Scottish Stroke Care Audit: 2010 National Report Stroke Services in Scottish Hospitals. Data relating to 2005 - 2009.
Paper editions of the above are available, please contact Hazel Dodds for a copy.
SSCA National Report Tables and Charts (only available on-line)
SSCA Hospital Tables - Inpatients (only available on-line)
SSCA Hospital Tables - Outpatients (only available on-line)
There is strong evidence that well organised stroke care improves the outcome of patients having a stroke. In Scotland, the Scottish Intercollegiate Guidelines Network (SIGN) and NHS Quality Improvement Scotland (NHS QIS) have developed guidelines and standards aimed at delivering that care. New NHS QIS standards for stroke were published in June 2009.
The Scottish Stroke Care Audit monitors the quality of care provided by the hospitals in all NHS Boards by collating data collected by the Managed Clinical Networks (MCNs). These data are used by the Scottish Government Health Department to monitor progress against the NHS QIS standards for stroke and the Better Heart Disease and Stroke Care Action Plan also published in 2009.
NHS Boards are expected to identify aspects of their stroke services which do not meet National Standards and to work with their stroke MCNs to improve their performance.
The 2010 National Report includes data describing the quality of stroke care in each acute hospital grouped by NHS Board from 2008 to 2009. This allows each hospital and NHS Board not only to compare their performance with national standards, but also with other organisations. Hospitals with less satisfactory performance can learn from those where services are of higher quality. This year the report includes case studies demonstrating how improvements have been made in relation to management of mini strokes (transient ischaemic attacks) and Appendix A contains submissions from all fourteen boards sharing and outlining their MCNs plans to improve performance against NHS QIS standards in their local area.
This year's report also includes trend analysis presenting data from 2005-2009 for Scotland overall which demonstrates improvement in performance against the current NHS QIS standards.
Five key quality indicators are:
Proportion of stroke patients admitted to a Stroke Unit on day of admission and within 1 day of admission to hospital. Evidence suggests that stroke unit care is associated with fewer deaths and less residual disability after a stroke. The current NHS QIS standard is that at least 60% of patients should be admitted to a stroke unit on day of admission to hospital (Day 0) and 90% by the day following admission to hospital (Day 1). In 2009 37% (2008 - 35 %) of patients were admitted to a stroke unit on Day 0 and 61% (57%) by Day 1.
The trend analysis from 2005-2009 demonstrates that the percentage of stroke patients admitted to a Stroke Unit on Day 0 has increased from 28% to 37% and on Day 1 from 49% to 61%. There has also been a significant improvement in the number of patients admitted to a Stroke Unit at any time during their admission, an increase from 71% to 81%.
Proportion having a documented Swallow screen on day of admission. About half of all stroke patients will not be able to swallow safely on admission to hospital. If given fluids or food inappropriately patients may develop, and possibly die from, pneumonia and if not treated appropriately they may become dehydrated and malnourished which may lead to slowed recovery and/ or worse outcome.
The current NHS QIS standard is that all patients should have a swallow
screen on the day of admission. In 2009 61% (2008: 55%) of patients had
a swallow screen recorded on the day of admission. The trend analysis
from 2005-2009 demonstrates that the percentage of stroke patients receiving
a swallow screen on the day of admission has increased from 47% to 61%.
Proportion having a brain scan on day of admission. A brain scan is essential to confirm the diagnosis of stroke and to distinguish stroke due to ischaemia (a blocked blood vessel) or a haemorrhage (burst blood vessel). Treatments for a blocked blood vessel are very dangerous to those with a burst blood vessel, e.g. Aspirin. The current NHS QIS standard is that at least 80% should have a brain scan on the day of admission. In 2009 49% (2008: 42%) of patients had a brain scan on the day of admission. The trend analysis from 2005-2009 demonstrates that the percentage of stroke patients having a brain scan on the day of admission has increased from 27% to 49%.
Proportion of patients with ischaemic (a blocked blood vessel) stroke who receive aspirin within 48 hours of admission. As noted above only patients with ischaemic stroke should be given aspirin. It would be very dangerous to give patients with a stroke caused by a burst blood vessel aspirin therefore aspirin is not given until the patient has had a brain scan to determine the type of stroke. If there are delays to brain scanning this will cause a delay in aspirin prescribing.
Aspirin started within the first 48 hours reduces the proportion of patients having recurrent strokes and residual disability. The NHS QIS standard is that all patients should receive aspirin on the day of admission or the day after unless contraindicated. In 2009 68% (2008: 67%) of ischaemic stroke patients received aspirin within 48 hours of admission. The trend analysis from 2005-2009 demonstrates that the percentage of stroke patients receiving aspirin on the day of admission or the day following admission has increased from 41% to 68%.
Proportion of patients with a mini stroke, who do not need immediate admission, assessed in a specialist neurovascular clinic within 7 days of receipt of referral. The average risk of a stroke after a mini stroke is approximately 10% in the first week and for certain sub-groups may be as high as 30%. Early recognition, diagnosis and initiation of secondary prevention are likely to prevent many more strokes if started immediately after the initial mini stroke.
The NHS QIS standard is that 80% should be seen within 7 days from referral. In 2009 80% (2008: 58%) of patients seen in neurovascular clinics were seen within 7 days. The trend analysis from 2005-2009 demonstrates that the percentage of stroke patients seen within 7 days from referral has increased from 30% to 80%.
Good or bad performance with respect to these five indicators will usually
reflect the actual performance of the service. However, if the audit methodology
is not strictly adhered to, the local data may be misleading - most likely
they will give a reassuringly good measure of performance. For instance,
if the audit does not include patients managed outwith the stroke unit
an overly optimistic view of the quality of the service will result. It
should be noted that in November 2009 we created for the first time a
national database so calculations in this year's report may not match
exactly those presented in previous reports.
For individual hospitals (and the trend analysis) these data are presented in charts. Further detailed charts and tables are available at the top of this page.
The quality of stroke services varies greatly across Scotland. Further action is required in all NHS Boards since areas of poor performance are likely to be reflected in worse outcomes (more deaths and more disability) for their patients. In addition, poor care leads to longer lengths of hospital stay, greater residual dependency and thus higher costs to health services. No hospital meets all of the NHS QIS standards, so all need to strive to improve their stroke services.
The Better Heart Disease and Stroke Care Action Plan published in June 2009 highlights many additional aspects of stroke services which need to be developed.
The revised and more challenging NHS QIS stroke standards also published in June 2009 reflect the latest evidence included in the latest stroke SIGN guidelines and include new standards relating to thrombolysis and carotid endarterectomy:
- Thrombolysis will be administered according to SIGN guidelines to at least 5 per 100,000 population per year and that 80% of treated patients should start treatment within 60 minutes of arrival at hospital
- 80% of patients undergoing carotid endarterectomy for symptomatic carotid stenosis have the operation within 14 days of the stroke event
The numbers (percentage) of stroke patients thrombolysed in 2008 and 2009 were 260 (3%) and 411 (5%) respectively. These numbers equate to 5 patients per 100,000 persons in 2008 and 8 patients per 100,000 persons in 2009. The 2011 report will present numbers thrombolysed and door to needle times.
It was agreed to pilot the Carotid Intervention aspect of the audit in two centres and an update is included in this report.
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