(i) This FAQ does not deal with clinical issues (eg What is the definition of a stroke unit? or

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1 STROKE INTEGRATED PERFORMANCE MEASURE RETURN (IPMR) FREQUENTLY ASKED QUESTIONS (FAQ) Prepared by NHS North West, Lancashire & Cumbria Cardiac & Stroke Network, Cheshire and Merseyside Clinical Networks and Greater Manchester & Cheshire Cardiac and Stroke Network building on the work done by DH Stroke Team. JUNE 2012 Notes (i) This FAQ does not deal with clinical issues (eg What is the definition of a stroke unit? or What blood tests should patients be given?) Those questions are addressed in the relevant guidance (eg the RCP's National Clinical Guideline for Stroke (third edition), The National Stroke Strategy etc.) (ii) A revised version of the full Integrated Performance Measures Return (IPMR) guidance for stroke has been published. If you are in doubt about whether you are using the latest version, please download it again. Among other changes, the revised version contains clearer information about TIA clinics. (iii) Patients should always be cared for in the most appropriate clinical setting irrespective of the requirements of the stroke integrated performance measure. (iv)this guidance, like The Stroke Strategy itself, applies and refers to adult patients only. 1 P a g e

2 CONTENTS LINE 2004: Patients who spend at least 90% of their time on a Stroke Unit When does the clock start? What is the unit of measurement? If a patient has to legitimately spend time out of the stroke unit for a non-stroke-related co-morbidity/injury should trusts count that episode within the length of stay calculation? If a patient has to legitimately spend time out of the stroke unit for a stroke related co-morbidity/injury should trusts count that episode within the length of stay calculation? What if a patient has a second stroke when they are already on a stroke unit? Can stroke patients who are on a general elderly rehabilitation ward, with their care overseen by a specialist stroke nurse or a stroke out-reach team, be counted as being on a stroke unit? If a patient is admitted to a stroke unit, then subsequently transferred to a stroke specialist rehabilitation unit in a different trust, should this count as two episodes? Is a neurological rehabilitation unit the same as a stroke specialist rehabilitation unit? If a patient is admitted to a stroke unit, then subsequently transferred to a community rehabilitation unit in a different trust, should this count as two episodes? When does the pathway stop for time spent on a stroke unit? Does the clock stop if a patient is medically fit for discharge (eg, when a patient is awaiting a social care package)? Isn't it possible that early supported discharge (ESD) could skew the data? The episodes will not be coded until the patient is discharged, while we are being asked to count admissions in the period, therefore we cannot have 100% data completeness where patients are still in hospital, including their rehabilitation episode if applicable How should length of stay be calculated when a patient is admitted and discharged on the same day?...6 LINE 2005: number of people who were admitted to hospital following A stroke Can you clarify which of the ICD10 codes define stroke? Patients can have up to 12 ICD10 admission codes: primary, secondary, etc. Do we want to include patients who have a stroke code in any of these 12 codes or just the primary code? Regarding the definition of "admitted with a stroke", should we include only patients (provider spells) where a diagnosis of stroke appears in the first episodes of consultation? If the consultant writes in the notes that the patient s notes that the episode of stroke care has finished, can their IP stay after this be excluded from the 90%?...6 LINE 2006: Transient Ischaemic Attack (TIA) cases with a higher risk OF stroke WHO ARE TREATED WITHIN 24HRS Please can you clarify what is meant by 'treatment within 24 hours'? The IPMR guidance says: P a g e

3 21. Could you please define presentation? Is this onset of the TIA or admission? Should both the test and the subsequent action be undertaken in the time frame? Could you clarify whether the carotid imaging results are to be obtained in 24 hours rather than just the request done? The guidance says that investigations for high risk TIA include blood tests. Do they have to be taken within this attendance? What if the patient is already being prescribed aspirin or statins? What happens if a patient does not want to be seen in 24 hours? And what about DNAs etc? A lot of the TIA patients were seen in clinic, therefore we do not have the coding to identify these patients Are admitted patients excluded for TIA vital signs? What about ward attenders?...8 Line 2007: NUMBER OF PEOPLE WHO HAVE A TRANSIENT ISCHAEMIC ATTACK (TIA) WHO ARE AT HIGHER RISK OF STROKE When does the clock stop and start? Are patients who present later to 'first contact' to be fast-tracked ahead of other, more acute, TIAs? Which patients are included in the denominator? What if there is no ABCD2 score with the referral? What if patients present as high risk 7 days after the TIA? What are the expected performance levels in 2012/13 for Stroke & TIA? P a g e

