Irish National Audit of Irish National Audit of Stroke Care (INASC)Stroke Care (INASC)

Professor Hannah McGee RCSIProfessor Hannah McGee RCSIProfessor Des O’Neill TCDProfessor Des O’Neill TCDDr Frances Horgan RCSIDr Frances Horgan RCSI

Dr Anne Hickey RCSIDr Anne Hickey RCSI

INASC OverviewINASC Overview

Stroke – assembling the jigsawStroke – assembling the jigsaw

Dr Frances HorganDr Frances Horgan

INASC

INASC

Stroke in IrelandStroke in Ireland• 3rd most common cause of death• Leading cause of acquired major disability• Stroke - a singular and complex illness• Major concerns over adequacy of services

but very little data available• Aims of this project

• to conduct a national audit of stroke care across the trajectory of care in hospital and the community in the Republic of Ireland

Council on Stroke, 2001

INASC

First comprehensive auditFirst comprehensive auditAlliedHealth

ProfessionalsPHN

Nursing Homes

GPsPrevention

Organisationof Hospital

care

Actual Hospital

Care

Supportin the

Community

INASC

INASC PROJECT: Six StudiesINASC PROJECT: Six StudiesMarch 2006-September 2007March 2006-September 2007

HOSPITAL- Organisational audit - 37 hospitals………. √- Clinical (chart) audit - 2570 charts ………. √ [based on UK Sentinel audit system]

COMMUNITY- GP Survey - 204 GPs……..………………. √- AHP & PHN survey…75 professionals….. √- Patient & carer survey…139 patients, 72 carers…√- Nursing home survey…60 homes …….… √

INASC

Hospital Audit - MethodsHospital Audit - Methods

• Organisational Audit:

• Aim - Audit of the organisational aspects of stroke care in acute hospitals with regard to resources for organised stroke care

• Structured face-to-face interview with Management Team

• Clinical Audit:

• Aim: Audit of Stroke Care - review clinical case notes (2,570) for representative sample of patients

• Charts identified for Jan-March 2005 and July-Sept 2005 (HIPE ICD10 I61 I63 I64)

INASC

Emergency and acute hospital careEmergency and acute hospital care

• Only one Irish hospital had a stroke unit

• Thrombolysis almost non-existent - 1%

• Swallow screening - available 5 sites

• 16% of hospitals had TIA clinics

INASC

Staffing and acute hospital careStaffing and acute hospital care

• One third of hospitals had lead consultant for stroke care (only 5 protected time)

• 5 clinical nurse specialists• 2 clinical specialist therapists• Availability of MDT limited• Clinical psychology almost non-existent

INASC

Acute hospital care Acute hospital care Access to rehabilitation Access to rehabilitation

• 35% of hospitals had access to on-site rehabilitation

• Limited access to rehabilitation for younger stroke patients

• Stroke specific MDT meetings in only 22% hospitals

• 22% had documented rehabilitation goals (76% UK06)

INASC

Who gets stroke?Who gets stroke?

- Men 52% Women 47%- 19% < 65 years (17%)- 92% living at home at the time of the stroke- 73% independent in activities of daily living

(ADL) pre-stroke

- On discharge…• 56% discharged home• 15% newly institutionalised (13%)• Only 28% independent in ADL at discharge (39%)

UK 06

INASC

Co-morbidity ProfileCo-morbidity Profile Known co-morbidities prior to admission with stroke (Q2.1) (n=2173) Co-morbidity INASC 2006

%(N) Sentinel UK 2006

Sentinel UK 1998

Atrial fibrillation 22% (469) 20% NA Previous stroke/TIA 25% (541) 29% NA Impaired glucose tolerance 1% (22) NA NA Diabetes mellitus 12% (260) 16% NA Hyperlipidaemia* 17% (372) 19% NA Hypertension^ 51% (1108) 53% NA MI or angina 14% (307) 20% NA Valvular heart disease 4% (92) 3% NA Other 18% (388) 5% NA None apply/detected 17% (362) 21% NA None of the above 1 of the above 2 of the above 3 or more of the above

22% (479) 29% (626) 24% (524) 25% (544)

21% 29% 27% 23%

NA NA NA NA

* Hyperlipidaemia = total cholesterol >5 or LDL >3.0mmo l/L ^ Hypertension = systolic > 140 or diastolic > 85 Other = Congestive cardiac failure (CCF) and Polymyalgia Rheumatica NA not available

