Welcome

1. Welcome First National Stroke Audit Meeting RCP(Ed) 17th Dec 02

2. Agenda • Who is here and who isn’t? • Background • relationship to national strategy • purpose • Examples of output which will be available • Overview of National Audit of Stroke • How to run the system locally • Tea/coffee • Live demonstration of software system • Questions • Future Plans

3. Establishing a National Audit of Stroke in Scotland Joint project: Intercollegiate committee on audit & standards Scottish Stroke Collaboration Information & Statistics Division funded so far by CHSS & RCP (Edin) now by the Scottish Executive

4. Who’s Here • Members of the steering group • MSD • Gordon Lowe - SIGN & RCPE • David Stott - Intercollegiate Standards Committee • Campbell Chalmers - CHSS • Beatrice Cant - CRAG/CEPS • Apologies from Rod Muir - ISD

6. Who’s Here • Audit & IT co-ordinators • Robin Flaig & Mike McDowall • Lead clinicians & other staff from interested hospitals • Information & Statistics Division (ISD) • Graham Mitchell • Marian Bain (Public health) • Diana Beard (STAG) • Clinical effectiveness fellow - Christine Meek

7. Background

8. Recent audits of stroke services

9. National Sentinel Audit(England, Wales & N Ireland) • Co-ordinated by RCP (Lond) • Organisation, min dataset, case note review • Uses modified, extended and tested version of RCP stroke Audit Package • Inter-rater reliability tested • Completed for 40 consecutive patients in most Trusts • 6894 cases in first round • third round now completed

11. Auditing process - coping with casemixNational Sentinel Audit of Stroke 1999

12. Auditing process - SwallowingNational Sentinel Audit of Stroke 1999

13. Problems of Sentinel Audits • Only 40 sets of case notes per Trust - therefore imprecise • Little control over sampling - therefore potentially biased • Data extraction not resourced • No independent data extraction - therefore potentially biased

14. Proportions of patients dying within 30 days after emergency admission with stroke

15. Problem of Stroke Outcome Indicators • Diagnostic inaccuracies • Lack of confidence in data • Insufficient data on outcomes • Virtually no data on process • Inadequate casemix adjustment

16. 6 month Case Fatality Rate Crude Adjusted

17. Death or dependency at 6 month Crude Adjusted

18. Variations in Process

19. Clinical Standards Board (CSBS) Produce standards SIGN Reviews Evidence Guidelines National Audit Monitors performance Managed Clinical Networks (MCNs) Improve performance Overall Plan

20. Clinical Standards Board (CSBS)Timetable • Draft standards & self assessment questionnaire in preparation • Wider consultation - Spring 2003 • Pilot visits - Summer 2003 • Scotland wide visits - October 2003

21. Some current draft standardsCSBS >70% admitted to a stroke unit within 24 hours >90% having a CT or MR scan (within 7 days of admission) >90% of ischaemic strokes given aspirin within 48 hours of admission >80% of patients seen in Neurovascular clinics within 14 days A system is in place to collect data specified in the Scottish Minimum Data Set for all patients

22. The CHD & Stroke Strategy • All hospitals which routinely admit patients with acute stroke should introduce systems to facilitate the collection of a nationally-defined minimum dataset for each patient admitted, in order to allow monitoring of performance against nationally agreed standards

23. The CHD & Stroke Strategy • All hospitals which routinely admit patients with stroke should join the pilot phase if the Scottish Executive project to establish a National Monitoring System for hospital-based stroke services.

24. The CHD & Stroke Strategy • Hospitals will need to identify a lead clinician for this project as well as staff to ensure complete data collection. • Where an IT system already exists, resources should be identified to ensure its compatibility with nationally-agreed methods and datasets;

25. The CHD & Stroke Strategy • Further development work should be resourced to establish the feasibility and methods of linking the hospital-based systems with those in primary care, to allow capture of information relating to longer-term management of stroke patients and outcome.

26. Why should your hospital participate? • To identify deficiencies of service which can be addressed • To inform development of Managed Clinical Network • To meet data needs of CSBS • To help monitor progress of CHD & Stroke strategy • To meet requirements for appraisal & revalidation

27. Any Comments or Questions?

28. Examples of Outputfrom SSCAS Based on data collection in Lothian

29. Hospital Comparisons on Inpatient Data • Edinburgh Royal Infirmary (RIE) n = 440 • Western General Hospital (WGH) n = 525 • St Johns Hospital (SJH) n = 185

30. Hospital Median Length of Stay RIE 21 days WGH 10 days SJH 12 days

31. Discharge Destination

32. Hospital Median Age RIE 77 years WGH 75.3 years SJH 73.4 years

33. Ages of stroke patients

34. Casemix - all Stroke Patients

35. % admitted to stroke unit

36. Degree of specialisation in WGH

37. WGH Specialisation across Lothian St Johns RIE

38. % having a CT scan

39. Delays to CT Scans

40. Drugs on Discharge - all strokes %

41. % of ischaemic strokesdischarged on antiplatelet drug

42. % of ischaemic strokes in AFdischarged on Warfarin

43. Performance of WGH Neurovascular Clinic

44. Neurovascular Clinic Casemix(n= 1061)

45. 8 Days 4 days First NV Appointment Referral Received Event Referral 3 Days Median delays in accessing WGH Neurovascular Clinic Remember half the cases wait longer than the median!

46. Use of investigations in stroke & TIA in WGH Neurovascular Clinic (n=656)

47. Delays in CT scanning Neurovascular Patients with stroke or TIA (n=421) • Median delay from assessment to CT • 0 days • Median delay from last event to CT • 15 days • % scanned within 7 days of assessment • 85% • % scanned within 7 days of last event • 24%

48. £ £ £ Antithrombotic prescribing for ischaemic events in WGH Neurovascular Clinic (n=633)

49. £££ ££ £ Antihypertensive prescribing for ischaemic events in WGH Neurovascular Clinic (n=633)

50. £ £ £ Statin prescribing for ischaemic events in WGH Neurovascular Clinic (n=633)