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National Stroke Audit: a tool for change?
Abstract
To describe the standards of care for stroke patients in England, Wales and Northern Ireland and to determine the power of national audit, coupled with an active dissemination strategy to effect change.
A national audit of organisational structure and retrospective case note audit, repeated within 18 months. Separate postal questionnaires were used to identify the types of change made between the first and second round and to compare the representativeness of the samples.
157 trusts (64% of eligible trusts in England, Wales, and Northern Ireland) participated in both rounds.
5589 consecutive patients admitted with stroke between 1 January 1998 and 31 March 1998 (up to 40 per trust) and 5375 patients admitted between 1 August 1999 and 31 October 1999 (up to 40 per trust). Audit tool-Royal College of Physicians Intercollegiate Working Party stroke audit.
The proportion of patients managed on stroke units rose between the two audits from 19% to 26% with the proportion managed on general wards falling from 60% to 55% and those managed on general rehabilitation wards falling from 14% to 11%. Standards of assessment, rehabilitation, and discharge planning improved equally on stroke units and general wards, but in many aspects remained poor (41% formal cognitive assessment, 46% weighed once during admission, 67% physiotherapy assessment within 72 hours, 24% plan documented for mood disturbance, 36% carers' needs assessed separately).
Nationally conducted audit linked to a comprehensive dissemination programme was effective in stimulating improvements in the quality of care for patients with stroke. More patients are being managed on stroke units and multidisciplinary care is becoming more widespread. There remain, however, many areas where standards of care are low, indicating a need for investment of skills and resources to achieve acceptable levels.
... Clinical audit in UK hospitals has adopted these objective, criterion-based approaches, [23][24][25] using explicit standards that are not profession dependent and have shown, for example, substantial variations in organisation and clinical care between hospitals. 23 Nevertheless, criterion-based review has been criticised as an insensitive method that may not identify unexpected factors that might influence outcomes of care, 26,27 so that implicit review may have still retain some advantages. ...
... Clinical audit in UK hospitals has adopted these objective, criterion-based approaches, [23][24][25] using explicit standards that are not profession dependent and have shown, for example, substantial variations in organisation and clinical care between hospitals. 23 Nevertheless, criterion-based review has been criticised as an insensitive method that may not identify unexpected factors that might influence outcomes of care, 26,27 so that implicit review may have still retain some advantages. In some North American studies mixed methods have been adopted, 6,9 where nurses used criterion-based review to identify a subset of problematic cases for subsequent holistic review by doctors, although this two-stage approach carries a risk of hindsight bias, such that those cases identified as problematic by nurses might be reviewed more harshly by the physicians. ...
... People with heart failure often have repeated episodes of hospital readmission. To support our choice of heart failure as one of the two study conditions, we took into account the availability of an evidence-based guideline, 23 together with a limited set of audit review criteria that had recently become available from NICE and was produced by the RCP Clinical Effectiveness and Evaluation Unit (RCP CEEu). The guideline and review criteria also provided a basis for developing, within the study, an externally referenced set of review criteria for safety and quality assessment for heart failure management. ...
Objectives:
To determine which of two methods of case note review--holistic (implicit) and criterion-based (explicit)--provides the most useful and reliable information for quality and safety of care, and the level of agreement within and between groups of health-care professionals when they use the two methods to review the same record. To explore the process-outcome relationship between holistic and criterion-based quality-of-care measures and hospital-level outcome indicators.
Data sources:
Case notes of patients at randomly selected hospitals in England.
Review methods:
In the first part of the study, retrospective multiple reviews of 684 case notes were undertaken at nine acute hospitals using both holistic and criterion-based review methods. Quality-of-care measures included evidence-based review criteria and a quality-of-care rating scale. Textual commentary on the quality of care was provided as a component of holistic review. Review teams comprised combinations of: doctors (n = 16), specialist nurses (n = 10) and clinically trained audit staff (n = 3) and non-clinical audit staff (n = 9). In the second part of the study, process (quality and safety) of care data were collected from the case notes of 1565 people with either chronic obstructive pulmonary disease (COPD) or heart failure in 20 hospitals. Doctors collected criterion-based data from case notes and used implicit review methods to derive textual comments on the quality of care provided and score the care overall. Data were analysed for intrarater consistency, inter-rater reliability between pairs of staff using intraclass correlation coefficients (ICCs) and completeness of criterion data capture, and comparisons were made within and between staff groups and between review methods. To explore the process-outcome relationship, a range of publicly available health-care indicator data were used as proxy outcomes in a multilevel analysis.
Results:
Overall, 1473 holistic and 1389 criterion-based reviews were undertaken in the first part of the study. When same staff-type reviewer pairs/groups reviewed the same record, holistic scale score inter-rater reliability was moderate within each of the three staff groups [intraclass correlation coefficient (ICC) 0.46-0.52], and inter-rater reliability for criterion-based scores was moderate to good (ICC 0.61-0.88). When different staff-type pairs/groups reviewed the same record, agreement between the reviewer pairs/groups was weak to moderate for overall care (ICC 0.24-0.43). Comparison of holistic review score and criterion-based score of case notes reviewed by doctors and by non-clinical audit staff showed a reasonable level of agreement (p-values for difference 0.406 and 0.223, respectively), although results from all three staff types showed no overall level of agreement (p-value for difference 0.057). Detailed qualitative analysis of the textual data indicated that the three staff types tended to provide different forms of commentary on quality of care, although there was some overlap between some groups. In the process-outcome study there generally were high criterion-based scores for all hospitals, whereas there was more interhospital variation between the holistic review overall scale scores. Textual commentary on the quality of care verified the holistic scale scores. Differences among hospitals with regard to the relationship between mortality and quality of care were not statistically significant.
Conclusions:
Using the holistic approach, the three groups of staff appeared to interpret the recorded care differently when they each reviewed the same record. When the same clinical record was reviewed by doctors and non-clinical audit staff, there was no significant difference between the assessments of quality of care generated by the two groups. All three staff groups performed reasonably well when using criterion-based review, although the quality and type of information provided by doctors was of greater value. Therefore, when measuring quality of care from case notes, consideration needs to be given to the method of review, the type of staff undertaking the review, and the methods of analysis available to the review team. Review can be enhanced using a combination of both criterion-based and structured holistic methods with textual commentary, and variation in quality of care can best be identified from a combination of holistic scale scores and textual data review.
... 7,12 Clinical record audits use pre-recorded patient medical documentation as the primary source of information 13 and are commonly used to measure adherence to stroke guideline recommendations. 2,3,14 Little is known about allied health clinicians' adherence with implementing recommendations from clinical guidelines. A systematic review identified only 1 study investigating allied health clinicians' implementation of recommendations from clinical guidelines. ...
Objective
To design and establish reliability of a local stroke audit tool by engaging allied health clinicians within a privately funded hospital.
Methods
Design: Two‐stage study involving a modified Delphi process to inform stroke audit tool development and inter‐tester reliability. Participants: Allied health clinicians. Interventions: A modified Delphi process to select stroke guideline recommendations for inclusion in the audit tool. Reliability study: 1 allied health representative from each discipline audited 10 clinical records with sequential admissions to acute and rehabilitation services. Main Outcome Measures: Recommendations were admitted to the audit tool when 70% agreement was reached, with 50% set as the reserve agreement. Inter‐tester reliability was determined using intra‐class correlation coefficients (ICCs) across 10 clinical records.
Results
Twenty‐two participants (92% female, 50% physiotherapists, 17% occupational therapists) completed the modified Delphi process. Across 6 voting rounds, 8 recommendations reached 70% agreement and 2 reached 50% agreement. Two recommendations (nutrition/hydration; goal setting) were added to ensure representation for all disciplines. Substantial consistency across raters was established for the audit tool applied in acute stroke (ICC .71; range .48 to .90) and rehabilitation (ICC.78; range .60 to .93) services.
Conclusions
Allied health clinicians within a privately funded hospital generally agreed in an audit process to develop a reliable stroke audit tool. Allied health clinicians agreed on stroke guideline recommendations to inform a stroke audit tool. The stroke audit tool demonstrated substantial consistency supporting future use for service development. This process, which engages local clinicians, could be adopted by other facilities to design reliable audit tools to identify local service gaps to inform changes to clinical practice.
... These data can be used to influence the commissioning of local and specialised AAC services within the UK and elsewhere as they provide evidence to support the identification of a level of need within a population. National audit can also be a tool for promoting service improvement (17) and it is also hoped that the survey developed for this study can be used to form the basis of a regular audit of AAC service provision. ...
BACKGROUND: Provision of Augmentative and Alternative Communication (AAC) interventions have been acknowledged to be highly variable in England and elsewhere. OBJECTIVE: The aim of the project described in this paper was to provide data to inform service planning and delivery of services delivering AAC including communication aids. METHODS: A survey was developed by an expert group and administered by telephone interview to service managers of primary and secondary services providing AAC interventions at a local level in England and data were included from two hundred and twenty respondents. RESULTS: Services included had mean caseload sizes of 0.09% of the catchment population for AAC provision, with a mean of 0.017% of the catchment population for high tech communication aids. Significantly higher levels of caseload and spend were reported for services working with children and young people as compared to those working with adults. Mean levels of unmet need for AAC equating to approximately one in every eight individuals on services' caseloads were reported. CONCLUSIONS: Although these data should be treated with caution, they suggest a significant level of variation of provision of AAC by local services.
... Z założenia pacjent oceniany jest 2 godziny po leczeniu, 24 godziny od wystąpienia pierwszych objawów, 7-10 dni i 3 miesiące po incydencie udarowym. Możliwa jest również ocena w innym czasie [39]. ...
The basis of modern general and psychiatric care should be the serving help according to patients' need. The analysis of the patient-oriented services demonstrates the high therapeutic effectiveness and considerable economic benefits. Comprehending the need in the course of years was being defined to a lot of ways. This diversity of epithets can suggest both diversifying human needs, as well as is pointing on various prospects taking this topic up. In order to uncover needs of patients a lot of diagnostic tools were being created. Straighter leaned on measuring malfunction up and symptomatology. They were replaced by these tools which let on widely assessment of many areas of the patient's life and examining his needs, and farther also given to the quality of services. Unfortunately the majority of questionnaire forms to date constructed was adapted for persons in the age till 65 yrs. what was a major limitation of applying them. Specificity of somatic and psychological complaints pointed out by older persons after 65 yrs. and differences of problems connected with existing in the society shows a necessity of use questionnaire forms appropriately created. Creating the multidisciplinary tool serving for diagnosing of the elderly patients' needs with somatic diseases requires further research.
... Z założenia pacjent oceniany jest 2 godziny po leczeniu, 24 godziny od wystąpienia pierwszych objawów, 7-10 dni i 3 miesiące po incydencie udarowym. Możliwa jest również ocena w innym czasie [39] CarenapD to multidyscyplinarne narzędzie oceny potrzeb dla osób z demencją mieszkających w społeczeństwie oraz ich opiekunów. Oceny dokonywano w różnych miejscach, w tym: w domach opieki społecznej, wśród pracowników środowiskowych zajmujących się opieką nad osobami z demencją, w oddziałach dziennych i stacjonarnych. ...
... In acute stroke, positive associations between the alignment with recommended stroke management and health outcomes have been documented (Hubbard et al 2012). Research conducted in countries such as the United Kingdom (UK) (Hammond et al 2005, Roberts et al 2000, Rudd et al 2007, Rudd et al 1999, Rudd et al 2001, Walsh et al 2009, Wolfe et al 1997), Australia (Cadilhac et al 2004, Harris et al 2010, Hubbard et al 2012, Luker and GrimmerSomers 2009) and New Zealand (Gommans et al 2003, Gommans et al 2008) concludes that standards of stroke care could be more aligned with guidelines. However, these studies refer to the stroke management provided by Australian and UK rehabilitation units and cannot be easily generalised to a New Zealand setting. ...
Clinical guidelines provide a summary of published research to aid the delivery of evidence-based health care. Although alignment with clinical guidelines is associated with positive outcomes in stroke care, there is a lack of evidence to show that physiotherapy management is aligned with the New Zealand Clinical Guidelines for Stroke Management 2010. A retrospective audit was performed on the clinical records of 101 patients discharged from a public hospital in the Auckland region with a diagnosis of stroke in 2012. Issues of management were identified and recorded as in alignment with the guidelines or not. Results showed wide variation in areas of alignment. The highest overall alignment was for management of shoulder pain (100%) and follow up physiotherapy (99%). The alignment with guidelines for activity related limitations (sitting balance, sit to stand, standing balance, walking/mobility, difficulties with activities of daily living, and upper limb functional deficits) were consistently addressed, with a focus on lower limb function and mobility. Recommendations with lower levels of evidence and for issues which do not appear to be a primary functional problem had lower alignment. Ongoing audit cycles would be useful to provide setting specific information of stroke management for improving stroke care. Johnston J, Mudge S, Kersten P, