National Stroke Register Report 2017

Transcription

1 National Stroke Register Report 2017 National Stroke Programme August 2018 Document reference number Approval for publication date Document developed by Document approved by National Stroke Programme

2 Executive Summary Introduction The 2017 National Stroke Register Annual Report is the sixth report since its inception in 2012 and it continues to reflect the increased commitment to data collection and reporting. The data used for this analysis is based on routinely collected HIPE data and on additional data inputted onto the stroke portal by individual hospitals. We remain thankful for the on-going support of the Clinical Nurse Specialists and Advanced Nurse Practitioners who continue to collect and report data on stroke patients. The National Stroke Register remains under the governance of a National Stroke Register Steering Group, however, it remains without any data analytic or research support and the National Stroke Programme continues to work towards finding a solution for the long term governance of the register. We strongly recommend that the governance of the National Stroke Register sits within a Quality Improvement framework and are working with NOCA to support us in this endeavour. Results This report presents an analysis of all cases that were discharged from acute public hospitals between January 1st and December 31st 2017 with a principal diagnosis of Intracerebral Haemorrhage (i61) or Cerebral Infarction (i63) that have additional stroke register data recorded in >80% of cases. 19 acute public hospitals met this criteria and the sample size obtained for analysis is 3,481 which is similar to 2015 and Of those hospitals, HIPE data identified a total of 4205 cases of Cerebral Infarction or Intracerebral Haemorrhage, of these, 3726 were entered into the National Stroke Register in 2017 which gives a coverage rate of 89% across all 19 hospitals. As in previous reports there remains concerns around the completeness of the data and this is reflected in the reduced cohort for analysis in some areas e.g. onset times and medical review times. Demographics The demographic data reported is consistent by and large with that found in the 2015 Irish Heart foundation / HSE National Stroke Audit (McElwaine et al 2015) with 75% of strokes occurring in over 65s. The proportion of strokes occurring in men of working age rose slightly from 26% in 2016 to 28%. Data recorded on time of onset suggests high levels of wake-up or unwitnessed stroke with time of onset recorded as unknown in 40% of cases. The date and time of stroke onset was only recorded in 2

3 54% of cases therefore caution is advised when reviewing onset to admission results, however, there is a trend towards delayed hospital arrival in rural areas, >3hrs in eight hospitals. This would support the need for increased public awareness campaigns such as the FAST campaign. The UK SSNAP 2017 report have a known time of onset in 68% of cases with a median time to hospital arrival of 2hrs 50 mins (IQR 1:28-8:46) slightly increased on Irish results of 2hrs 36mins (IQR 1:28-8:46). Acute Stroke Treatment Hospital arrival date and time was available in 95% of cases which is a good sample to allow analysis of acute stroke treatment. In terms of delivery of acute treatment, 69% of patients were seen by the stroke team within 3hrs of admission increased from 54% in Data on thrombolysis was available in 98% of ischaemic stroke (i63, i64) cases. Thrombolysis was administered in 11.9 % of cases of cerebral infarction in this stroke population. 271 patients received endovascular thrombectomy in either Beaumont Hospital or Cork University Hospital. Data on antithrombotic therapy and atrial fibrillation (AF) is reported in 92% of cases. Of those with known AF 47% were not on anticoagulation pre-stroke. On discharge, inclusive of pre-existing and new diagnosis AF, 93% of patients were anticoagulated. There appears to be a strong preference (17:1) for non-vitamin K antagonist oral anticoagulants (NOACs) % of patients were admitted to an acute stroke unit and spent a median of 9 days in a stroke unit. Data on stroke severity and intensity of rehabilitation is not captured so comparisons about stroke unit length of stay cannot be made. However, data that suggests the quality of care in stroke units is higher given that patients are three times more likely to have a swallow screen and a mood screen compared to those who do not access stroke unit care. 81% of stroke patients are reviewed by the multidisciplinary team, similar to 2016, however, the data does not interrogate the intensity of therapy. The new HSCP dataset commenced in 2018 will record more detail in this domain. Outcomes This is the first report where we have outcome data based on the Modified Rankin Score (MRS). 71% of cases have a pre-stroke and discharge MRS and results will be monitored over time. Challenges remain in our definition of mortality when comparing to other European figures where 30- day mortality or standardised mortality ratios are often used. In-hospital mortality, in this sample, without a standardised mortality ratio is 14.2%. When mortality is reported by stroke type, ischaemic stroke mortality is 10.8% and haemorrhagic stroke is 36.2%. This is comparative to HIPE data for The accuracy of the data related to discharge to nursing home remains a concern. An analysis of HIPE discharge destination to nursing home (15.8%) compared to the discharge destination recorded in the stroke portal (7.5%) is conflictual and could be explained to some extent by discharge to non-acute hospital. The NSP will continue to work with the Health Pricing Office in this matter. 3

4 Recommendations This registry report highlights that patient presentation times to hospital after symptom onset remain poor and the need for a sustained public health campaign on stroke. Door to CT remains challenging and needs ongoing Quality Improvement (QI) focus in hospitals. Thrombolysis rates remain low in some hospitals although this is also impacted by delayed presentations. Admission rates to an acute stroke unit are inadequate against a national target of 90% and highlights the need for both a stroke unit capacity review and a stroke unit accreditation process. Overall the data coverage of the national register continues to improve but work remains to ensure a more complete capture particularly from large centres missing in this report, and to understand the gap between registry and HIPE stroke case finding. Definition of stroke and stroke mortality need universal agreement. While reassuringly the 2017 data seems consistent with previous reports and the findings of the 2015 Irish Heart Foundation /HSE National Stroke Audit, the National Stroke Register now needs appropriate professional governance structures to ensure it is GDPR compliant and can become a sustainable professional audit responsive to the data needs of individual stroke services and the country to monitor trends, highlight service needs, effect change and allow for international comparison. Ronan Collins, Clinical Lead, National Stroke Programme Joan McCormack, Programme Manager, National Stroke Programme 25/9/18 4