INASC

Acute hospital - diagnosticsAcute hospital - diagnostics

• 71% admitted on day of stroke, 5% within 2 hours of stroke (UK 39%)

• 30% did not have routine access to CT within 48hr of stroke and only 41% emergency MR scanning

• Time from stroke to scan mean 2.6 days, median* 1 (1 day* UK06)

• INASC 4% scanned within 3 hours (9% UK06)

INASC

Standards within 72 hoursStandards within 72 hours

• SLT swallow screen 26% (66%)• SLT swallow assessment 25% (67%)• Physiotherapy assessment 43% (71%)• Nutrition assessment 81% (93%)• Aspirin within 48 hours 43% (67%)

UK 06

INASC

Standards within 7 daysStandards within 7 days

• SLT communication assessment 29% (69%)

• OT assessment 22% (68%)

• Continence plan 13% (54%)

UK 06

INASC

INASC - Onset/Hospital StayINASC - Onset/Hospital Stay

INASC 2006

% (N)

Sentinel 2006 Sentinel 1998

Died in hospital

Unknown

19% (408)

4%

26%

1%

NA

30-day mortality

Unknown

15% (317)

13%

22%

5%

29%

Length of stay mean 29.8 days

median 14

Mean 27.7 days

median 15

INASC

Communication patients and carersCommunication patients and carers

• Discussion stroke diagnosis 22% (69%)• Discussion stroke prognosis 18% (59%)• Assessment of carers needs 24% (68%)• Skills taught to carers 12% (71%)• 7% Irish patients had a home visit (63%)

• Only 4 hospitals had a hospital/community liaison person

UK 06

INASC

MedicationsMedications

Cardiovascular medication profile pre-admission (Q2.3i) INASC 2006

% (N) Sentinel 2006

Antihypertensives 56% (1219) 57% Antiplatelet/anti thrombotic 52% (1133) 51% Lipid lowering treatment 25% (546) 33%

Cardiovascular medication profile at discharge (Q6.3) INASC 2006 % (N) Sentinel 2006

Antihypertensives 78% (1306) 57% Antiplatelet/antithrombotic 85% (1423) 86% Lipid lowering treatment 70% (1177) 79%

INASC

Acute hospital care - secondary Acute hospital care - secondary preventionprevention

• 51% cause stroke identified/documented (73%)• Smoking cessation 9% (79%)• Reduce alcohol 7% (80%)• Exercise 8% (41%)• Diet advice 14% (42%)• 67% Blood cholesterol documented (NA)

UK 06

INASC

Discharge from hospital & follow-upDischarge from hospital & follow-up

• GP informed of patient’s discharge

• 56% of GPs notified on day of discharge

• 24% of discharge summaries indicated functional status

• 35% had carotid imaging within 3 months

INASC

INASC

Ireland 2006

UK 2002 UK 2004 UK 2006

Stroke unit* 3% 73% 79% 91%

Rapid transfer to hospital

3% NA 4% 12%

Routine Thrombolysis

0% NA NA 18%

Neurovascular

clinic16% NA 65% 78%

Mobile stroke team*

14% NA 23% 29%

Early support discharge team*

0% NA 14% 22%

Specialist community rehab team (CRT)*

0% NA 25% 32%

Consultant with responsibility for stroke*

32% 80% 90% 98%

Audits and improvement - INASC vs. Sentinel Rounds UK

INASC

12 Key standards and indicators of stroke care INASC vs. Sentinel Key standards

% Compliance with indicator Patients

INASC 2006 2173 %

Sentinel 2004 8697 %

Sentinel 2006 13625 %

Q1.2iii Brain scan within 24 hours 40 59 42 Q1.7 Treated on a stroke unit during their stay 2 46 62 Q1.9 > 50% stay on a stroke unit 1 40 54 Q3.1 Screened for swallow within 24 hours 26 63 66 Q3.3 Aspirin started by 48 hours 45 68 71 Q3.5 Physiotherapy assessment within 72

hours of admission 43 63 71

Q4.2 Occupational therapy assessment within 7 days of admission

22 57 68

Q5.1 Weighed at least once during admission 41 52 57 Q5.3 Mood assessed by discharge 28 47 55 Q6.3 On anti-thrombotic therapy by discharge 85 95 100 Q5.5 Rehabilitation goals agreed by MDT 22 68 76 Q7.4 Home visit performed by discharge 7 69 63 Average for 12 indicators 30 61 65