4 LINE 2004: PATIENTS WHO SPEND AT LEAST 90% OF THEIR TIME ON A STROKE UNIT 1. WHEN DOES THE CLOCK START? Clock starts from the point of entry at hospital, including time in A and E. We are aware that this is different to the data dictionary definition of the start of an admission which is at the point of the start of the FCE. The intention of this vital sign is for patients to move rapidly to an acute stroke unit and spend a high proportion of their hospital stay there, so calculation of the vital sign needs to begin at the point of entry to hospital rather than from the decision to admit which could be potentially hours later. 2. WHAT IS THE UNIT OF MEASUREMENT? There has been debate on whether this measure should be calculated in either days or the more granular hours/minutes. A survey of stroke networks in April 2011 to ascertain their ability to measure in hours and minutes showed that about 20% of organisations would not be able to do so. Therefore, as this is a national indicator in order for all organisations to be measured on a strictly comparable basis it is necessary for the measurement to continue to be calculated in days. 3. IF A PATIENT HAS TO LEGITIMATELY SPEND TIME OUT OF THE STROKE UNIT FOR A NON- STROKE-RELATED CO-MORBIDITY/INJURY SHOULD TRUSTS COUNT THAT EPISODE WITHIN THE LENGTH OF STAY CALCULATION? When a patient, for clinical reasons, spends time out of stroke unit (e.g. they have to spend time on an orthopaedic ward because they have a broken hip) that amount of time does not count towards the vital sign numerator. This means that the percentage time spent on a stroke unit will decrease; however we expect that these vagaries will be the same across all providers. We also believe that this will serve to encourage the patient being transferred promptly to a stroke unit. 4. IF A PATIENT HAS TO LEGITIMATELY SPEND TIME OUT OF THE STROKE UNIT FOR A STROKE RELATED CO-MORBIDITY/INJURY SHOULD TRUSTS COUNT THAT EPISODE WITHIN THE LENGTH OF STAY CALCULATION? Time spent in any specialist unit to enable the patient to receive appropriate care for a stroke-related condition (e.g. surgical ward post-carotid endarterectomy or neurosurgical ITU post-neurosurgery) should not be included either in the total time spent in the stroke unit or in the total length of hospital stay. In other words, the percentage of time spent on a stroke unit will not change. Once the patient is stable from a surgical point of view and no longer requires ward-based surgical care, they should be transferred to the acute stroke unit for continuing management/rehabilitation. 5. WHAT IF A PATIENT HAS A SECOND STROKE WHEN THEY ARE ALREADY ON A STROKE UNIT? The second stroke does not alter the counting: the length of stay begins with the first stroke and is not affected by subsequent strokes until and if the patient is discharged and readmitted with stroke again. It is at that point that the clock is restarted. 6. CAN STROKE PATIENTS WHO ARE ON A GENERAL ELDERLY REHABILITATION WARD, WITH THEIR CARE OVERSEEN BY A SPECIALIST STROKE NURSE OR A STROKE OUT-REACH TEAM, BE COUNTED AS BEING ON A STROKE UNIT? No, as there will be no assurance that all the other elements that define stroke unit care will be available (e.g. regular specialist MDT ward rounds, stroke consultant input, information for patients and relatives, etc) 4 P a g e

