Sentinel Audit: Changes seen and the future of audit for stroke

1. Sentinel Audit: Changes seen and the future of audit for stroke Tony Rudd

3. St Thomas’ Hospital

4. St Thomas’ Hospital Stroke Care in 1988 Patients admitted under care of any of 17 general physicians to any one of 15 wards Very little happened acutely Brain scans difficult to obtain and therefore rarely done Referred to geriatricians for rehabilitation – long wait No stroke specialist service either in hospital or community

5. What are the problems that still need solving? Unacceptable variation in the quality of care between hospitals Variable quality of clinical and managerial leadership Variable resources provided for stroke care UK slow to adopt new technologies e.g. Thrombolysis Still a belief amongst many people (professionals and public) that stroke untreatable disease of old people

6. Early Stroke Audit Results (1998/9) 18% of patients through stroke unit 23% cognitive assessment 44% visual fields recorded 55% rehabilitation goals set 41% G.P. contacted within 3 days of discharge

7. Key Forces for Change Research Guidelines summarising the research evidence and clinical consensus (RCP Guidelines and NICE Guidelines on Acute Stroke and TIA and NICE Technology Appraisal on alteplase) National Audit Sentinel audit SINAP Carotid endarterectomy audit National Audit Office report National Stroke Strategy

8. Key Forces for Change NICE Quality Standards Commissioning Outcomes Framework (COF) standards Performance standards set by Care Quality Commission Stroke Improvement Programme and Stroke and Cardiac Networks Stroke Research Network Public opinion Media reports Voluntary sector campaigning

9. Stroke Programme at the RCP Guidelines (3rd edition) –2008 NICE Guidelines on Acute care and TIA Intercollegiate Guidelines on the rest National Audit Organisation of Care Clinical/Process of Care Carotid interventions audit Profession Specific Audit Acute Continuous Stroke Audit (SINAP) Change management Presentations Workshops Peer Review Stroke improvement network links

10. History of Stroke Audit in the UK 1997 Department of Health commissioned national stroke audit Intercollegiate stroke working party Audits conducted every 2 years Structure Process (Outcome) Patient experience (Picker survey) Primary care audit Now funded by HQIP

11. Features of Audit 1 100% participation Run by clinicians Exceptional level of data quality and completeness Detailed analysis centrally to allow tailored interrogation of data Performed every 2 years allowing time for implementation of change Rapid production of results

12. Individual detailed hospital reports with results benchmarked against national/regional averages Reports to Strategic Health Authorities, Healthcare Commission, Networks, Department of Health and Parliament Extensive media coverage because public data of key indicators Features of Audit 2

13. Other sources of data Primary care – Quality Outcomes Framework (QOF) Vital signs data Accelerated metrics for SIP Routine Hospital Statistics (HES). Used by Dr Foster

14. Results: Stroke unit provision –comparison over time

19. See page 54 of your hospital report The key nine process indicators were kept the same as in the last two rounds to allow comparisons with these key process figures. Table gives median % compliance with each indicator, for applicable patients See page 54 of your hospital report The key nine process indicators were kept the same as in the last two rounds to allow comparisons with these key process figures. Table gives median % compliance with each indicator, for applicable patients

20. See page 58See page 58

21. See page 55 for 12 Key Process Indicators See page 55 for your site’s quartile position We have added four additional indicators to the previous nine for this round of the audit and removed one. The reasons for are to reflect standards given in the recent NICE Quality Standard for stroke and to include more aspects of stroke care. See page 55 for 12 Key Process Indicators See page 55 for your site’s quartile position We have added four additional indicators to the previous nine for this round of the audit and removed one. The reasons for are to reflect standards given in the recent NICE Quality Standard for stroke and to include more aspects of stroke care.

22. Comment: Only 32% of patients received all nine of the original key interventions and only 16% received all of the 12 interventions. What these figures show is that although great progress has been made in improving the delivery of individual standards the chances of a patient receiving high quality care across the whole pathway is low. None of these key indicators should be regarded as optional. These data show that we have a lot of work still to do to ensure that care is uniformly good for all patients in all hospitals at all times. Comment: Only 32% of patients received all nine of the original key interventions and only 16% received all of the 12 interventions. What these figures show is that although great progress has been made in improving the delivery of individual standards the chances of a patient receiving high quality care across the whole pathway is low. None of these key indicators should be regarded as optional. These data show that we have a lot of work still to do to ensure that care is uniformly good for all patients in all hospitals at all times.

23. How are the data used to influence change? Workshops Slide toolkits Publicity “I’ve been trying to get the trust to offer scanning for stroke patients for 5 years, within a day of receiving the audit report the chief executive had convened a meeting with stroke service and radiology” A stroke physician after publication of performance indicators 2004 audit Influencing policy at a national level Influencing policy at SHA level

24. Transforming Stroke care in London:Case for change

25. The scale of the problem of stroke in London In complete opposite to major trauma, most cases of stroke occur in the suburbs – where older people tend to live. The next two most important factors in stroke are i) ethnicity (there is a 60% greater incidence of stroke within the black African and black Caribbean populations than the white population and ii) social deprivation. However the actual numbers of people from BME communities having a stroke are not as high as would be expected as there are fewer older black and minority ethnic people in London. In complete opposite to major trauma, most cases of stroke occur in the suburbs – where older people tend to live. The next two most important factors in stroke are i) ethnicity (there is a 60% greater incidence of stroke within the black African and black Caribbean populations than the white population and ii) social deprivation. However the actual numbers of people from BME communities having a stroke are not as high as would be expected as there are fewer older black and minority ethnic people in London.