INASC Main findings: INASC Main findings: community stroke managementcommunity stroke management

Dr Anne HickeyDr Anne Hickey

INASC

Community Surveys: MethodsCommunity Surveys: Methods

• National GP survey:• Randomly selected (n=204: 46% response), postal survey

• Allied health professional (AHP) & public health nurse (PHN) survey (3 phases):

• N=75 interviews/postal survey involving Local Health Office managers, AHP/PHN managers and frontline staff across 8 disciplines

• Patient & carer survey:• Interviews with 139 (55% response) patients and 72 carers

• Nursing home survey:• Interviews with proprietor/manager in 60 nursing homes

(20 Dublin, 40 outside Dublin) and residents with stroke

INASC

GP Survey - Stroke ManagementGP Survey - Stroke Management

• Information letter at discharge focused almost entirely on diagnosis; little information on functional ability, rehabilitation or community services organised

• Staff shortages most significant barrier to rehabilitation - lack of OT, SLT, physiotherapy and home help

• GP stroke patients residing in nursing homes - c. 25%

INASC

AHP/PHN Survey - Stroke AHP/PHN Survey - Stroke Management/Service ProvisionManagement/Service Provision

• PLANNING: • No stroke statistics/registers - Absence of information on

prevalence of stroke in community makes planning for comprehensive community-based stroke service very difficult

• DISCHARGE:

• Communication at discharge absent, delayed or limited

• Equipment / support often not in place at discharge

• TEAMWORK: • Separate notes; few team meetings

• Multidisciplinary service, not operating as multidisciplinary team

• Access to dietetics, social work & psychology largely non-existent

• LIMITS: • Services age-related (younger have limited access)

• Limited input to nursing homes

INASC

AHP/PHN Survey - ConclusionsAHP/PHN Survey - Conclusions

• Inequitable access to rehabilitation - no programmes in some areas

• Community AHP staffing levels do not reflect availability for stroke-related service provision

• Need for key worker to ensure streamlined services

• Current staffing levels and employment ceilings restrict service development - complete absence of some disciplines in some areas (notably social work, speech & language therapy, dietetics, psychology)

INASC

Patient/carer perspectives on Patient/carer perspectives on hospital dischargehospital discharge

• Inconsistent, haphazard discharge planning:• 75% no family conference prior to discharge• 67% no contact name after discharge• 33% necessary services not in place on

discharge• 34% no information on purpose of medication,

70% not informed of potential medication side-effects

INASC

Patient/carer perspectives on Patient/carer perspectives on community stroke carecommunity stroke care

• Poor community rehabilitation• 50%+ not getting sufficient mobility

treatment• Approx. 50% not getting sufficient SLT

treatment • 75% no support with emotional difficulties

• Less likely to receive services if under 65 years

INASC

Stroke carersStroke carers

• Need for information and support about diagnosis, prognosis and post-hospital care

• Carer expected to become ‘expert’ once patient came home

• Need for ‘key worker’ to provide contact if needed

• One in 10 carers classified as ‘at risk’ of health problems; all women, predominantly over 65

INASC

Nursing Home Residents Nursing Home Residents and Strokeand Stroke

N= 570 residents with stroke: 83% > 75yrs; 2% < 65yrs

Percentage of nursing home residents with stroke

<65 yrs 65-74 yrs 75+ yrs

Affected by stroke

8% 23% 18%

INASC

Stroke Resident Stroke Resident ImpairmentsImpairments

Overall (% of the total number)N=570

Communication Difficulty 51

Swallow difficulty 52

Cognitive impairment 64

Positioning needs 85

Limited independence 86

Risk of falls 87

Decreased independence in transfers (bed to chair and back)

88

Decreased balance 86

Poor mobility / Mobility needs 83

Residual weakness after stroke 92

INASC

Nursing Homes: Access to Nursing Homes: Access to ServicesServices

• Access to GP ‘very good’ • Access to rehabilitation professionals-’POOR’

• Stroke patients described as ‘discharged from active rehabilitation services’

