Quality Standards: Information
challenges in clinical practice
(Stroke)
Tony Rudd
What are the problems that need
solving?
 Unacceptable variation in the quality of care
between hospitals
 Variable quality of clinical and managerial leadership
 Variable resources provided for stroke care
 UK slow to adopt new technologies e.g.
Thrombolysis
 Still a belief amongst many people (professionals
and public) that stroke untreatable disease of old
people
National Initiatives for Change
NAO 2005
National Stroke
Strategy 2007
National Sentinel Stroke Clinical Audit 2010
Round 7
Stroke Improvement Programme
NICE Acute Stroke
and TIA
Guidelines
No shortage of policy documents!
ICSWP
Stroke Guidelines
2008
Data requirements for Stroke







Accelerated metrics
NICE Quality Standards
Integrated Performance Measures Reporting (Vital signs)
Local stroke and cardiac network requirements
Commissioning Outcomes Framework
Quality Outcomes Framework
National audits
 SINAP
 Sentinel
 carotid
 HES Data
 Patient satisfaction
 CQC
Stroke Quality Standards: criteria for
inclusion
 Standards covering whole pathway (therefore not just
those in NICE Acute stroke and TIA guidelines). Used
RCP National Clinical Guidelines
 Important clinically and some areas resistant to change
 Measurable, achievable and comparable between units
 Evidence based or very strong clinical consensus
 Excluded secondary prevention because already well
covered by QOF
 Largely process measures where the process is known
to affect outcome
Using Quality Standards
 Setting the national agenda for Quality
improvement
 Informing providers
 Including the QS in quality accounts
 Comparing performance between provider units
 Informing the users
 Public release of data on performance
Using Quality Standards
 Informing commissioners
 Providing framework for commissioning of services
 But cannot be used as the exclusive document for
defining components that are needed for a service.
Indicative of the type of care needed
 Challenging the conventional models of care
 Use for CQUINS (Commissioning for Quality
Improvements) and for World Class Commissioning
 Informing the regulators
 Informing the politicians
No.
NICE Quality Standards for Stroke
1
Patients with stroke are assessed and managed by stroke nursing staff and at least one member of the
specialist rehabilitation team within 24 hours of admission to hospital, and by all relevant members of
the specialist rehabilitation team within 72 hours, with documented multidisciplinary goals agreed within
5 days.
2
Patients with suspected stroke are admitted directly to a specialist acute stroke unit and
assessed for thrombolysis, receiving it if clinically indicated.
Patients who need ongoing inpatient rehabilitation after completion of their acute diagnosis and
treatment are treated in a specialist stroke rehabilitation unit.
All patients discharged from hospital who have residual stroke-related problems are followed up within
72 hours by specialist stroke rehabilitation services for assessment and ongoing management.
3
4
5
Patients with stroke are offered a minimum of 45 minutes of each active therapy that is required, for a
minimum of 5 days a week, at a level that enables the patient to meet their rehabilitation goals for as
long as they are continuing to benefit from the therapy and are able to tolerate it.
6
(a) People seen by ambulance staff outside hospital, who have sudden onset of neurological symptoms,
are screened using a validated tool to diagnose stroke or transient ischaemic attack (TIA).
(b) People with persisting neurological symptoms who screen positive using a validated tool, in whom
hypoglycaemia has been excluded, who have a possible diagnosis of stroke, are transferred to a
specialist acute stroke unit within 1 hour.
Patients with acute stroke receive brain imaging within 1 hour of arrival at the hospital if they meet any
of the indications for immediate imaging.
Patients with acute stroke have their swallowing screened by a specially trained healthcare professional
within 4 hours of admission to hospital, before being given any oral food, fluid or medication, and they
have an ongoing management plan for the provision of adequate nutrition.
7
8
9
10
11
All patients after stroke are screened within 6 weeks of diagnosis, using a validated tool, to identify
mood disturbance and cognitive impairment.
Patients with stroke who have continued loss of bladder control 2 weeks from diagnosis are reassessed
for the cause of incontinence, and have an ongoing treatment plan involving both patient and carer/s.
