GOVERNANCE BOARD. 14th January Clinical Audit of Stroke Services. At Shrewsbury and Telford Hospitals NHS Trust

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1 GOVERNANCE BOARD 14th January 2014 Clinical Audit of Stroke Services At Shrewsbury and Telford Hospitals NHS Trust 1.0 Introduction A clinical review of cases recorded and coded as with a 0-1 day length of stay was carried out at Shrewsbury and Telford Hospitals on 4 th December 2013 by Dr Jo Leahy and Christine Morris, Executive Nurse. 2.0 Background In reports from the Chief Finance Officer previously to the Board it has been reported that there has been significant growth in this area in the past 12 months and the aim of the audit was to explore the context for this, aligned to the clinical pathway in place in the Hospital Trust. (Appendix 1) 3.0 Audit process The reviewers used the simple audit tool shown in appendix 2 and reviewed 35 of the 38 sets of case notes coded as with a 0-1 day length of stay during the period 1 st may st August (The two remaining sets of notes belonged to 2 current inpatients.) Inclusion criteria was based on there being a primary diagnosis of there is a zero or 1 day length of stay the place of discharge is either home or Other Provider General Ward Of these 38 cases, 34 were coded as Stroke Best Practice Tariff. 4.0 Audit Findings The findings of the review are detailed in appendix 3. However, throughout review of the 35 sets of cases notes a number of themes were evident: the term Transient Ischaemic Attack (TIA) was not in use within the case notes for this cohort of patients. Some patients were given diagnosis of based on clinician s findings and not confirmed through diagnostic investigations. Some cases were coded as when they were not e.g. UTI, chronic exacerbation of a long term condition, previous. 1 P a g e

2 2 cases were immediately transferred to specialist units for care and not treated in SATH The pathway was considered excellent for patients with evidence of all having rapid access to multi -disciplinary team reviews and diagnostics. Royal College of Physicians national clinical guidance for can be found at: The guidance is informative and demonstrates that the pathway in place at SATH is aligned to best practice. All patients whose acute symptoms and signs resolve within 24 hours (ie TIA) should be seen by a specialist in neurovascular disease (eg in a specialist neurovascular clinic or an acute unit) A pxiii Transient ischaemic attack (TIA) is traditionally defined as an acute loss of focal cerebral or ocular function with symptoms lasting less than 24 hours and which is thought to be due to inadequate cerebral or ocular blood supply as a result of low blood flow, thrombosis or embolism associated with diseases of the blood vessels, heart, or blood (Hankey and Warlow 1994). A definition more recently suggested is: an event lasting less than 1 hour without cerebral infarction on a magnetic resonance imaging brain scan, but this requires early scanning. In practice the precise definitions used are not of great importance as however quickly or slowly recovery occurs and whether or not there is evidence of neuronal damage on brain imaging, the investigations and medical treatment will be broadly similar. All cerebrovascular events need to be taken seriously and treated with urgency. TIAs affect 35 people per 100,000 of the population each year and are associated with a very high risk of in the first month after the event and up to 1year p4 This raises the question what clinical presentation does the trust code as TIA and what is classified as a? Feedback in relation to the clinical pathway has been given to the Clinical leaders within the Trust. 5.0 Recommendations The reviewers would recommend that series of formal questions are posed the Trust via the contractual process to gain an understanding into the question above before considering next steps by the Chief Finance Officer. The CCG would want clarified what presentation does the Trust consider to be categorised as a TIA and what is a? Why were some cases coded as when they were not proven to be so? Why were cases immediately transferred to other centers (UHNS) coded as? Is there 24/7 7 day access to diagnostic investigations and thrombolysis? Dr Jo Leahy GP Board Member. Christine Morris Executive Nurse. 2 P a g e

3 Stroke and TIA 0-1 day: Length of stay Appendix 1 3 P a g e

4 Appendix 2 Clinical Audit of Stroke coding at SATH 4/12/13 1. Pt No: 2. Dob: 3. Date of admission: 4. Symptoms: 5. Duration of symptoms 6. Investigations: 7. CT result 8. Where discharged to: 9. Arrangements for follow-up 10. Comments Signature: 4 P a g e

5 Appendix 3 Audit Findings Symptoms Duration Investigations Scan result Discharge date Expressive dysphasia & dysphagia onset unsure - resolved by 9.30am Carotid doppler - no stenosis Follow up arrangements Comments No haemorrhage/ischaemia None Not proven Stroke.?alcohol Slurred speech, difficulty lifting leg, new onset AF uncertain unremarkable not recorded Anti-coagulation team Vascular Dementia patient. Readmitted Slurred speech due to dentures not in. NOT STROKE rt sided weakness & paraesthesia, visual disturbance 2 weeks Carotid doppler - no stenosis. No MRI - pt claustrophobic OPD 6-8w treated as Lacunar Stroke" L arm weakness, slurred speech, headache 3 hours on admission Carotid doppler - no sig stenosis. ECG abnormal no haemorrhage/infarct identified OPD 6w Clinical dx of. Early Supported discharge. C2C referral to cardiology - appropriate heaviness rt arm & leg, frontal headache 2 days small focal infarct. No evidence of haemorrhage community rehab PACS - confirmed 5 P a g e

