6 hr 55 mins 4 hr 8 mins 5:00:00 3 hr 30 mins 0:00:00 Altnagelvin Hospital Antrim Area Hospital Causeway Hospital Craigavon Area Hospital Team Daisy Hill Hospital South West Acute Hospital

South West Acute Hospital achieved an A for the Thrombolysis domain. Nationally, only 7% of teams have achieved an A for this domain (teamcentred).

3 teams achieved a team-centred score of B for the Physiotherapy domain. These are South West Acute Hospital, Craigavon Area Hospital and South Tyrone and Lurgan Hospitals.

% of patients treated by a stroke skilled Early Supported Discharge team Discharge processes 70 60 50 40 30 20 10 0 Antrim Area Hospital SSNAP Regional Summary Report (Oct Dec 2015) Causeway Hospital Altnagelvin Hospital Craigavon Area Hospital Team Daisy Hill HospitalSouth West Acute Hospital

Conclusions Data essential to persuade policy makers and clinicians that something needs to be done Continuous data collection is a lot more powerful than snapshot data collections but more time consuming and requires much greater resource. Comparing performance with rest of UK would be very valuable. Although systems different in Northern Ireland your patients are the same and the treatments they receive should be the same Don t be frightened of initially performing badly. It may actually help you get the resources you need Data collection just one small part of the process of quality improvement Please all start taking part in SSNAP!