26. 30-minute blue light ambulance travel time from the hyper-acute stroke units

27. London Stroke Strategy Additional £20m per year for stroke care but only paid if hospitals delivering the required quality Centralise hyperacute (hyperacute stroke units HASU) care into 8 units situated to provide easy access to the whole population (no more than 30 minutes by ambulance) All acute stroke patients admitted to HASU. This is not just a thrombolysis service Further 20 stroke units for on going rehabilitation Improve community care and longer term rehabilitation Neurovascular services for patients with TIA

28. London SHA Stroke Strategy Bidding process to provide care London Clinical Director Regular inspections to ensure quality of care maintained Obliged to submit continuous audit

29. 1 year outcomes

30. 1 year outcomes

31. 1 year outcomes

32. Cost-effectiveness analysis of the London Stroke Service: Results based on 6438 strokes per annum

33. Cost-effectiveness analysis of the London Stroke Service: Results based on 6438 strokes per annum

34. Cost-effectiveness analysis of the London Stroke Service: Results based on 6438 strokes per annum

36. Hospital participation and quartiles for participants

37. East of England

49. In 2008 only 1% of all stroke patients received thrombolysis and this figure has now increased to 8%, a significant improvement. The median number of patients treated per hospital in this cohort is 12/year, suggesting that some units are thrombolysing very low numbers. This figure needs to be monitored, as it suggests that the staff may have little experience in its use. It is of note that 22% of thrombolysed patients are over the age of 80. In 2008 only 1% of all stroke patients received thrombolysis and this figure has now increased to 8%, a significant improvement. The median number of patients treated per hospital in this cohort is 12/year, suggesting that some units are thrombolysing very low numbers. This figure needs to be monitored, as it suggests that the staff may have little experience in its use. It is of note that 22% of thrombolysed patients are over the age of 80.

50. Timings – comparison of thrombolysed and non-thrombolysed patients It is perhaps unsurprising that thrombolysed patients are seen and treated much more quickly than non-thrombolysed patients. It is perhaps unsurprising that thrombolysed patients are seen and treated much more quickly than non-thrombolysed patients.

51. Timings – comparison of hospitals based on percentage of eligible patients thrombolysed The major differences shown here suggests that there is inequity of care not just between thrombolysed and non-thrombolysed patients, but for all patients based on whether they go to a successful thrombolysis centre or not The major differences shown here suggests that there is inequity of care not just between thrombolysed and non-thrombolysed patients, but for all patients based on whether they go to a successful thrombolysis centre or not

52. The effects of getting to a SU quickly

53. Equity of care across hospitals

55. The New World of SSNAP A wish by certain people to have prospective data collection for stroke The ‘need’ to collect outcome data

56. Sentinel Stroke National Audit Programme (SSNAP) Replacing all other statutory data collection. Includes data needed for: NICE QS NHS Outcomes Framework Accelerated metrics Vital signs (except TIA) COF Funded by HQIP

57. SSNAP Prospective data collection for all stroke admissions Web tool for direct data entry Good data validation systems Facility for instant local downloads Uploading facility from other data sets Quarterly national reporting with benchmarking against national data Annual public reports 6 month follow-up data entry Linkage to ONS for mortality data HES linkage Option for user defined fields

58. SSNAP: Structure Core data set for all patients Comprehensive dataset (optional items) Developed by wide group of stakeholders Spotlight audits Audits on areas not covered by the core dataset. E.g. TIA, community rehabilitation Sprint audits short specific audits focussing on specific areas of the pathway that are of concern e.g. Therapy intensity, intermediate care. Organisational audit Hospital Community PROMS

59. SSNAP Reporting Ability to download own data anytime 3 monthly reports benchmarked against national data Annual public reports – ‘state of the nation’ Outcomes required by DH Mortality at 30days and 6 months Modified Rankin Score at 6 months Institutionalisation rate at 6 months

60. SSNAP Timetable Some uncertainty We hope May 2012 Organisational audit of hospital care August 2012 Clinical data set starts SINAP continues until SSNAP starts 1st Spotlight and Sprints audits in year 2 Initial funding 3 years

61. SSNAP Team Intercollegiate Stroke Working Party overseeing the process Clinicians at RCP in Associate Director Roles Geoff Cloud, Pippa Tyrrell, Martin James, Tony Rudd Alex Hoffman, James Campbell, Sara Kavanagh plus a statistician, web developer and admin support

62. SSNAP Risks Funding Currently debates over data protection and intellectual property Participation rates Major burden for clinicians/trusts Freedom of information act ‘Number 10 Openness Agenda’ Technical challenges

63. Conclusions Stroke care has transformed over the last 20 years Audit has been one of the factors that has driven improvements No prospect of avoiding monitoring of quality of care that we provide We are starting a new era of prospective audit Huge benefits for all if everyone participates