Learn more about stroke

1. Learn more about stroke Free on line e-learning resource www.strokecorecompetencies.org

2. Scottish Stroke Care Audit Annual Meeting 24th June 08 RCPE

3. Acknowledgements • Robin Flaig • Mike McDowall • Audit coordinators • Contributing clinicians and managers • Margaret Farquhar & team RCPE

4. Menu • A Scottish perspective • Performance of individual hospitals 2005 – 2007 learning lessons from good and bad practice • Inpatients • Outpatients • Swallowing - KarenKrawczyk • Plans to review NHSQIS standards • Future plans for the audit • Tea • Carotid endarterectomy

5. Reasons for variation in “Performance” • Method of collection data • Definitions, case ascertainment and audit period • Method of analysing data • Which numerator and denominator • Chance • Actual performance of service

6. Proportions • Numerator / Denominator = Proportion • 100 patients admitted • 60 enter stroke unit • Proportion is 60/100 = 0.6 or 60% • NHS QIS ask % admitted SU within 1 day • Denominator is 100 for NHSQIS standards? • Most challenging

7. Data Quality • Complete ascertainment? • Data extraction? • Finding info • Clinical support • Keeping up to date

8. National Performance

9. Comparisons between hospitals Inpatients

10. Stroke unit care

11. Outcome Stroke unit Control Risk difference Home, (independent) 44 % 38 % 5 (1, 8)* Home (dependent) 16 % 16 % 0 (-2, 3) Institutional care 18 % 20 % -2 (-5, 0)* Dead 22 % 26 % -3 (-6, -1)* Organised inpatient (stroke unit) careAbsolute outcomes at 6-12 months SUTC (2001)

12. Mean delay (days) from admission to entry into any Stroke Unit

13. % of patients admitted to a Stroke Unit ≤ 2 days of admission (NHS QIS Standard = 70%)

14. % of patients admitted to a Stroke Unit ≤ 2 days of admission (NHS QIS Standard = 70%)

15. How did you improve access? • Direct admissions? • Day & night? • Medical staffing out of hours? • Do you have a medical assessment unit? • How many beds for how many admissions? • Fixed bed numbers or flexible? • Ring fenced beds? • How do you clear your beds?

16. Why is access getting worse? • Lack of SU beds? • Filled with non stroke patients? • Problems with discharge?

17. Swallow screen

18. Why screen for swallowing problems • 50% of patients cannot swallow safely • Increased risk of pneumonia & death • Need for fluids • Need for nutrition – modified diet or tube • Need for medication

19. Mean delay (days) from admission to Swallow screen

20. % of patients with a Swallow screen on day of admission (NHS QIS Standard = 100%)

21. How did you improve performance? • Who does the screening? • How were they trained? • Where do they do it? • How is it documented? • Are they missing cases?

22. Brain scanning

23. Brain scanning • To exclude alternative diagnoses • To distinguish haemorrhage and infarction • To allow safe use of antithrombotic treatment

24. Mean delay (days) from admission to Scan

25. % of patients Scanned ≤2 days of admission (NHS QIS = 80%)

26. Brain scanning • Most places with a scanner meet NHSQIS standards • HTA review suggested immediate scan is most cost effective timing • English strategy emphasises earlier scanning • ? A case for changing the NHSQIS standard

27. Early aspirin use

28. Effect of two weeks of aspirin in acute ischaemic stroke Treat 1000 patients • 9 avoid recurrence • 12 avoid death or dependency • 10 more make a complete recovery

29. Effect of aspirin in acute stroke: hours from stroke onset

30. % of patients with Ischaemic event given Aspirin ≤2 days of admission (NHS QIS Standard = 100%)

31. Almost everyone is improving? • Protocol or ICP? • Rapid scanning? • No scanning? • Immediate reporting or PACS on ward? • Nurse prescription?

32. Blood pressure loweringafter stroke

33. PROGRESS - StrokeAll participants 28% risk reduction 95%CI 17 - 38% p<0.0001 0.20 0.15 Proportion with event 0.10 Placebo Active 0.05 0.00 0 1 2 3 4 Follow-up time (years)

34. % of stroke patients discharged alive on any anti-hypertensive medication

35. % of stroke patients discharged alive on any anti-hypertensive medication

36. Why such variation in blood pressure lowering? • Chance – low numbers? • Different views on risks vs benefits? • Preferring to start after discharge • Different levels of co-morbidity? • Presence or absence of protocols? • Data collection?

37. Antiplatelet or anticoagulant treatment after ischaemic stroke

38. Absolute effects of antiplatelet treatment - % with vascular events Treat 1000 9 avoid event in 2 weeks Treat 1000 36 avoid event in 29 months

39. % of Ischaemic patients discharged on Antiplatelet, Warfarin

40. % of Ischaemic patients discharged on Antiplatelet, Warfarin

41. Lowering cholesterol after ischaemic stroke

43. % discharged on statin

44. Warfarin for patients with ischaemic events and Atrial Fibrillation

45. Effect on stroke risk in the randomised trials of warfarin vs aspirin in fibrillating patients(Hart et al 1999)

46. % of Patients in AF discharged on Warfarin

47. Why such variation in Warfarin use? • Chance – low numbers • Different views on risks vs benefits • Delaying treatment till after discharge • Different levels of co-morbidity • Variation in quality of anticoagulation service

48. Outpatients

49. High early risk of stroke after TIA 14 OXVASC OCSP 12 10 8 Risk of stroke (%) 6 10% risk of stroke by 7 days 4 2 0 0 7 14 21 28 Days Lancet 2005; 366: 29-36

50. 10 8 6 Risk of stroke (%) 4 2 0 0 30 60 90 Days from medical attention EXPRESS: Clinic-referred population Slow clinic P<0.0001 Same day clinic