5 Table of Contents EXECUTIVE SUMMARY... 2 INTRODUCTION... 6 METHOD... 7 RESULTS... 9 DEMOGRAPHICS... 9 ADMISSION/DISCHARGE DATA Admission Type Admission Source and Discharge Destination Stroke Onset and Admission Hospital Length of Stay STROKE CARE Assessment by Stroke Team Brain Scanning (CT or MRI) Thrombolysis Thrombectomy Antithrombotic therapy Atrial Fibrillation ADMISSION TO STROKE UNIT Swallow Screening in Stroke Units Mood Screening Stroke Unit Length of Stay (LOS) OUTCOMES MRS and Stroke Type Multidisciplinary Team Assessment APPENDICES APPENDIX 1. NATIONAL STROKE REGISTER STEERING GROUP MEMBERS APPENDIX 2. NATIONAL STROKE REGISTER DATASET REFERENCES

6 Introduction The National Clinical Programme for Stroke was launched in 2010 and included nine different work streams, one of which was the development of a National Stroke Register. The National Stroke Register was developed in partnership with the Health, Research and Information Division at the Economic and Social Research Institute (ESRI) 1. The Register is considered a fundamental component of integrated stroke services being developed by the National Clinical Programme for Stroke project team. It is essential to measure the effect of the implementation of the National Clinical Programme for Stroke, in addition to providing data for planning and estimation of resource requirements for stroke services, evaluation and clinical audits, and hospital accreditation. The Register was developed and is governed by a Steering Group derived from the project team, together with expert input from the Healthcare Pricing Office, clinical practitioners, coding managers and the Irish Heart Foundation Council on Stroke (Appendix 1). The National Stroke Register was developed within the existing HIPE data collection system. The Healthcare Pricing Office provides an add-on screen to HIPE where the stroke team enters the data (Appendix 2) while the patient is still in hospital. This is merged automatically with the HIPE discharge record to provide enhanced information on the hospital care of the stroke patient. Hospitals commenced participation in the National Stroke Register on a phased basis, with 24 hospitals currently participating out of the 27 that were provided with access to the Stroke Register. It is noted that some hospitals are not yet entering data on all acute stroke patients although this is improving over time. While there is no clear evidence of bias, i.e. hospitals submitting data on patients with the mildest or most severe strokes, an element of caution is advised in interpreting the data. In 2017, both Connolly Hospital and Kerry University Hospital commenced data entry and full year data will be presented for both services in From January 1 st 2014 the National Casemix Programme and the Health Research & Information Division at the ESRI became the Healthcare Pricing Office (HPO 6

7 Method Coverage is the term used to describe the proportion of stroke patients discharged from a hospital with an ICD 10 code of i61, i63 or i64 that have additional data inputted onto the National Stroke Register. Table 1. Identifies all HIPE cases that were discharged from acute public hospitals between January 1st and December 31st 2017 and the cases with additional stroke register data. Hospital HIPE Cases i61, i63, i64 Registered Cases i61, i63, i64 Coverage St Luke s Hospital Kilkenny % Cavan General Hospital % Letterkenny University Hospital % Bantry General Hospital % Our Lady of Lourdes Drogheda % University Hospital Waterford % University Hospital Galway % Mercy University Hospital % Mayo University Hospital % Tallaght University Hospital % St Vincent s University Hospital % Beaumont Hospital % Midland Regional Hospital Mullingar % Wexford General Hospital % Sligo University Hospital % Naas General Hospital % St James s Hospital % Portiuncula Hospital % Cork University Hospital % South Tipperary General Hospital Clonmel % Our Lady s Hospital Navan % Mater Misericordiae University Hospital % University Hospital Limerick % Grand Total % Table HIPE i61, i63, i64 cases with additional NSR data. This report presents an analysis of all National Stroke Register cases that were discharged from acute public hospitals between January 1st and December 31st 2017, with approximately 80% coverage, with a principal diagnosis of Intracerebral Haemorrhage or Cerebral Infarction. Analysis is based on the aggregate data of these 19 hospitals and measured against previous annual reports and comparative data from the UK SSNAP 2017 results. For the purposes of this annual report, as was the case for the all previous reports data are presented on Intracerebral Haemorrhage and Cerebral Infarction patients, based on the cohort of patients that have been assigned a principal diagnosis in HIPE of Intracerebral Haemorrhage (ICD-10 I61) or Cerebral Infarction (ICD-10 I63), table 2. 7

8 Table NSR data i61, i63, i64 cases Hospital Total Registered Cases I61, i63, i64 Registered Cases Final Dataset for analysis Registered Cases i61, i63 St Luke s Hospital Kilkenny Cavan General Hospital Letterkenny University Hospital Bantry General Hospital Our Lady of Lourdes Drogheda University Hospital Waterford University Hospital Galway Mercy University Hospital Mayo University Hospital Tallaght University Hospital St Vincent s University Hospital Beaumont Hospital* * Midland Regional Hospital Mullingar Wexford General Hospital Sligo University Hospital Naas General Hospital St James s Hospital Portiuncula Hospital Cork University Hospital Total *Beaumont Hospital had 174 cases recorded within HIPE and the NSR that were admitted for thrombectomy and were transferred back to the referring hospital without admission. These cases have been excluded from this analysis. If the aggregate data from these 19 hospitals is used for any comparison by individual hospitals it is important that stroke teams: Compare like with like by only analyzing cases with a principal diagnosis of Intracerebral Haemorrhage (ICD-10 I61) or Cerebral Infarction (ICD-10 I63) Consider the implications of differences between national and local demographic profiles For the time period in question, there were 4, 784 discharges recorded in the National Stroke Register across the 19 2% 1% hospitals. However, not all of the 4,784 cases recorded on the National Stroke 2% 4% 8% Register were ultimately assigned a 6% principal diagnosis of Intracerebral Haemorrhage or Cerebral Infarction in HIPE. When cases coded as TIA or recorded as in-patient strokes are excluded it is found that 10.9% of cases recorded on the stroke register did not have a primary diagnosis of stroke (figure 1). The i64 Cerebral Infarction Undifferentiated was recorded in 114 (4%) of cases. Figure 1. Stroke Register Case Stroke Register Case HIPE Codes n % PDx Stroke i61, i63, TIA PDx i64 In-patient Stroke 2nd Dx Stroke 3rd Dx Stroke Other 8

