Download Developing Intelligent Targets for Stroke

IT Apr 05
Developing Intelligent Stroke Targets
Background
Stroke is caused by a disruption to the brain’s blood supply. This, in most
cases, occurs acutely and has spawned the term ‘brain attack’ to reflect
that Stroke warrants the same response and degree of urgency afforded to
the patient with a ‘heart attack’. Disruption to the blood supply most
commonly occurs through:
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an occlusion caused by a clot narrowing or blocking blood vessels:
ischaemic stroke
or
a stroke caused by a leak of blood from the blood vessel wall:
haemorrhagic stroke
Both cause damage to the brain tissue which can result in impairment of
physical and mental function including cognition [thinking ability]. Although
stroke has a defined early mortality, many patients can make a good
recovery. A significant minority are left with very disabling limitations in
physical and mental ability.
Transient ischaemic attacks (TIAs) are defined as brain attacks where the
symptoms resolve completely within 24 hours. However, there is now
increasing evidence (through use of modern brain scanning techniques) that
these patients have sustained damage to the brain tissue and the term small
stroke or mini stroke is more accurate. Use of the word “transient” is of
value in reflecting that these symptoms should not be ignored and reflects a
very important opportunity in preventing a more severe stroke event.
Evidence suggests that about one half of patients with true TIA/Mini stroke
will ‘proceed’ to a major stroke within one year of initial presentation.
Stroke is the third largest cause of death in the UK and the single largest
cause of adult disability.
Stroke within Wales
The 2006 Stroke Sentinel Audit published by the Royal College of Physicians
in May 2007 indicated an underperformance in delivery of stroke care in
Wales. In response, the Welsh Assembly Government (WAG) published the
Welsh Health Circular (2007) 052 which:
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confirmed that tackling stroke is now one of the Welsh Assembly
Government’s top priorities for the NHS and Social Services
announced a formal programme of work for 2008-11 to guide and
direct the progressive implementation of the standards for stroke
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care set out in the National Service Framework for Older People
which was published in the WHC (2007) 082
One of the work streams of the Stroke Service Improvement
Programme is the All Wales Stroke Services Improvement
Collaborative (AWSSIC). This collaborative is based on the Welsh
Critical Care Improvement Programme and 1000 Lives Campaign
models. These models require participating organisations to collect
robust prospective data to monitor compliance with evidence based
care interventions which then informs small cycles of change within
organisations. The AWSSIC interventions are based on the
recommendations in the RCP National Clinical Guideline for Stroke for
the first seven days of care following stroke. They are grouped into
care bundles, and the aim is for each organisation involved to
demonstrate improvement in their compliance rates with these four
acute stroke care bundles over the next 12 months.
Stroke and Intelligent Targets
It is recognised that target setting, such as 4hr waits in A and E and in
improving waiting times for new patients, has been very successful in driving
forward change in practice. However, there is increasing recognition that
such targets, based on numerical outcome, produce positive change in one
narrow area of the care pathway but can have a negative impact on other
areas of the pathway and a detrimental effect on quality of care and the
culture of staff delivering care.
In response, target setting now represents a major area of collaboration
between the Professional Advisory Structures in Wales and the Welsh
Assembly Government.
The Directorate of Performance and Operations in the Department for
Health and Social Services recently invited a core group of clinicians
involved in stroke care to develop a set of Intelligent Targets that would
drive improvement in the quality of stroke services in Wales. Similar groups
have been set up to develop targets for cardiac, unscheduled care and
mental health and well-being services.
In defining the Pathway of Care the following key areas were identified
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preventing stroke through improved management of TIA
thrombolytic therapy
improving stroke care in the first seven days following stroke
supporting individuals to achieve their optimal level of functional
recovery in the first four to six weeks following stroke
the longer term management of patient with significant on-going
disability
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It was decided that the initial tranche of Targets would focus on; TIA/Mini
stroke, the first seven days post significant stroke and the initial 4-6weeks
of post stroke rehabilitation.