5 7. IF A PATIENT IS ADMITTED TO A STROKE UNIT, THEN SUBSEQUENTLY TRANSFERRED TO A STROKE SPECIALIST REHABILITATION UNIT IN A DIFFERENT TRUST, SHOULD THIS COUNT AS TWO EPISODES? No, this should be counted once. The episode must be counted as a super-spell that would include both admissions as part of the same episode, whether they are within the same trust or not. The superspell spans time spent in A&E as well as any FCEs. (A 'super-spell' is where a patient s care spans two trusts / providers, e.g. acute stroke in trust and rehabilitation in a PCT provider. Spells are handled in accordance with the NHS Data Dictionary definition and cover the care delivered by an individual provider organisation from patient admission to discharge). 8. IS A NEUROLOGICAL REHABILITATION UNIT THE SAME AS A STROKE SPECIALIST REHABILITATION UNIT? Only if it has all of the defined characteristics of a specialist stroke unit 9. IF A PATIENT IS ADMITTED TO A STROKE UNIT, THEN SUBSEQUENTLY TRANSFERRED TO A COMMUNITY REHABILITATION UNIT IN A DIFFERENT TRUST, SHOULD THIS COUNT AS TWO EPISODES? This should be counted once, within a superspell. Generic community hospital or intermediate care facilities are not appropriate for stroke care. If the person is transferred to these facilities because they have no further need for stroke rehabilitation but their transfer of care is delayed all of the time spent in hospital needs to be included in the spell. 10. WHEN DOES THE PATHWAY STOP FOR TIME SPENT ON A STROKE UNIT? When there is a change of primary diagnosis for the patient, or death, discharge, or self-discharge. 11. DOES THE CLOCK STOP IF A PATIENT IS MEDICALLY FIT FOR DISCHARGE (EG, WHEN A PATIENT IS AWAITING A SOCIAL CARE PACKAGE)? No. If the person is transferred to generic or community care facilities because they have no further need for stroke rehabilitation but their transfer of care is delayed all of the time spent in hospital needs to be included in the spell. 12. ISN'T IT POSSIBLE THAT EARLY SUPPORTED DISCHARGE (ESD) COULD SKEW THE DATA? Yes; it is therefore important for this reason, and others, that admissions should go directly to a stroke unit. Short length of stay affecting the vital sign achievement has been considered in the tolerance for the stroke vital sign. 13. THE EPISODES WILL NOT BE CODED UNTIL THE PATIENT IS DISCHARGED, WHILE WE ARE BEING ASKED TO COUNT ADMISSIONS IN THE PERIOD, THEREFORE WE CANNOT HAVE 100% DATA COMPLETENESS WHERE PATIENTS ARE STILL IN HOSPITAL, INCLUDING THEIR REHABILITATION EPISODE IF APPLICABLE. If this is the case, then the patient should be reported in the next quarter s data, once they have been discharged. We expect that, over a period, these vagaries will balance out and that the data impact will accordingly reduce. 5 P a g e