9 Results In this report the data are presented in table format along with a brief commentary. The analysis is broken down into a number of sections: Demographics Admission/discharge data Acute Stroke Interventions Stroke Unit Care Outcome Demographics As in all previous reports, over half, 56.5 % of all stroke cases coded as ICD-10 I61 or I63 in the 19 hospitals in 2017 were male (table 3). This is similar to the gender breakdown when compared to the Irish Heart Foundation/HSE National Stroke Audit 2015 where males accounted for 57% of stroke cases (McElwaine et al, 2015). This figure was 52% in the Irish National Audit of Stroke Care in 2008 (Horgan et al, 2008). N % Male Female Table 3: Gender (n=3,481) There remains some differences in age profile by gender (table 3). The mean age for males was 71.8 years and for females it was 73.1 years Irish National Audit of Stroke Care 2008 found 72 years males, 78 years female (Horgan et al, 2008). <65 Years Years 80+ Years Mean (±SD) Male (70.6 ± 13.3) Female (75.5 ± 13.7) Table 4: Age Profile (%) (n=3,481) 9

10 Figure 2: Age Profile Figure 3: Mean age of stroke patients by gender Age Profile <65yrs 65-79yrs (INASC) Male and Female Age Profile Trends Male Female Male Female Using data from the 2012 to 2017 the trend in mean age by gender is shown in (Figure 3). While most strokes occur in those aged 65 years and over, 28% of male strokes occur in working age an increase from 26% in 2016 (figure 4). With regard to females the proportion of strokes occurring in the under 65 age group appears to be increasing 17.2% in 2013 to 18.4% in 2017 (figure 5). Male Strokes by Age Trend Female Stroke by Age Trend (INASC) (INASC) < < Figure 4: Male strokes by age group 2012 to 2017 Figure 5: Female strokes by age group 2012 to

11 Admission/Discharge Data HIPE records data on a number of variables relating to the admission and discharge of each patient, such as the type of admission (e.g. elective or emergency), admission source and discharge destination. The patient s length of stay is also collected, in addition to clinical codes recording what diagnoses were made during the hospital stay. Admission Type As expected, the vast majority (98%) of stroke cases registered were classified as emergency admissions (table 5). Table 5: Admission Type of Stroke Register cases (n=3,481) N % Emergency Elective Emergency readmission Elective readmission Admission Source and Discharge Destination Analysing admission source without any other morbidity or stroke severity data does not inform to any great extent. However, it does provide useful information when analysed in conjunction with discharge destination to provide data on outcomes for stroke patients. The admission source data for cases entered onto the National Stroke Register (table 6) shows that the majority of stroke patients (90.3%) are living at home prior to their stroke. Table 6: Admission Source (n=3,481) N % Home 3, Acute hospital Transfers Nursing home Non-acute Hospital Transfers Temporary place of residence Other

12 Table 7 outlines the discharge destination of cases as coded by HIPE and also the discharge destination as recorded within the NSR. HIPE data is complete while the NSR has 85% (2956/3481) coverage. In 2016, an anomaly was identified in the coding of patients going to nursing homes and to external rehabilitation facilities. The comparative data suggests that there is variance in how cases are coded particularly when discharged to nursing home and/or rehabilitation facilities. The National Stroke Programme is working with the Health Pricing Office to correct this anomaly. At present, the discharge to nursing home data should be viewed with caution as it is more probable that it is a lower rate than the 15.8% recorded in HIPE. Table 7: Discharge Destination HIPE n=3481 Stroke Register n=2956 (525 missing) N % N % Home Nursing home Died Transfer to acute hospital Non-emergency Emergency hospital transfer Transfer to external rehab non-hipe facility Transfer to non-acute hospital Other Hospice Temporary Residence Self-discharge Absconded Transfer to Psychiatric Hospital Within the NSR cohort the in-hospital mortality rate was 14.2%. The Irish Heart Foundation/HSE National Stroke Audit 2015 reported a mortality rate of 14% and the Sentinel Stroke National Audit Programme, SSNAP (Royal College of Physicians 2017) report a 14.3% in-hospital mortality rate. When reported by stroke type the NSR shows that the mortality for ischaemic stroke is 10.8% (326/3019) and 36.2% (167/462) for haemorrhagic stroke. 12

13 Percentage Figure 6. National Mortality Rates NQAIS National Stroke Mortality Rates Ischaemic Stroke Haemorrhagic Stroke Figure 6. indicates the mortality based on stroke type using the National Quality Assurance & Improvement System (NQAIS) of all i61, i63 and i64 cases from 2015 to These results reflect the correlation between NSR results and national HIPE data results. Caution is advised in comparing Irish mortality rates with International and National mortality rates in stroke, such as the National Audit of Hospital Mortality (NAHM) and the National Healthcare Quality Reporting System (NHQRS) as data is adjusted for casemix. Stroke Onset and Admission While HIPE records date of admission to hospital, time of admission is not recorded. Stroke teams are asked to enter hospital arrival date and hospital arrival time. This can then be used to calculate delays to hospital arrival from stroke onset in hours and minutes, which is more appropriate for stroke care when Time is Brain. However, both the date and time for stroke onset and hospital arrival must be known and recorded in order to calculate accurately the delay between stroke onset and hospital arrival. This analysis excludes in-patient stroke cases. The date of stroke onset was recorded for 97% of cases (n=3078) but a stroke onset date and time was only recorded in 54% of cases (n=1,723). It was recorded as unknown in 40% of cases (n=1,268). The date of hospital arrival was recorded in 99% of cases (n=2,845) and the date and time of hospital arrival was recorded in 94.8% of cases (n=3007). It was recorded as unknown in 1% of cases (n=37) with no time recorded in 3% of cases (n=101). The number of cases analysable for time of onset to hospital arrival is 1665, 52.5% increased from 46% in Table 8 below outlines the median time from stroke symptom onset to hospital arrival but note the reduced cohort available for this analysis, signifying a large portion of unknown, incorrect and/or missing dates/times. For those cases that had times available, 61% arrived at hospital within four hours of symptom onset, 53% within three hours and 47% within 2.5 hours (table 8). The Irish Heart Foundation/HSE National Stroke Audit reported that 56% of patients arrived at hospital within 3 hours (McElwaine et al, 2015). 13