The remaining pathways of Thrombolysis, and the Longer Term Care of
patients with significant persisting disability are deferred to a second
tranche of targets for the following reasons:
- Care for Stroke Patients with ongoing significant disability is dependent on
other emerging strategies including Long Term Conditions Management and
provision of Continuing Care Management
-It is recognised that the introduction of thrombolysis is a requirement of
the WHC (2007) 082, by 2010. However, the RCP recommended in the
publication of the results of the 2007 organisational audit that thrombolysis
should not be introduced until the other components of the acute stroke
service are functioning well. It stated that:
“There are greater benefits to the stroke population as a whole by having
an effective acute stroke unit delivering ‘basic’ stroke care than by having
a thrombolysis service without the other components. This audit
unfortunately suggests that in some cases thrombolysis may have been
introduced too early.”
-The Welsh Health Circular (2007) 082 requires local implementation of
thrombolysis by March 2010. Process and outcome measures will need to be
established by March 2010 to enable compliance to be monitored from April
2010. The data collected for the acute care bundles should help to inform
planning and development of services in the interim.
Target derivation: process adopted by the working group
Performance targets can have a significant impact on driving improvement
in health services. Some current examples of the annual operating
framework (AOF) targets are the four and eight hour wait targets in A&E and
the Access 2009 referral to treatment targets.
However, while performance targets can be effective at driving change,
they are viewed by clinicians as managerially driven, sometimes based on
issues that can be politically sensitive or that just patch a weakness in the
system. They may fix one problem but cause another one elsewhere in the
patients’ journey. This can be damaging to the process of whole system
planning and can have a negative effect on clinical leadership and
engagement, as clinicians delivering the service may feel these targets are
being imposed on them.
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The characteristics of an Intelligent Target were felt to be that they:
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are easily understood
drive organisations to achieve clinical excellence
are easily measurable (underpinned by robust prospective data
collection)
engage whole workforce
are owned by clinicians
There have been two meetings of the core group. For membership of the
core and clinical reference group see Appendix 1. In the first it was agreed
that although targets may concentrate on certain aspects of stroke care,
they need to take into account the whole care pathway for stroke from
primary prevention through to integration back into the community and
palliative care.
There are very clear national evidence-based guidelines on what constitutes
high quality and effective stroke care. There are currently some excellent
examples of good practice in stroke care around Wales, but there is also
huge variability in the quality of stroke care, both within and between
organisations.
It was agreed that the first step in improving stroke services across Wales
should, therefore, be to reduce the variability and improve the reliability of
basic stroke care interventions, before going on to develop “gold standards”
in care. It was felt that to be able to understand how well we are delivering
stroke care in Wales; we need to know what is happening to every patient
who has a stroke by collecting a core set of data on the care they receive.
As discussed it was agreed that in the first instance the Intelligent Targets
should concentrate on TIA services, acute stroke care, and the first four to
six weeks of recovery and rehabilitation. The targets should align with the
Welsh Assembly Government’s directives for stroke services, and should be
achievable within allocated resources within the next 12/18 months.
The process was agreed as:
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First meeting of core group 23/01/09
o Discussion and agreement of key interventions for the three
areas of care outlined above
Draft driver diagrams circulated to core group for comment
Second meeting of core group 03/02/09
o Agreement of format for targets, process and outcome
measures
o Amendments to interventions and driver diagrams
Circulation to wider clinical reference group (Welsh Stroke Alliance)
by e-mail 09/03/09 for comment by 18/03/09
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Comments collated and reflected back to Core group chairs 20/03/09
(available on the stroke intranet site nww.stroke.wales.nhs.uk).
These will help inform ongoing target development.
Final proposals for intelligent targets for stroke re-circulated
electronically to core group for sign off 24/03/09
Submission to WAG by core group chair by 31/03/09
It was felt that the targets needed to be flexible enough to allow for
different models of care to develop to reflect different local needs and
existing infrastructure. It was therefore decided to avoid targets that
concentrated on the form of services- such as TIA clinics and Stroke Units,
and concentrate more on the functions that are carried out within themsuch as specialist assessment and interventions.
The Targets
Measures are divided into three domains:
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Uptake
Process
Outcome
The uptake indicators are organisational preconditions. These are
conditions that will need to be met if centres are going to make progress on
their intelligent targets.