Carers of patients with stroke are provided with a named point of contact for stroke information, written
information about the patient’s diagnosis and management plan, and sufficient practical training to
enable them to provide care.
National Sentinel Audit Data 2004-2010
SINAP
Audit 2011
Thrombolysis
 5% of patients received altepase in 2010
Sentinel Audit (increased from 1.8% in 2008)
 14% of patients should be receiving it
(presented within 3 hours, 80 yrs or under,
infarction)
 Still many areas of the country where
hyperacute stroke care not adequately provided
SINAP Audit
2011
Thrombolysis rates in London after introduction
of London Stroke Strategy
16%
Thrombolysis rates have
increased since
implementation began to a
rate higher than that reported
for any large city elsewhere in
the world
Feb – Jul 2009
AIM
Feb – Jul 2010
14%
12%
12%
10%
10%
8%
6%
4%
2%
0%
3.5%
No.
NICE Quality Standards for Stroke
1
Patients with stroke are assessed and managed by stroke nursing staff and at least one member
of the specialist rehabilitation team within 24 hours of admission to hospital, and by all relevant
members of the specialist rehabilitation team within 72 hours, with documented
multidisciplinary goals agreed within 5 days.
2
Patients with suspected stroke are admitted directly to a specialist acute stroke unit and assessed for
thrombolysis, receiving it if clinically indicated.
Patients who need ongoing inpatient rehabilitation after completion of their acute diagnosis and
treatment are treated in a specialist stroke rehabilitation unit.
All patients discharged from hospital who have residual stroke-related problems are followed up within
72 hours by specialist stroke rehabilitation services for assessment and ongoing management.
3
4
5
Patients with stroke are offered a minimum of 45 minutes of each active therapy that is required, for a
minimum of 5 days a week, at a level that enables the patient to meet their rehabilitation goals for as
long as they are continuing to benefit from the therapy and are able to tolerate it.
6
(a) People seen by ambulance staff outside hospital, who have sudden onset of neurological symptoms,
are screened using a validated tool to diagnose stroke or transient ischaemic attack (TIA).
(b) People with persisting neurological symptoms who screen positive using a validated tool, in whom
hypoglycaemia has been excluded, who have a possible diagnosis of stroke, are transferred to a
specialist acute stroke unit within 1 hour.
Patients with acute stroke receive brain imaging within 1 hour of arrival at the hospital if they meet any
of the indications for immediate imaging.
Patients with acute stroke have their swallowing screened by a specially trained healthcare professional
within 4 hours of admission to hospital, before being given any oral food, fluid or medication, and they
have an ongoing management plan for the provision of adequate nutrition.
7
8
9
10
11
All patients after stroke are screened within 6 weeks of diagnosis, using a validated tool, to identify
mood disturbance and cognitive impairment.
Patients with stroke who have continued loss of bladder control 2 weeks from diagnosis are reassessed
for the cause of incontinence, and have an ongoing treatment plan involving both patient and carer/s.
Carers of patients with stroke are provided with a named point of contact for stroke information, written
information about the patient’s diagnosis and management plan, and sufficient practical training to
enable them to provide care.
SINAP Audit
2011
No.
NICE Quality Standards for Stroke
1
Patients with stroke are assessed and managed by stroke nursing staff and at least one member of the
specialist rehabilitation team within 24 hours of admission to hospital, and by all relevant members of
the specialist rehabilitation team within 72 hours, with documented multidisciplinary goals agreed within
5 days.
2
Patients with suspected stroke are admitted directly to a specialist acute stroke unit and assessed for
thrombolysis, receiving it if clinically indicated.
Patients who need ongoing inpatient rehabilitation after completion of their acute diagnosis and
treatment are treated in a specialist stroke rehabilitation unit.
All patients discharged from hospital who have residual stroke-related problems are followed up within
72 hours by specialist stroke rehabilitation services for assessment and ongoing management.