14 Table 8: Time from stroke symptom onset to hospital arrival n=1665 Median (IQR)* Time (hh:mm) 1:53 (1:29-6:34) *IQR = interquartile range, time by which 25% and 75% of patients arrived The most recent clinical audit report from SSNAP states that the median time from onset to hospital arrival in SSNAP was 2 hours and 50 minutes (IQR 1:28-8:46) (Royal College of Physicians 2017). Table 9: Distribution of time from stroke symptom onset to hospital arrival (n=1,665) < 2.5 hours < 3 hours < 4 hours Time (%) Table 10 indicates a wide variation of onset to hospital arrival times. This information could be used when reviewing time related emergency treatments such as thrombolysis. Table 10. Time from stroke symptom onset to hospital arrival by hospital Onset to Hospital Arrival Median IQR Beaumont Hospital 01:31 00:49 02:04 Tallaght University Hospital 01:39 01:09 05:26 St Vincent s University Hospital 01:53 01:13 03:40 Cavan General Hospital 02:16 01:32 05:17 Cork University Hospital 02:17 01:31 03:29 St Luke s Hospital Kilkenny 02:20 01:24 05:14 Midland Regional Hospital Mullingar 02:21 01:30 09:42 Our Lady of Lourdes Drogheda 02:26 01:23 07:53 Naas General Hospital 02:30 01:34 05:07 St James s Hospital 02:32 01:15 06:08 University Hospital Letterkenny 02:49 01:44 08:34 University Hospital Galway 03:03 01:41 13:58 Mayo University Hospital 03:12 02:00 06:00 University Hospital Waterford 03:12 01:48 09:10 Sligo University Hospital 03:14 01:40 06:40 Wexford General Hospital 04:01 02:00 06:10 Portiuncula Hospital 05:05 03:31 08:32 Mercy University Hospital 05:57 02:22 14:34 Bantry General Hospital 07:00 03:37 31:00 14

15 Hospital Length of Stay Table 12 outlines the overall length of stay for stroke patients recorded on the stroke register. Hospital length of stay can be related to the age of the patients and table 13 highlights the hospital length of stay by age group. As expected, older patients have longer lengths of stay. The overall median length of stay of stroke patients recorded on the stroke register remains at 9 days. Median (IQR) Mean (±SD) Length of stay 9 (5 19) 18.2 (±28.4) Table 12: Hospital Length of Stay (days, n=3,481) < 65 Years Years 80+ Years Median (IQR) 7 (4 14) 9 (4 19) 11 (9-24) Mean (±SD) 15.1 (±26.3) 18.3 (± 31.1) 20.3 (±25.9) Table 13: Hospital Length of Stay (days) by age group (n=3,281) Stroke Care Assessment by Stroke Team Timely emergency department (ED) evaluation and stroke team assessment is paramount in review of all stroke patients but in particular regarding the potential treatment of ischaemic stroke with thrombolysis. Guidance from the American Heart Association/American Stroke Association advises that ED patients with suspected acute stroke should be triaged with the same priority as acute myocardial infarction or serious trauma, regardless of the severity of neurological deficits (Jauch et al, 2013). Figure 7 shows that where data was available, 69% of stroke patients were seen by the stroke team within 3hrs of admission. This is up from 54% in % Within the National Stroke Register, stroke teams are asked to document the date and time of hospital arrival and also the date and time that the patient was seen by the stroke team. This enables calculation of the delay to review by the stroke team. However, the reduced cohort available for this analysis (2101) must be noted, signifying a large portion of missing dates/times. 21% 45% 13% 11% 30mins 60mins 3hrs 24hrs >24hrs 15

16 Minutes Figure 7. Time seen by Stroke Team n= The median time to assessment by the stroke team after admission was 43 minutes; figure 8 reflects a significant improvement in timeliness of assessment by the medical team. Figure 8. Number of minutes to be seen by medical team Brain Scanning (CT or MRI) Data in relation to CT or MRI brain scanning was available for 3323 patients and this includes the patients who had a stroke as an inpatient. In total, 97% of patients had a CT or MRI scan after their stroke in their hospital of admission with a further 2.8% of patients having a CT or MRI scan performed pre-admission or in a previous hospital in cases of hospital transfer as per Table 14. N % Yes No Performed pre admission/hospital transfer Unknown Table 14: Brain CT or MRI Performed n=3323, (Missing data = 158) Data in relation to the timeliness of imaging has always been important in order to ensure prompt decision to treat, however given recent advances in the acute phase of stroke it is even more important to become aware of access to imaging and treatment within each hospital. In 2018, a national quality improvement programme commenced in conjunction with the RCPI which aims to reduce door to decision to treat times. Baseline data from 2016 and 2017 will be valuable in its evaluation. Table 15 indicates the Door to Imaging times for each hospital. 16

