Scottish Stroke Care Audit Driving Improvement in Practice Iona - - PowerPoint PPT Presentation

Scottish Stroke Care Audit Driving Improvement in Practice

Iona Lancaster Anne Davidson

Scottish Stroke Care Standards

• 90% of all patients admitted to hospital with a diagnosis of stroke

are admitted to the stroke unit on the day of admission, or the day following presentation at hospital, and remain in specialist stroke care until in-hospital stroke-related needs are met. (By day 1)

• 90% of patients have CT/ MRI imaging within 24 hours of

admission.

• 90% of patients are screened by a standardised assessment

method to identify any difficulty swallowing safely due to low conscious level and/ or the presence of signs of dysphagia on the day of admission before the patient is given any food/ drink or oral

• medication. The result of the screen/ test should be clearly

documented in the patients’ notes. (By day 0)

• Aspirin is given on the day of admission or the following day for all

patients in whom a haemorrhagic stroke, or other contraindication, as specified in the national audit, has been excluded. (By day 1)

• 80% of new patients with a stroke or TIA are seen within 4 days of

receipt of referral to the neurovascular clinic.

• The MCN monitors the delay between arrival at the first hospital

and administration of the bolus of recombinant plasminogen

• activator. 80% of patients receive the bolus within one hour of

arrival.

SSCA Changing Culture

• Key in promoting the integration of audit findings into practice
• Key in prompting the development of a new stroke

patient pathway for PRI

• Helped to change attitudes to stroke patients
• patients with a stroke are now seen as a medical

emergency

• Promoted increased staff knowledge in stroke.
• Setting up of a Stroke Pathway Quality Improvement Group
• Setting up exception reporting

Exception reporting

• Monthly (could be done daily or weekly)
• Looks at where we have failed to meet the standards
• Team pull medical, nursing and AHP records and look for the specific

reason the patient/s failed e.g.

‘This patient was on 75mg of aspirin pre admission, they were written up to have 300mg as stated in the standard however this was then withheld. The patient had also been thrombolysed. Dr Nair has followed this up with the member of medical staff involved.’ ‘2 patients failed to receive their thrombolysis within 1 hour and the reason for missing the target in both cases was a delay between CT and thrombolysis. Both these patients were admitted in the OOH period.’

• Monthly report written and any instances where the pathway was not

followed are addressed with individual staff members.

• Over time we have been able to identified the key issues and start to

address them.

Role of the Acute Medical Unit

• AMU key to stroke Care in PRI
• Stroke was not a priority
• Exception reporting had identified the key issues in

the AMU (stroke pathway not followed and stroke low priority)

• Needed an easy and quick way to ensure care was

appropriate

• Team identified that they wanted an ‘easy, see at a

glance’ checklist of what had been done and more importantly what still needed to be done.

• Team developed a checklist
• Amended over and over

Creation Of Checklist

What has the Checklist Achieved?

• Helps staff focus on priorities
• Ability to answer queries regarding what was still to be done
• Assisting audit
• Focus on essential care bundle for Stroke patients
• Handover to Stroke Unit more effective

Improvements For Patients

• Safer care, evidenced based practise
• Patients are prioritised
• Quality assurance in care delivery
• Nurses knowledge of stroke care improved
• Nurses feeling empowered
• Transfer to Stroke Unit promptly
• Reduced time of patient unnecessarily remaining NBM

Stroke Patients Today In The AMU

• Staff actively promote appropriate treatment of

patients thus ensuring :

– CT scanning occurs on day of admission – swallow screen and neurological observations are prioritorised on admission and aspirin is appropriately prescribed – Blood glucose monitoring undertaken

• Improvement in communication with Stroke Unit

regarding in-patients and pending transfers

• Stroke unit actively ‘pull’ patients into unit
• Feedback from the Stroke Unit which identifies staff

who failed to follow the stroke patient pathway appropriately

• Regular stroke education for nursing staff

Feedback

• Staff feel they now have the confidence to safely look after a patient

with a stroke

• Support from project lead in stroke care
• Statistics showing steady improvement

Future

• Ever evolving in correlation with national

guidelines

• Continue to look at individual patients who

fail to meet standards

• Open to criticism
• Patient feedback

Admission To The Stroke Unit By Day 1

Admission to the stroke unit by day 1

7 67 79 81 88 20 40 60 80 100 2009 2010 2011 2012 2013 Year Percentage Percentage

Swallow Screening

Swallow screening

70 78 87 90 85 20 40 60 80 100 2009 2010 2011 2012 2013 Year Percentage Percentage

Brain Imaging

Brain Imaging

47 49 83 94 95 20 40 60 80 100 2009 2010 2011 2012 2013 Year Percentage Percentage

Aspirin

Aspirin

58 69 88 92 89 10 20 30 40 50 60 70 80 90 100 2009 2010 2011 2012 2013 Year Percentage Percentage

Outpatient Examination

64 77 77 69 78 75 72 75 79 60 69 64 100 92 100 10 20 30 40 50 60 70 80 90 100

2012 2013 Latest 12 months May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14

%

% Outpatients Examination <= 4 days Quarterly Stroke Standard (Jan 2013)

Thrombolysis

52 41 40 50 60 50 33 33 50 10 20 30 40 50 60 70 80 90 100

2012 2013 Latest 12 months May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14

%

% Thrombolysed <= 60 mins Quarterly Stroke Standard (Jan 2013)