6 Paraesthesia L arm & leg 10 days Carotid doppler normal Minor small vessel disease, no sign of haemorrhage/infarct Reviewed in TIA clinic Consultant opinion - small lacunar Rt sided facial weakness & confusion 1 week Carotid doppler - no stenosis Focal hypo density in keeping with recent infarction extensive - community therapists, continence service, community neuro rehab team confirmed L facial weakness, slurred speech not recorded Carotid doppler - no significant stenosis. Generalised disease. Ventricular ectopics on ECG Old infarction. No evidence acute intracranial haemorrhage or infarction. Generalised cerebral atrophy not recorded no facial weakness on admission. Notes state "cranial n's intact". "treated as acute CVA" but not compelling evidence Dizziness, vomiting, off legs, occipital headache not recorded. Slight l sided weakness on discharge ECG - AF No new haemorrhage or infarct. Previous cerebellar OPD 6w fully recovered on discharge Sudden onset weakness L arm. not recorded Bloods, ECG etc normal Chronic ischaemic changes, no acute segmental infarction/haemorrhage unclear "treated as " but condition appears to be chronic 6 P a g e

7 numbness rt arm, dysarthria not recorded but present on discharge apparently ECG normal. Carotid doppler - no stenosis no haemorrhage. Old basal ganglia lacunar infarct clinic f/u physio & SALT TREATED AS STROKE headache & blurred vision intracerebral bleed initially admitted and transferred immediately to UHNS. Transferred back from UHNS for rehab. NOT STROKE weakness rt limbs & face resolved within 24h MRA carotid - no stenosis. Echo normal MRI - acute infarct L lentiform nucleus & caudate was booked for further ix & OPD but DNA all Stroke Paraesthesia L arm & face symptoms persisting on discharge Carotid doppler x 2 small plaques, normal flow no infarct/haemorrhage? clinic f/u phyisio & SALT reassured at f/u that no sign of Sudden onset headache & neck pain 3 days Sub-arachnoid haemorrhage transferred UHNS should be coded for subarachnoid - immediate transfer to tertiary care 7 P a g e

8 Intermittent slurring of speech approx 2 hrs/day for 3 months bloods normal. ECG 1st degree heart block only small vessel ischaemic changes none medical clerking proforma inadequately completed. Unlikely 3 episodes numbness & paraesthesia left arm min each Carotid doppler NAD NAD? OPD 8w described as " mimic" in discharge letter Slurred speech & headache resolving on admission?30min Carotid doppler - tortuous vessels but normal flow widespread small vessel cerebrovascular ischaemia no record of f/u consultant opinion - small ischaemic L SIDED FACIAL WEAKNESS & SLURRED SPEECH 6-8H GLUCOSE 7.4. Carotid doppler NAD NAD OPD Described as "small ". Cranial n's intact at 12h. Still dragging foot on f/u Headache, paraesthesia & weakness R arm & leg, rt facial weakness > 17 hours TC/HDL ratio 6.3 No haemorrhage/infarction. MRI normal OPD improved mobility at f/u Heaviness L arm & leg? Area of acute infarction. No haemorrhage?? Stroke (PACS). GP referral. Check not charged for ED headache, dysphasia 2 days. Resolved by discharge CT changes consistent with hr tape - NAD. OPD Stroke 8 P a g e

9 fall, slurred speech < 1 hour no evidence of haemorrhage. Low density changes consistent with cerebrovascular disease GP to monitor statins not or TIA Headache, slurred speech, left sided weakness, collapse, seizure no further seizures Raised blood sugar previous burr-holes DN to manage insulin. GP to monitor BP Discharged from UNHS day before admission. Not R sided weakness & dizziness resolved on admission Carotid doppler & ECG NAD NAD? OPD 6w 72 hr tape Described as "lacunar ". R facial weakness, slurred speech, confusion - sudden onset 24h Carotid doppler, ECG, CXR old infarct in L caudate. Low density white matter suggesting small vessel disease GP to rep U&E Acute ischaemic sudden onset headache blurred vision resolved same day SMALL VESSEL DISEASE - NO INFARCT/BLEED xr CHEST & CX SP. GP to rv INR acute onset confusion 1 day Carotid doppler, bloods No acute lesions anticoagulation monitoring "treat as minor ischaemic " good recovery s/b MDT in timely fashion. Not collapse and confusion unclear U/S, CT KUB, bloods old infarct GP & CMHT UTI, not sudden onset dysphasia & slurred speech unclear ECG - in AF. Carotid doppler L cerebral infarct OPD 6w Stroke 9 P a g e

10 feeling "not right". Slurred speech short Carotid doppler NAD NAD neuro referral Not (consultant opinion) R sided weakness. 1 day large area establishes cerebral loss R temporal region. Old cerebral infarct & CVD OPD 4w. Referred cardiology following 72h tape. Old sudden onset weakness & numbness l hand? Carotid doppler No evidence acute intracranial bleed. Focal area of low density in R thalamus - suggests previous insult MRI as OP & nerve conduction tests treating as small until further notice L facial plasy, L eye weakness, diplopia Sudden onset R sided weakness, slurred speech & facial droop 1 day CT/MRI NAD "treat as " >1h BP high CT NAD GP to monitor statins Recorded as TIA but thrombolysed 10 P a g e