17 Table 15: Door to imaging median and interquartile range by hospital. Number of cases with DTI times recorded Number of cases within 45mins N (%) Median IQR Door to Imaging Bantry General Hospital 54 7 (13) 01:13 00:56-01:59 Beaumont Hospital (44) 00:52 00:23-03:21 Cavan General Hospital 17 5 (29) 01:10 00:29-03:51 Our Lady of Lourdes Drogheda (24) 01:38 00:43-04:57 University Hospital Galway (40) 01:11 00:20-05:38 St James's Hospital (38) 01:14 00:28-03:23 St Luke s Hospital Kilkenny (15) 02:09 01:01-14:54 University Hospital Letterkenny (14) 03:27 01:14-16:55 University Hospital Mayo (13) 02:31 01:04-13:24 Mercy University Hospital 84 9 (11) 02:58 01:29-07:47 Midland Regional Hospital Mullingar (27) 01:26 00:42-05:08 Naas General Hospital (46) 00:48 00:16-03:42 Portiuncula Hospital :47 02:14-22:39 Sligo University Hospital (13) 02:43 01:10-12:08 St Vincents University Hospital (32) 01:05 00:36-03:34 Tallaght University Hospital (14) 01:59 01:10-04:55 University Hospital Waterford (17) 02:37 01:13-05:31 Wexford General Hospital (5) 05:53 01:48-20:38 Thrombolysis Administration of recombinant tissue plasminogen activator (tpa/thrombolysis) is a proven effective treatment for ischaemic stroke and should be administered as soon as possible after onset of symptoms within a 4.5 hour window in the absence of contraindications. In this analysis the denominator for the thrombolysis data is different from the rest of this report at 3,133 as it interrogates both i63 and i64 codes to align with the National Stroke KPIs. Table 16. Thrombolysis rates n=3133. N % Yes No 1, Contraindicated Combined IV and intra-arterial thrombolysis Blank Table 16 shows that for patients with a principal diagnosis of i63 or i64, the IV thrombolysis rate was 11.9% when unknown and missing/not recorded cases were removed. SSNAP reported a thrombolysis rate of 11.6% in their most recent report (Royal College of Physicians, 2017). Table 17 indicates the IV thrombolysis rates by hospital. 17

18 i63 i64 cases TPA cases %TPA i63 cases Mercy University Hospital % Mayo University Hospital % University Hospital Galway % Naas General Hospital % St Luke s Hospital Kilkenny % Bantry General Hospital % Beaumont Hospital % St James s Hospital % Sligo University Hospital % Letterkenny University Hospital % Midland Regional Hospital Mullingar % Our Lady of Lourdes Drogheda % Wexford General Hospital % St Vincent s University Hospital % Tallaght University Hospital % Cavan General Hospital % University Hospital Waterford % Cork University Hospital % Portiuncula Hospital 58 0 N/A Table 17: Principal Diagnosis of i63 or i64 n=3133 and thrombolysis rates. TPA with DTN data Median Time Interquartile Range Mercy 6 00:45 00:42 01:02 Mayo 8 00:51 00:27 01:06 Galway 25 00:51 00:30 01:26 Naas 24 00:51 00:27 01:06 Kilkenny 17 00:57 00:39 01:12 Bantry 2 00:57 00:51 01:04 Beaumont 51 00:58 00:28 01:28 James 35 01:06 00:49 01:28 Sligo 6 01:10 00:51 01:14 Letterkenny 12 01:12 01:07 01:28 Mullingar 10 01:37 01:03 02:03 Drogheda 12 01:25 00:57 02:17 Wexford 4 01:31 01:22 01:41 SVUH 15 01:33 01:07 02:14 Tallaght 29 01:34 01:02 02:15 Cavan 13 01:43 01:05 01:55 Waterford 9 01:45 01:11 02:02 The Door to Needle time was available in 76% (278) cases. The median time from door to needle nationally was 71 minutes with an interquartile range of minutes. SSNAP UK reports a median door to needle time of 52mins (IQR 36 75). Table 18. Door to Needle times to patients who received thrombolysis n=

19 Thrombectomy Thrombectomy in stroke is the mechanical removal of a blood clot within the large vessels of the cerebral circulation. Thrombectomy for acute stroke is provided by Beaumont Hospital on a 24 hour basis, 7 days a week. Additionally, Cork University Hospital provides an 8-8 hour service, 5 days a week for their surrounding network. Outside these hours, suitable patients may be transferred to Beaumont Hospital for treatment. Data on thrombectomy is collected in Beaumont Hospital and Cork University Hospital and recorded on the National Stroke Register. The National Thrombectomy Service produced an annual report in 2017 and provides further detailed analysis of the thrombectomy service. In 2017, 271 cases were recorded as having had a thrombectomy on the National Stroke Register. These cases were referred from hospitals throughout the country including those not analysed in this report therefore thrombectomy rate is not reportable in this report. The rate of thrombectomy reported in the National Thrombectomy Service Annual Report is 5.6%. Antithrombotic therapy 91.8% (3196/3481) had data recorded on antithrombotic therapy. Figure 9 indicates the number of patients who were treated with antithrombotics. In 2017, 72.2% (2513/3481) were reported as treated with antithrombotics. Figure10 shows that 76% (1923/2513) of cases were commenced on antithrombotics within 24hrs. 0% 13% 2% 14% 8% 8% 20% 56% 79% Yes No Contraindicated Unknown Day 1 Day 2 Within 7 Days > 7Days Unknown Figure 9. Antithrombotic therapy n=3185 Figure 10. Start times for antithrombotics n=