3
4
5
Patients with stroke are offered a minimum of 45 minutes of each active therapy that is required,
for a minimum of 5 days a week, at a level that enables the patient to meet their rehabilitation
goals for as long as they are continuing to benefit from the therapy and are able to tolerate it.
6
(a) People seen by ambulance staff outside hospital, who have sudden onset of neurological symptoms,
are screened using a validated tool to diagnose stroke or transient ischaemic attack (TIA).
(b) People with persisting neurological symptoms who screen positive using a validated tool, in whom
hypoglycaemia has been excluded, who have a possible diagnosis of stroke, are transferred to a
specialist acute stroke unit within 1 hour.
Patients with acute stroke receive brain imaging within 1 hour of arrival at the hospital if they meet any
of the indications for immediate imaging.
Patients with acute stroke have their swallowing screened by a specially trained healthcare professional
within 4 hours of admission to hospital, before being given any oral food, fluid or medication, and they
have an ongoing management plan for the provision of adequate nutrition.
7
8
9
10
11
All patients after stroke are screened within 6 weeks of diagnosis, using a validated tool, to identify
mood disturbance and cognitive impairment.
Patients with stroke who have continued loss of bladder control 2 weeks from diagnosis are reassessed
for the cause of incontinence, and have an ongoing treatment plan involving both patient and carer/s.
Carers of patients with stroke are provided with a named point of contact for stroke information, written
information about the patient’s diagnosis and management plan, and sufficient practical training to
enable them to provide care.
Duration of Rehabilitation
 Research evidence to show a link between intensity
of therapy after stroke and outcome
 In UK majority of rehabilitation resources
concentrated in hospitals
 Length of hospital stay falling after stroke (reduced
from mean of 35 days to 20 days over last 10 years)
 Patients frequently complain that they sit in hospital
doing nothing for long periods of time
time (min.)
160
140
Belgium
120
England
100
Switzerland
80
Germany
60
40
20
0
total therapy
physio-therapy occupational therapy speech therapy
other therapies
Appropriateness for Therapy
Intensity of Therapy Received
How deliver increased intensity?
 Different patterns of working e.g. Cutting
down on bureaucracy
 Less one to one therapy and more group
treatment
 Using non specialist therapists to provide
cover
 Focussing treatment just on patients likely to
benefit e.g. Stopping treatment earlier
 More therapists
Stroke Data Collection in the Future:
Sentinel Stroke National Audit
Programme (SSNAP)
 Replacing all other statutory data collection
(except IPMR!). Includes data needed for:




NICE QS
NHS Outcomes Framework
Accelerated metrics
COF
 Funded by HQIP
Information Challenges
 Need to link datasets to cover the stroke
pathway:




Ambulance trust data (often without an NHS number)
Acute hospital and primary care data
Social care data
Patient reported data
 Data protection requirements and the
Information Commissioner making life
unbelievably complex to obtain section 251
approval
Information Challenges
 Freedom of information act:
 We will be reluctant to collect any data that might
be in any way experimental
 We will be reluctant to do analyses of data that
are exploratory
 We will be reluctant to collect any data that might
be misinterpreted or not be statistically robust
because of sample size issues
Information Challenges
 Intellectual property rights
 HQIP issues with IPR to the audits it funds
including those of commercial web developers
 HQIP (presumably therefore DH) wanting control
over data analysis and publishing. Therefore at risk
of losing clinical independence over national audit
data
Information Challenges
 Failure to make data collection in healthcare
mandatory
 Proliferation of private companies offering
third rate data collection tools at great
expense resulting in failure to adequately
collect data in a format that can be used for
national data reporting
 Organisations that publish without any regard
to accuracy or data quality
Information Challenges
 Demands for reporting outcome data at a
level that is clinically meaningless and
misleading e.g. Individual stroke
physician/hospital
 Numbers too small
 Difficulty adjusting for case mix
 Outcomes dependent upon large teams working
in collaboration
Conclusions
 NICE Quality Standards alongside other quality
initiatives have undoubtedly resulted in
improvements in clinical practice
 We need to simplify data collection; currently
too great a burden for clinicians
 Major threats to our ability to conduct
national audit