For stroke these are:
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Use of the agreed Monitoring Tool supported by Information
Technology
Identified Clinical Champions and Stroke Specialist Team and
associated patient facilities
Evidence of Progress based on compliance with the performance
requirements of the Intelligent Targets. See section on Reporting
Mechanisms
The process measures constitute the intelligent targets. These are
measures of quality. For stroke services the intelligent target would be 100%
compliance with the following care bundles;
TIA/Mini-Stroke
1. First Point of Contact for TIA- symptom recognition and referral
2. Timely, specialist assessment and treatment of high risk TIA (ABCD2
Score =/> 4)
3. Timely, specialist assessment and treatment of low risk TIA (ABCD2
Score =/<3)
4. Ongoing secondary prevention and risk management following TIA
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First Week post established Stroke
1. First Hours Bundle - Rapid recognition of symptoms and diagnosis of
stroke within 3 hours
2. First Day Bundle - Emergency treatment for people with stroke within
24 hours
3. First 3 Days Bundle - Early mobilisation following stroke within 3 days
4. First 7 Days Bundle - Patient centred and goal-orientated specialist
care following stroke within 7 days.
Rehabilitation following an established Stroke – 4-6 week period
1. Seamless transition of care
2. Appropriate rehabilitation delivered in the most appropriate setting
The outcome
improvements:
measures
reflect
the
potential
impact
of
these
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Percentage of people with suspected TIA that go on to have a stroke
within 7 days
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Mortality rates
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Change in functional outcome following stroke
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Average length of stay in
o Stroke Unit
o Hospital
o Stroke Service (in patient and community)
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Percentage of people who return to their usual place of residence
These targets are summarised in Appendix 2 and the bundle details and
measures in driver diagrams in Appendix 3.
Reporting Mechanism
This data should be collected monthly and used by those planning and
delivering services to ensure appropriate process and quality in the delivery
of care. It could be reported to WAG quarterly.
A key element of the engagement of professionals in developing Intelligent
Targets is clinical ownership. Inherent in this will be professional and
organisational accountability as a key tool in performance management.
Ownership will be local, but accountability needs also to be in the
framework of achieving the improvement across the whole service in Wales
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It has been suggested that the data is reported to WAG in the form of a
stroke-specific chairs dashboard. This could report compliance rates for the
10 individual targets, or overall compliance with the three main clinical
areas of TIA, acute care and early recovery and rehabilitation.
Using the same sets of data it is also possible to report the process
capability of each organisation to deliver these services, which could also be
reported as a chairs dashboard.
Further work is needed to develop this. Please see Appendix 4 for examples
of data presented in a chairs dashboard.
Further Development
The data collected will help inform the development of future Intelligent
Targets for thrombolysis and long term rehabilitation and community
support aimed for 2010/11.
The interventions in the bundles can also be changed after the first year to
reflect changes in the evidence. For example, CT scanning could be moved
from the 24 hour bundle to the 3 hour bundle or OT could be moved from
the 7 day bundle to the 3 day bundle.
There is work going on in parallel with the intelligent targets and
collaborative work on standards of care around assessment and treatments
and competencies of specialist stroke staff (Stroke services Educational
Framework) which can be incorporated into the bundles as it becomes
available. Much of this work is being undertaken by various sub-groups of
the Welsh Stroke Alliance.
Conclusion
The professionals involved in stroke care have identified the interventions
they feel are key to improving the quality of stroke care across Wales. Their
role has been vital in identifying Targets which will drive organisations to
achieve clinical excellence while being mindful to what is achievable in the
next 12 to 18 months. There has been a concerted effort to make the
connection between the Targets, evidence-based processes of care and
clinical outcomes.
The targets incorporate evidence based standards of care, but allow the
flexibility for organisations to develop models of care that meet local need.
References
Clinical Effectiveness and Evaluation Unit (2008) National Clinical Guidelines for Stroke.
London. Royal College of Physicians.
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Royal College of Physicians (2008) National Clinical Guideline on the Management of People
with Stroke (3rd Edition). London. RCP Intercollegiate Stroke Working Party.
Royal College of Physicians (2008) National Sentinel Stroke Audit Phase One Organisational
Audit 2008 Report for England, Wales and Northern Ireland. London. RCP Clinical
Effectiveness and Evaluation Unit.
Welsh Assembly Government (2006) National Service Framework for Older People. Cardiff.
Welsh Assembly Government.
Welsh Assembly Government (2007) Welsh Health Circular (2007) 058. Cardiff. Welsh
Assembly Government.
Welsh Assembly Government (2007) Welsh Health Circular (2007) 082. Cardiff. Welsh
Assembly Government.
