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Scottish Stroke Audit

Scottish Stroke Audit. National Meeting 12th June 2007. Acknowledgements. Robin Flaig Mike Mcdowall Audit coordinators Contributing clinicians and managers. Menu. Proposed audit cycle Data quality and interpretation National performance in 2005

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Scottish Stroke Audit

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  1. Scottish Stroke Audit National Meeting 12th June 2007

  2. Acknowledgements • Robin Flaig • Mike Mcdowall • Audit coordinators • Contributing clinicians and managers

  3. Menu • Proposed audit cycle • Data quality and interpretation • National performance in 2005 • Performance of individual hospitals – learning lessons from good and bad practice • Future plans

  4. Proposed audit & reporting cycle • Send SSCAS exports to Robin by 31st March • Prepare draft report by June 1st • National meeting in June • MCNs report to SEHD on NHSQIS standards by June 30th • Incorporate data into MCN annual reports & QAF for Health Boards • Finalise National report and publish in Sept

  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% • We have had problems with denominators • NHS QIS ask % admitted SU within 1 day • Is denominator 60 or 100?

  7. Denominators We provide % based on two denominators with patients with missing data excluded which provides an optimistic estimate with patients with missing data included which is that defined by NHSQIS Large differences between the two often indicates incomplete data collection

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

  9. Performance across Scotland in 2005

  10. Comparisons between hospitals Inpatients

  11. % of patients treated according to NHSQIS standard NHS QIS standard Mean in 2005 Hospital Number

  12. Key to Hospital

  13. Stroke unit care

  14. 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)

  15. Observational studies of stroke unit implementation

  16. % Admitted to a stroke unit during admission,including missing - 2006

  17. Poor access in Perth, St Johns &Victoria Infirmary

  18. Why such poor access? • Lack of SU beds? • Filled with non stroke patients? • Problems with discharge?

  19. % Admitted to a stroke unit within 1 day of admission, NHS QIS– 2006

  20. WIG, SGH & Lorn & Islands

  21. >10% improvement 2005-2006ARI, RIE, Crosshouse, Forth Valley

  22. How do they do it? • Direct admissions? • Day & night? • Medical staffing out of hours? • Do they have a medical assessment unit? • How many beds for how many admission? • Fixed bed numbers or flexible? • Ring fenced beds? • How do they clear their beds?

  23. Swallow screen

  24. 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

  25. % Swallow screened during admission, including missing - 2006

  26. % Swallow screened on day of admission NHS QIS – 2006

  27. GRI, WIG & Crosshouse

  28. >10% improvement 2005-2006Aberdeen, Stobhill, Raigmore

  29. How do they do it? • Who does the screening? • How were they trained? • Where do they do it? • How is it documented? • Are they missing cases?

  30. Brain scanning

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

  32. % Scanned during admission, including missing - 2006

  33. % Scanned within 2 days of admission NHS QIS - 2006

  34. Ninewells, WGH, SGH, WIG, Lorn & Islands

  35. >10% improvement 2005-2006 ARI, GRI, Stobhill, Crosshouse

  36. How do they do it? • Protocols or ICP? • Where is the scanner? • Week end scanning • Out of hours scanning? • Additional sessions?

  37. Early aspirin use

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

  39. Absolute effects of antiplatelet treatment - % with vascular events Treat 1000 9 avoid event in 2 weeks

  40. 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

  41. % Received aspirin during admission, including missing - 2006

  42. % Received aspirin within 2 days of admission NHS QIS – 2006

  43. SGH, WIG, Caithness, Orkney

  44. >10% improvement 2005-2006GRI, WIG, Ayr, Crosshouse, Orkney, Shetland

  45. How do they do it? • Protocol or ICP? • Rapid scanning? • No scanning? • Immediate reporting or PACS on ward? • Nurse prescription?

  46. Blood pressure loweringafter stroke

  47. 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)

  48. Updated Overview of BP-Lowering in Patients With Cerebrovascular Disease Event rate Odds ratio and 95% CI Trial N Study Control Patients with hypertension Carter 97 20.4% 43.8% HSCSG 452 18.5% 23.7% INDANA subgroups 514 11.4% 15.3% Subtotal 1,063 15.2% 21.6% Patients with or without hypertension TEST 720 19.9% 19.8% Dutch TIA 1,473 7.1% 8.4% PATS 5,665 5.6% 7.7% PROGRESS 6,105 10.1% 13.8% Subtotal 7,858 7.2% 8.9% 35% SE 13 reduction 26% SE 7 reduction 0.0 0.5 1.0 1.5 2.0 NB mean BP reduction about half as great in patients with or without hypertension, quasi-randomization in PATS andsubgroups of 5 trials with INDANA. 1832 Rodgers Slides #48

  49. % Strokes discharged alive on any antihypertensive or Trial - 2006

  50. High use – Stobhill & WIGLow use – RAH & Fife

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