6 14. HOW SHOULD LENGTH OF STAY BE CALCULATED WHEN A PATIENT IS ADMITTED AND DISCHARGED ON THE SAME DAY? If a patient is admitted and discharged on the same day LOS will be zero. The patient should not be included in the denominator or the numerator. There are likely to be very few of these cases but they should be excluded from the counting. (We realise that this may include those admitted directly to a stroke unit who die the same day.) LINE 2005: NUMBER OF PEOPLE WHO WERE ADMITTED TO HOSPITAL FOLLOWING A STROKE 15. CAN YOU CLARIFY WHICH OF THE ICD10 CODES DEFINE STROKE? As the IPMR guidance says, the codes are ICD10 codes I61, I63, and I64 (including the various sub-sets of coding for each of these main codes). These ICD codes are the same as currently used by the Royal College of Physicians' Stroke Sentinel Audit for this purpose. 16. PATIENTS CAN HAVE UP TO 12 ICD10 ADMISSION CODES: PRIMARY, SECONDARY, ETC. DO WE WANT TO INCLUDE PATIENTS WHO HAVE A STROKE CODE IN ANY OF THESE 12 CODES OR JUST THE PRIMARY CODE? These patients should be included in the vital sign data collection only if the primary diagnosis is a relevant ICD code. All patients with acute stroke should go directly to an acute stroke unit and remain in a specialist stroke unit until that episode is complete and the patient is transferred to home or other residential setting. Patients with catastrophic stroke should be admitted directly to the stroke ward in the first instance. A decision that palliative care is required the patient is no reason to transfer the patient off the stroke ward. Decisions about end of life care should be made with the patient, family and stroke team about which is the most appropriate setting to meet the patient and families needs, this might include their continued stay on the stroke ward. If the patient is transferred to another hospital ward, rather than discharged to out of hospital care, the clock would not stop and the whole hospital length of stay would be used for the measure. 17. REGARDING THE DEFINITION OF "ADMITTED WITH A STROKE", SHOULD WE INCLUDE ONLY PATIENTS (PROVIDER SPELLS) WHERE A DIAGNOSIS OF STROKE APPEARS IN THE FIRST EPISODES OF CONSULTATION? No; any consultant episode counts where the primary diagnosis is of stroke. 18. IF THE CONSULTANT WRITES IN THE NOTES THAT THE PATIENT S NOTES THAT THE EPISODE OF STROKE CARE HAS FINISHED, CAN THEIR IP STAY AFTER THIS BE EXCLUDED FROM THE 90%? No For Reference See: Q10. When does the pathway stop for time spent on a stroke unit? Q11. Does the clock stop if a patient is medically fit for discharge (e.g., when a patient is awaiting a social care package)? 6 P a g e

7 LINE 2006: TRANSIENT ISCHAEMIC ATTACK (TIA) CASES WITH A HIGHER RISK OF STROKE WHO ARE TREATED WITHIN 24HRS 19. PLEASE CAN YOU CLARIFY WHAT IS MEANT BY 'TREATMENT WITHIN 24 HOURS'? The IPMR guidance itself makes clear that the following treatments should be commenced for higher risk TIA cases within the 24-hour time window: The following investigations for high risk TIA cases should be completed within the 24-hour time window: Blood tests (all patients). Electrocardiogram (ECG: all patients). Brain scan (if vascular territory or pathology uncertain. Diffusion-weighted MRI is preferred, except where contraindicated, when CT should be used). Completion of carotid imaging (where indicated) and referral for carotid surgical intervention (where indicated) The following treatments should be commenced for high risk TIA cases within the 24-hour time window: Aspirin (where needed or alternative if contraindicated). Statin (where needed or alternative if contraindicated). Control of blood pressure (where needed unless contraindicated) 20. THE IPMR GUIDANCE SAYS: Higher risk patients with TIA should be counted only if they attended an out-patient TIA or neurovascular clinic, or an alternative relevant out-patient clinic (e.g. neurology clinic or by attending a stroke unit directly.) In this context, patients who are admitted to hospital are not counted. Should these patients still be seen by specialists? Yes, as part of a specialist service and in accordance with the National Stroke Strategy and the NICE clinical guideline for stroke (third edition). The IPM guidance does not endorse non-specialism in these circumstances. 21. COULD YOU PLEASE DEFINE PRESENTATION? IS THIS ONSET OF THE TIA OR ADMISSION? Within 24 hours of presentation, i.e. the first time an individual with a suspected TIA presents with symptoms to medical personnel. For example for patients who dial '999', the 24-hour clock starts as soon as a paramedic reaches the patient; or, if a patient calls their GP, the clock starts when the GP sees the patient. 22. SHOULD BOTH THE TEST AND THE SUBSEQUENT ACTION BE UNDERTAKEN IN THE TIME FRAME? Results of tests must be obtained within 24 hours of presentation. If the test shows unexpected results then they too need to be acted upon, but within what timeframe would be for the clinician to decide in the individual case. 23. COULD YOU CLARIFY WHETHER THE CAROTID IMAGING RESULTS ARE TO BE OBTAINED IN 24 HOURS RATHER THAN JUST THE REQUEST DONE? Yes, the carotid imaging should be completed within the 24-hour time window. 24. THE GUIDANCE SAYS THAT INVESTIGATIONS FOR HIGH RISK TIA INCLUDE BLOOD TESTS. DO THEY HAVE TO BE TAKEN WITHIN THIS ATTENDANCE? Blood tests must be taken, and results obtained, within 24 hours of presentation. 7 P a g e