20 Atrial Fibrillation 93% (3236/3481) had data recorded on atrial fibrillation (AF). 33% (1073/3236) of cases were reported to have AF and 61.5% (660/1073) of those cases were known to have AF prior to stroke. This was reported as 57.2% in % 3% 33% 59% Yes No Results pending Unknown Figure 11. No. of cases with Atrial Fibrillation n=3236 (245 missing data). Of the cases that were known to have AF pre stroke 53% (350/660) were prescribed anticoagulation pre stroke, two thirds of which were prescribed NOACs. 61% (74/121) of cases on warfarin pre stroke were not within the 2-3INR range on admission. Table 19 indicates the breakdown of Afib data by stroke type AF Dx Pre Stroke 374 No AF Pre Stroke 24 Unknown Stroke Type Ischaemic n3020 Haemorrhagic n461 Afib known prior to stroke % (n) On anticoagulation prior to stroke % (n) Table 19 Breakdown of Ischaemic and Haemorrhagic Afib data Prescribed NOACs % (n) Figure 12 Afib diagnosis pre stroke. Prescribed Warfarin % (n) If on Warfarin was INR 2-3 on admission % (n) 18.8% 51.7 (294/568) 63.2 (186/294) 36.7 (108/294) 29.6 (32/108) (568/3020) 19.9 (92/461) 58.7 (54/92) 68.5 (37/54) 31.5(17/54) 29.4 (5/17) Secondary prevention data for patients with AF was available in 85.9% (922/1074) cases. Secondary Prevention for AF % (n) NOAC 85% (491/574) Warfarin 5% (30/574) Antiplatelet Therapy 6% (36/574) Antiplatelet and Anticoagulant 3% (17/574) 73.8% (680/922) of cases were prescribed antiplatelet and/or anticoagulation on discharge and in 84.4% (574/680) of those cases the treatment was identified. On discharge, 91% of cases with AF are on anticoagulation with the preference for NOAC prescribing. Table 20. Secondary prevention for AF cases n=574 (106 missing data). 20

21 Admission to Stroke Unit The admission of patients to stroke units, staffed by appropriate specialists, has been shown in numerous studies to reduce the rates of mortality and morbidity after stroke (European Stroke Organisation, 2008, Jauch et al, 2013,). Table 21 shows that 70.6% of stroke patients were admitted to a stroke unit after excluding not recorded data. This was 65.9% in 2016, 63.4% in Reasons for non-admission to the stroke unit are documented in table 22 for the 1004 patients who were not admitted. Table 21: Admission to Stroke Unit (n=3135, missing data = 146 (4.5%) N % Yes % No % A free text box was added in 2014 to provide further explanation for non-admission if required. The three main reasons for selecting other were: patients transferring to or from another hospital; end of life care; and intensive care unit admission. Table 22: Reasons for non-admission to stroke unit n=1004 N % No stroke unit Other Bed not available Infection control risk Unknown Table 23 indicates the percentage of cases admitted to a stroke unit by hospital. This is a National Stroke KPI and the 2017 KPI result is 69.2%, consistent with the outcome of this report. The national target is 90%. 21

22 Hospital Registered Cases i61, i63 Admitted to Stroke Unit % Admitted to Stroke Unit Bantry General Hospital % Beaumont Hospital % Cavan General Hospital % Our Lady of Lourdes Drogheda % University Hospital Galway % St James s Hospital % St Luke s Hospital Kilkenny % Letterkenny University Hospital* 191 N/A N/A Mayo University Hospital % Mercy University Hospital % Midland Regional Hospital Mullingar % Naas General Hospital % Portiuncula Hospital % Sligo University Hospital % St Vincent s University Hospital % Tallaght University Hospital % University Hospital Waterford % Wexford General Hospital % Cork University Hospital % Grand Total % Table 23. Admission to a stroke unit *No Stroke Unit Swallow Screening in Stroke Units Swallow screening is considered a good indicator of organized stroke care. In 2017, 65.9% (1905) of cases had a swallow screen completed, of those 32.3% (617) had the swallow screen completed within four hours Yes No Unknown Blanks Figure 13. Swallow Screening n=

23 Swallow Screen completed Admitted to a Stroke Unit n=2416 Not admitted to a Stroke Unit n= % (1619/2416) 28% (282/1004) Table 24 indicates that admission to a stroke unit triples the rate of having a swallow screen completed. Table 24: Swallow screening rates in Stroke Units Mood Screening The reporting of mood screening was added into the dataset in 2017 and there was a 75.4% (2624) response rate to this data point. The completion of a mood screen is low at 34.5% (620), excluding blank cases, and work is on-going within the National Stroke Programme to complete a mood guidance document. At present a depression pathway is available on the National Stroke Programme website Mood Screen completed Admitted to a Not admitted to a Stroke Unit n=2416 Stroke Unit n= % (570/2416) 11.1% (111/1004) As with the swallow screening admission to a stroke unit increases the rate of receiving assessment of mood as part of comprehensive stroke care. Table 25: Mood screening rates in Stroke Units Stroke Unit Length of Stay (LOS) The National Stroke Register captures the dates of admission and discharge from the stroke unit, which allows calculation of length of stay for each patient in the stroke unit and also the proportion of the patient s overall stay in the hospital that was in the stroke unit. There were 2416 patients admitted to the stroke unit and the length of stay was available for 2316 (96%) patients. Median (IQR) Mean (±SD) Stoke unit LOS 9(4 15) 14 (±18.4) Table 26: Length of Stay in Stroke Unit days, n=2316 (missing data = 100) 23

24 Outcomes In 2017, the addition of pre-stroke and discharge Modified Rankin Score (MRS) was introduced. In 2017, 72% (2512) of cases had a pre-stroke MRS and 73% (2551) had a discharge MRS. 71% (2472) had a prestroke MRS and discharge MRS recorded. Mortality results within this domain need to take into account the sample size for analysis (71%). Online training was offered to all data inputters to support accurate recording of the tool. It was agreed that results would be grouped as: no disability (0), Mild disability (1 or 2) and Moderate/Severe (3, 4 or 5), figure 14. Figure 14. Pre-Stroke and Discharge Modified Rankin Score n=2472 M O D I F I E D R A N K I N S C O R E O U T C O M ES N = ,2 3,4,5 6 P R E - S T R O K E M R S 68% 18% 14% 0 D I S C H A R G E M R S 27% 34% 26% 13% MRS and Stroke Type In 2017, the National Stroke Register recorded 87% (3019) ischaemic strokes (i63) and 13% (462) haemorrhagic strokes (i61). Figures 15 and 16 indicates the outcomes by stroke type. An increased level of disability and mortality is shown for haemorrhagic stroke. The mortality in this cohort is remarkably similar to the national mortality by stroke type in NQAIS. M O D I F I E D R A N K I N S C O R E O U T C O M E S - I S C H A E M I C N = ,2 3,4,5 6 M O D I F I ED R A N K I N S C O R E O U T C O M ES - H A EM O R R H A G E N = ,2 3,4,5 6 P R E - S T R O K E 68% 18% 14% 0% P R E - S T R O K E 66% 16% 18% 0% D I S C H A R G E 29% 35% 25% 11% D I S C H A R G E 12% 18% 35% 35% Figure 15. Ischaemic MRS Outcomes. Figure 16. Haemorrhagic MRS Outcomes. 24