Appendix 1: Core Group Membership
Name
Role / Profession
Organisation
Dr Anne Freeman
Chair WSA
Gwent Healthcare Trust
Dr Ed Wilkins
Chair WMC
ABMU NHS Trust
Andy Williams
Alan Willson
Paramedic
WAST
Director of R&D
NLIAH
Alun Morgan
Physiotherapy
Cardiff and Vale Trust
Carl James
WAG
Welsh Assembly Government
Carol Milton
Dietetics
ABMU NHS Trust
Cathy White
WAG
Welsh Assembly Government
Dr Chris Burton
Education
Bangor University
Dr Dick Dewar
Medicine
Cwm Taf NHS Trust
Dr Hamsaraj Shetty
Medicine
Cardiff and Vale NHS Trust
Dr Salah Elghanzai
Medicine
North West Wales NHS Trust
Heather Giles
Welsh Assembly Government
Janet Ivey
WAG
Speech and Language
Therapy
Occupational Therapy
Lynne Hughes
Nursing
North Wales NHS Trust
Nichola Pryce-Howard
WAG
Welsh Assembly Government
Nicola Davis
Nursing
Blaenau Gwent LHB
Suzanne Martin
Orthoptics
ABMU NHS Trust
Dr Vijay Sawlani
Neuroradiology
Morriston Hospital, ABMU
Gwyn Roberts
WAG
Welsh Assembly Government
Heather Graz
Clinical Reference Group
Welsh Stroke Alliance
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Gwent Healthcare Trust
Cwm Taf Trust
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Appendix 2: Intelligent Targets Summary
Organisational Uptake Indicators
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Use of Monitoring Tool
Identified Clinical Champion and Specialist Services dedicated to
stroke care
Evidence of Progress based on Performance Review of Intelligent
Targets
Intelligent Targets [For details of Bundles see Appendix 3]
Clinical Area
Target
No
1
2
TIA/Mini
Stroke
3
4
1
2
Acute Stroke
[First Week]
3
4
1
Rehabilitation
2
Week 4-6
Target focus
First Contact Bundle
Timely Management of High Risk TIA Bundle
Timely Management of Low Risk TIA Bundle
Ongoing Secondary Prevention Bundle
First Hours Bundle
First Day Bundle
First Three Days Bundle
First Seven Days Bundle
Seamless Transition of Care Bundle [From 1st
week]
Appropriate Rehab in Appropriate Setting
Bundle measured in weekly increments over
the individual patient’s treatment time frame
Measure
100%
compliance
100%
compliance
100%
compliance
100%
compliance
100%
compliance
100%
compliance
100%
compliance
100%
compliance
100%
compliance
100%
compliance
Outcomes
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Percentage of people with suspected TIA that go on to have a stroke
within 7 days
Risk Adjusted Mortality Rates
Average Length of Stay
o in hospital
o in stroke beds
o in stroke service
Change in average functional outcome score on discharge
Percentage of people who return to their usual place of residence
Percentage of people who are readmitted within 28 days
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Appendix 3: The three driver diagrams
1. Driver Diagram and Measures for TIA Management
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2. Driver Diagram and Measures for Acute Stroke Care
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3. Driver Diagram and Measures for Early Recovery and
Rehabilitation
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Appendix 4: Examples of data presented in a chairs
dashboard
The performance of each of the three clinical areas of stroke care can be
monitored, for example in the dashboard below, the Financial could display
the performance of TIA Services; Governance -Acute Stroke Services; and
Quality and Performance- Early Rehabilitation. It is then possible to
interrogate each of these dials further to investigate which aspects of care
are affecting overall performance.
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The performance of each of the targets in each of these three areas can also
be monitored as compliance rates with each bundle, presented as a
percentage.
For example, for TIA Services, Ambulance Performance could display the
compliance rate, as a percentage, of the First Contact Bundle; Emergency
Department could display Management of High Risk TIAs Bundle; GP Access
could display Management of Low Risk TIAs Bundle; and Waiting Times could
display compliance rate with Secondary Prevention Bundle.
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Each intervention within each bundle can also be presented as a run chart. This
allows more detailed interrogation of the data to find out how each aspect of care
within each bundle is performing. For example, what percentage of patients
presenting with a suspected TIA are given aspirin immediately.
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