8 25. WHAT IF THE PATIENT IS ALREADY BEING PRESCRIBED ASPIRIN OR STATINS? That treatment would effectively count as having been considered and completed. 26. WHAT HAPPENS IF A PATIENT DOES NOT WANT TO BE SEEN IN 24 HOURS? AND WHAT ABOUT DNAS ETC? The stroke vital sign deliberately has a tolerance built in to accommodate cases such as these. 27. A LOT OF THE TIA PATIENTS WERE SEEN IN CLINIC; THEREFORE WE DO NOT HAVE THE CODING TO IDENTIFY THESE PATIENTS. Patients seen in a clinic (i.e., an out-patient setting) should still be coded. From April 2011 there has been a separate identifiable treatment function code for TIA (329) 28. ARE ADMITTED PATIENTS EXCLUDED FOR TIA VITAL SIGNS? WHAT ABOUT WARD ATTENDERS? Yes, admitted patients are excluded for TIA. Ward attenders should be included. We recognise that limiting the count to non-admitted patients may be seen as contrary to decisions made in some areas to admit all TIA patients who are at higher risk of stroke. However, in England the vast majority of these patients are managed as out-patients, and the purpose of this guidance is to foster development of systems for timely out-patient assessment and treatment of such people. In areas where admission is a proxy for addressing resources issues (e.g. in imaging and diagnostics) we recommend that trusts explore with their commissioners designing open access services which can meet this 24 hour standard so that the majority of such people are not admitted. LINE 2007: NUMBER OF PEOPLE WHO HAVE A TRANSIENT ISCHAEMIC ATTACK (TIA) WHO ARE AT HIGHER RISK OF STROKE 29. WHEN DOES THE CLOCK STOP AND START? The clock starts the first time an individual with a suspected TIA presents with symptoms to medical personnel, not when the referral is received by secondary care. For example for patients who dial '999', the 24-hour clock starts as soon as a paramedic reaches the patient; or, if a patient calls their GP, the clock starts when the GP sees the patient. The clock stops 24 hours after first presentation regardless of whether the investigations have been completed and treatment commenced. 30. ARE PATIENTS WHO PRESENT LATER TO 'FIRST CONTACT' TO BE FAST-TRACKED AHEAD OF OTHER, MORE ACUTE, TIAS? This is an issue for clinical judgment on each individual case at the time. However, all higher risk patients (ABCD2 score of four or more) should be seen within 24 hours of their first presentation. All lower risk patients (ACBD2 score of less than four) should be seen within seven days. (The initial decision of who is at higher risk of stroke must, of course, be made by the referrer.) 31. WHICH PATIENTS ARE INCLUDED IN THE DENOMINATOR? The denominator includes all patients referred with suspected higher risk TIA and not just patients with confirmed higher risk TIA. 32. WHAT IF THERE IS NO ABCD2 SCORE WITH THE REFERRAL? The patient should be treated as if they were higher risk. 8 P a g e

9 33. WHAT IF PATIENTS PRESENT TO THE FIRST POINT OF CONTACT AS HIGH RISK 7 DAYS AFTER THE TIA? They should be treated by the TIA service as if they are at lower risk of stroke in line with NICE guidance 34. WHAT ARE THE EXPECTED PERFORMANCE LEVELS IN 2012/13 FOR STROKE & TIA? Performance in 2012/13 is expected to be maintained, therefore, the existing expectation for organisations to achieve is 80% against the Stroke integrated performance measure and 60% against the TIA measure. As outlined in previous versions of the Technical Guidance to support the NHS Operating Framework, this performance was expected to be delivered by the end of Q4 2010/11. Therefore, the situation for organisations as we move into 2012/13 is to maintain this position. 9 P a g e