25 Multidisciplinary Team Assessment The variables within the National Stroke Register relating to assessments by the multidisciplinary team, including Clinical Nurse Specialist and Health and Social Care Professionals (HSCP), only ask if the assessment was conducted. In 2017, a HSCP specific dataset was designed, looking at the time frames within which the assessment are carried out and other relevant variables. From 2018 data will be collected by HSCPs (physiotherapy, occupational therapy and speech and language therapy) which will increase the level of data on in-patient rehabilitation. We anticipate that this will take some time to embed into practice as it did for the main register and will support HSCPs in this initiative. Table 27 indicates that 81% of cases are assessed by a multidisciplinary team and 79% are assessed by a Clinical Nurse Specialist in Stroke (table 28). Table 27: Assessment by Multidisciplinary Team Multidisciplinary Team N % Yes 2, No Unknown Table 28: Assessment by Clinical Nurse Specialist/Advanced Nurse Practitioner Clinical Nurse Specialist/Advanced Nurse Practitioner n3481 N % Yes No Not Indicated 1.03 Unknown Missing/Not recorded

26 Data regarding assessment by the various Health and Social Care Professionals is shown in tables 29 and 30. Removing the data for patients for whom an assessment was not indicated and also removing the missing and unknown data shows that 98% of applicable patients received a Physiotherapy assessment, 96% received an Occupational Therapy assessment and 94% received a Speech and Language Therapy assessment, 76% were seen by a Dietitian, 56% were seen by a Medical Social Worker and 11% saw a psychologist. 73% were seen by a Clinical Nurse Specialist/Advanced Nurse Practitioner. However, the proportion of missing data range between 20 and 30% and this needs to be taken into account and addressed to ensure more accurate reporting of assessment by the Health and Social Care Professionals. Table 29: Assessment by Physiotherapist, Occupational Therapist and Speech and Language Therapist (n=3,481) Physiotherapist Occupational Therapist Speech & Language Therapist N % N % N % Yes No Not Indicated Unknown Missing/Not recorded Table 30: Assessment by Dietitian, Medical Social Worker and Psychologist (n=3,481) Dietitian Medical Social Work Psychology* N % N % N % Yes No Not Indicated Unknown Missing/Not recorded *Low referral rate may reflect low representation of psychologist on MDT as found in IHF/HSE National Stroke Audit

27 Appendices Appendix 1. National Stroke Register Steering Group Members Prof. Joe Harbison, Consultant Stroke Physician, St. James s Hospital- Chairperson Dr Ronan Collin, Clinical Lead National Stroke Programme Ms Ciara Breen, Occupational Therapist, University Hospital Galway Deirdre Cunningham, Coding Manager, Beaumont Hospital Ms Nora Cunningham, Clinical Nurse Specialist, University Hospital Limerick Ms Trish Daly, Advanced Nurse Practitioner, Naas General Hospital Dr Teresa Donnelly, Clinical Lead, MRH Tullamore Dr Rachael Doyle, Consultant Geriatrician, Chairperson, IHF Council on Stroke Mr Philip Dunne, I.T. Systems Support, Healthcare Pricing Office Ms Emma Hickey, Clinical Nurse Specialist, Beaumont Hospital Dr Frances Horgan, IHF Council on Stroke Prof. Peter Kelly, Consultant Neurologist, Mater Hospital (Chair May2011 June 2013) Ms Deirdre Lynch, Coding Manager, St Vincent s University Hospital Ms Joan McCormack, National Stroke Programme, Programme Manager, RCPI Ms Hannah Murugan, St Luke s Hospital, Kilkenny Jackie Naughton, Coding Manager, Mercy University Hospital Ms Imelda Noone, Advanced Nurse Practitioner, St Vincent s University Hospital Prof. Martin O Donnell, Consultant Geriatrician, University Hospital Galway Dr John Thornton, Consultant Radiologist, Clinical Stroke Lead, Beaumont Hospital Ms Triona Dooley, Coding Manager, University Hospital Limerick 27

28 Appendix 2. National Stroke Register Dataset HIPE Portal Data Entry / Stroke (V3.0.2) 06 Dec 2016 Question Options Short Name 1. Which hospital was patient transferred from (if any) 0000 Not Applicable 0941 Children s Crumlin 0101 St Columcille s 0102 Naas General 0908 Mater Hospital 0910 SVUH 0925 Peamount Hospital 0955 Cappagh Orthopaedic 0940 Temple Street 0947 St Luke s Rathgar 0904 SJH Dublin 0108 Connolly Blanchardstown 0912 Michaels Dun Laoghaire 0950 RVEEH 0960 National Rehabilitation 0930 Coombe Hospital 0932 Rotunda Dublin 0931 National Maternity Hosp 1270 Tallaght Hospital 1762 Josephs Raheny 0954 Clontarf Orthopaedic 1001 Blackrock Hospice 0600 Waterford 0601 St Luke s KK 0605 Wexford 0602 Kilcreene 0607 Clonmel 0705 Finbar s Cork 0704 Bantry 0913 Mercy Cork 0915 South Infirmary 0703 Mallow 0724 CUH 0726 Kerry 0301 Limerick Maternity 0300 Limerick 0302 Croom Limerick 0918 St Johns Limerick 0305 Ennis 0304 Nenagh 0803 Roscommon 0919 Portiuncula 0800 Galway 0802 Mayo 0801 Merlin Park 0203 Tullamore 0202 Mullingar 0201 Portlaoise 0500 Letterkenny 0501 Sligo 0922 Drogheda 0402 Cavan 0400 Louth County 0404 Monaghan 0403 Navan 8888 Other 1A. Why was the patient transferred 1 Thrombolysis 2 Thrombectomy 3 Neuro Surgery 8 Other Trans Hosp Trans Reason 1B. If other transfer reason, please specify Trans Reason Other 1C. If other transfer hospital, please specify Trans Hosp Other 2. Symptom onset date Onset Date 28