- some access to physiotherapy- very limited access to SLT, OT, dietician, social work; no access to psychology

• Many challenges appear similar to those of nursing home residents generally

INASC

Preventing and Managing Stroke Preventing and Managing Stroke in the Communityin the Community

• Little or no organised system of care for the management of stroke in the community

• Little systematic or organised primary prevention of stroke• Lack of awareness evident in other Irish research

• Major awareness and education campaign needed (rapid response essential):

• Public and those working with public

• Primary care professionals

• Hospital and rehabilitation professionals

INASC

Primary prevention of strokePrimary prevention of stroke

• Barriers to implementation of stroke primary prevention strategies in primary care:• Inadequate staffing• Time pressures• Lack of designated funding• Lack of screening protocols• Lack of risk factor management protocols

INASC

Potential for Stroke Prevention and Potential for Stroke Prevention and Screening in General PracticeScreening in General Practice

• Heartwatch (heart disease management) GP practices much more likely to have:

• Registers of patients with hypertension

• Registers of patients with diabetes

• Registers of patients with atrial fibrillation

• Registers of patients with stroke

• Regular practice audits

• Potential to expand to Cardiovascular Watch, to include key stroke-related variables (e.g., screening for atrial fibrillation)

INASC Implications of findings INASC Implications of findings for stroke services in Irelandfor stroke services in Ireland

Professor Desmond O’NeillProfessor Desmond O’Neill

INASC

‘After I got home, there should have been someone to help from the start’. (Patient)

‘No one seemed to know who was looking after him; there was no follow-up, and very little support was available’. (Carer)

‘A contact person would have been nice, someone to talk to’. (Patient)

‘I was only 52 and had my own business. I miss the contact with work colleagues and can go for weeks without seeing anyone’. (Patient)

INASC

INASC SummaryINASC Summary

• Allows quality of care comparisons against professional guidelines and neighbouring jurisdiction (UK National Sentinel Audit)

• Provides comprehensive profile of stroke care across primary and secondary prevention, acute treatment, rehabilitation and longer-term care

• Enables evidence-based planning and evaluation of strategies to improve service delivery

INASC

INASC ImplicationsINASC Implications

• National strategy for stroke• Regional governance, implementation of stroke

care• Stroke register• Primary prevention - supportive structures• Reconfiguration hospital services• Urgent development STROKE UNITS with

appropriate services and staff• Rehabilitation at all stages of care

INASC

Implications…Implications…

• Systems for sharing information and follow-up• Ongoing support and community rehab• Information on stroke patients and carers• Major developments staffing and specialist

training for all disciplines• Equitable needs based access to care• Public awareness programmes• Transportation• Repeat audit cycle

INASC

INASC

AcknowledgmentsAcknowledgmentsHospital staff; physicians, management team, HIPE staff, Medical Records.

Chart auditors

ESRI Health Policy Unit

National Hospitals Office

Sentinel team UK - Dr Tony Rudd and Mrs Alex Hoffman

Stroke patients and their carers

Nursing home staff

Community PHNs AHPs, AHP Managers and Frontline staff, LHOMs

General Practitioners

Professional organisational submissions

Ms Imelda Noone and Ms Aisling Creed

INASC

INASC Project Steering GroupINASC Project Steering Group• Professor Hannah McGee - Psychology RCSI (Co-PI)• Professor Des O’Neill - Gerontology TCD (Co-PI)• Dr Frances Horgan - Physiotherapy RCSI (Project Manager/Lead Hospital audit)• Dr Anne Hickey - Psychology RCSI (Lead Community Projects)• Professor Seamus Cowman - Nursing RCSI• Professor David Whitford - General Practice RCSI• Dr Emer Shelley - Epidemiology RCSI• Dr Sean Murphy - Midland Regional Hospital Mullingar• Professor Miriam Wiley - Economic & Social Research Institute

• INASC Project Research Staff• Research Staff at the Division of Population Health Sciences (Psychology), RCSI: Ms

Karen Galligan, Ms Helen Corrigan, Ms Maeve Royston, Ms Maeve Proctor, Ms Oonagh Mullan, Ms Abigail Henderick, Ms Anna-May Fitzgerald, Ms Philippa Coughlan, Dr Bernadette O’Sullivan, Ms Claire Donnellan and Dr Maja Barker