An audit of in-hospital stroke in NHS Lothian

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1 An audit of in-hospital stroke in NHS Lothian Dr Amanda Barugh Specialty registrar in Geriatric Medicine, General (Internal) Medicine and Stroke Medicine

2 NHS Lothian Population = 810, hospitalised strokes/100,000 pop St Johns: 260 strokes/yr WGH: 240 strokes/yr RIE: 950 strokes/yr

3 Scotland Ayr Crosshouse Borders DGRI GCH VHK FVRH ARI Dr Grays GRI IRH QEUH RAH Belford Caithness L&I Raigmore Hairmyres Monklands Wishaw RIE SJH WGH Balfour Gilbert Bain Ninewells PRI Uist & Barra Western Isles Percentage of strokes occurring as inpatients in 2015 and 2016 according to SSCA About 5% across Scotland Varied between hospitals in Lothian %

4 Concerns within QI group in Lothian What accounts for the variation between hospitals? Are the patients having strokes whilst inpatients receiving as good care as those admitted following a stroke? There appeared to be delays in: Recognition Swallow screens Specialist assessments Thrombolysis Stroke unit care Were these reflecting inadequate care, or reflecting casemix?

5 Aims of the audit To determine the frequency of in-hospital stroke in Lothian To determine in which departments the strokes were occurring To describe how in-hospital stroke is managed, including provision of: stroke unit care secondary prevention thrombolysis

6 Methodology 200 consecutive in-hospital strokes (January 2015-October 2016) Identified from the Lothian Scottish Stroke Care Audit (SSCA) database (captures all with a diagnosis of stroke on discharge letter) Data extraction proforma developed, piloted on 20 sets of casenotes and then refined Case notes (paper and/or electronic) scrutinised by a single auditor (AB)

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8 Characteristic Baseline characteristics Age (mean(sd)) 77 (11.4) N (%) Male sex 98(49%) Location by hospital Royal Infirmary 121 (60) Western General 56 (28) St. John s 23 (12)

9 Stroke characteristics 92% ischaemic, 8% haemorrhagic OCSP classification: TACS 29% PACS 36% LACS 16% POCS 11% Haemorrhage 8%

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12 Management (for all strokes vs in-patient strokes) All strokes In-patient strokes Swallow within 4 hours 74% 31% Aspirin within 1 day 93% 66% Stroke unit care 65% 54% Thrombolysis 8% 7%

13 Swallow assessment 91% of patients had a bedside swallow assessment documented at some point following onset of stroke symptoms. Median time from recognition of symptoms to swallow screen 4 hours (range hours) However only 31% overall met the target of having a swallow assessment within 4 hours of symptom onset Around half of the remaining patients had a documented reason why they did not have a swallow assessment (most commonly that they were intubated or thought to be dying)

14 Aspirin 121 (66%) of the 184 patients with ischaemic stroke prescribed aspirin within 24 hours of stroke onset Reasons aspirin was not given: 32 patients already on an anticoagulant (warfarin, heparin, apixaban) 17 patients thought to be dying 3 patients had a recent GI bleed 3 patients had a documented allergy to aspirin 2 patient had haemorrhagic transformation into the infarct 6 patients had no clear reason documented.

15 Acute Stroke Unit care 54% of patients were transferred to the acute stroke unit The most common reasons for not being transferred to the ASU were: Patient requiring ongoing specialist care from another specialty (n=59) Patient dying/died (n=16) Patient transferred to a stroke unit outwith NHS Lothian (n=7) Stroke team not contacted or involved in the patients care (n=10)

16 IV thrombolysis Of the 184 patients diagnosed with ischaemic stroke, 13 (7%) received IV thrombolysis, compared with a 8% overall rate in NHS Lothian. The reasons for thrombolysis not being delivered were: No known time of onset (n=71) Recent major surgery (n=32) Recent major haemorrhage (n=31) Recent aortic dissection (n=10) Already on an anticoagulant (n=6) Symptoms rapidly improving (n=3) Diagnosis unclear (n=2) In 16 patients (8%) the auditor judged that there was no clear reason why thrombolysis was not given.

17 IV Thrombolysis Median time from onset of symptoms to thrombolysis bolus 97 minutes (range minutes) No patients were treated in under 60 minutes from onset 62% of those admitted with acute stroke at the front door received thrombolysis within 60 minutes in Lothian.

18 Summary In-patient strokes receive care according to standards less often but sometimes for good clinical reasons However there are avoidable Delays in swallow screens Delays in/lack of specialist assessments (including SU care) Delays in/lack of thrombolysis

19 Next steps Develop processes for managing in patient strokes with the staff in those areas where in-patient stroke most common Focus staff training on those areas where in-patient strokes most common Many in patient strokes do not receive thrombolysis because of contraindications. However, they might be eligible for thrombectomy make sure we have clear pathways for this