29 3. Symptom onset time (enter 9999 if unknown) Onset Time 3A. If symptom onset time is unknown, what date was the patient last known to be well 3B. If symptom onset time is unknown, what time was the patient last known to be well 4. Did the stroke occur while the patient was in hospital for treatment of another 1 Yes, 2 No condition Last Well Date Last Well Time Hosp Str 4A. If no, date of presentation to hospital Arr Date 4B. If no, time of presentation to hospital Arr Time 4C. If presentation time is unknown, was presentation to hospital within 4.5 hrs of symptom onset 1 Yes, 2 No Arr 4.5hrs 5. Medical team / Stroke team assessment date Assess Date 5A. Medical team / Stroke team assessment time Assess Time 6. Brain CT or MRI performed 1 Yes, 2 No 3 Performed pre adm / hosp transfer Imaging 6A. If yes, First Brain Imaging date Img Date 6B. If yes, First Brain Imaging time Img Time 7. Did the patient receive I.V. Thrombolysis (Key Performance Indicator) 1 Yes, 2 No 5 Contraindicated Thrombolysis 7A. If yes, enter date Thromb Date 7B. If yes, enter time Thromb Time 7C. If yes, was intracerebral bleed seen on scan within 36 hrs 1 Yes, 2 No Intracereb Bleed 7D. If intracerebral bleed, was neuro deterioration associated with it 1 Yes, 2 No Neuro Deter Assoc *8. Did the patient have thrombectomy in this hospital (Beaumont / CUH only) 1 Yes, 2 No Thrombectomy 8A. NIHSS pre-thrombectomy NIHSS Pre 8B1. Date of performance of non contrast CT Non Con CT Date 8B2. Time of performance of non contrast CT Non Con CT Time 8C1. Date of performance of non contrast CTA Non Con CTA Date 8C2. Time of performance of non contrast CTA Non Con CTA Time 8D1. Date of contact with the endovascular stroke centre Contact Endo Date 8D2. Time of contact with the endovascular stroke centre Contact Endo Time 8E1. Date of decision to transfer patient Trans Dec Date 8E2. Time of decision to transfer patient Trans Dec Time 8F1. Date of arrival at the endovascular stroke centre Date Arr Endo 8F2. Time of arrival at the endovascular stroke centre Time Arr Endo 8G1. Did the patient have repeat non invasive imaging in the endovascular stroke centre 1 Yes, 2 No 8G2. If yes, please specify 1 Non contrast CT 2 CTA 3 Perfusion CT 4 MRI 8H. Site of most proximal occlusion 1 MCA 1 2 MCA 2 3 Basilar 4 ICA carotid T/L 5 ICA cervical segment 6 PCA 7 Vertebro basilar Img Repeat Img Type Most Prox Occ 8J. Second occlusion site 2nd Occ Site 8K. Associated carotid stenosis greater than 50% 1 Yes, 2 No Assoc Carotid 29

30 8L1. TICI pre thrombectomy TICI Pre 8L2. TICI post thrombectomy TICI Post 8M1. Date of groin puncture Groin Punc Date 8M2. Time of groin puncture Groin Punc Time 8N1. Date of first pass 1st Pass Date 8N2. Time of first pass 1st Pass Time 8P1. Date of first reperfusion 1st Reperf Date 8P2. Time of first reperfusion 1st Reperf Time 8Q1. Date of final angio Final Angio Date 8Q2. Time of final angio Final Angio Time 8R. Immediate complications 0 Not Applicable 1 Haemorrhage 2 Embolus into separate vascular territory 3 Dissection 8 Other Imed Comp 8S. NIHSS 24 hour post-thrombectomy NIHSS Post 8T1. Following procedure was patient transferred immediately back to primary receiving hospital 1 Yes, 2 No 8T2. If no, when was patient admitted to the endovascular stroke centre hrs hrs hrs hrs 9. Was a swallow screen completed 1 Yes, 2 No 9A. If yes, was swallow screen completed within 4 hours of presentation 1 Yes, 2 No 10. Modified Rankin Scale pre stroke 0 Zero 1 One 2 Two 3 Three 4 Four 5 Five 6 Six Trans Prim Rec Trans Endo Centre Swallow Swallow 4hrs Pre Strk Rankin 11. Admitted to Stroke Unit (Key Performance Indicator) 1 Yes, 2 No Stroke Unit 11A. If yes, date admitted to Stroke Unit (Key Performance Indicator) SU Adm 11B. If yes, date discharged from Stroke Unit (Key Performance Indicator) SU Dis 11C. If no, reason why 1 No Stroke Unit 2 Bed Not Available 5 Infection Control Risk 8 Other SU No 11C2. If other reason, please specify SU No Other 12. Allied Health Professional (AHP) Assessment 1 Yes, 2 No AHP 12A. If yes, Physiotherapy 1 Yes, 2 No 3 Not Indicated 12B. If yes, Occupational Therapy 1 Yes, 2 No 3 Not Indicated 12C. If yes, Speech and Language 1 Yes, 2 No 3 Not Indicated 12D. If yes, Dietetics 1 Yes, 2 No 3 Not Indicated Physio Occup SLT Dietet 30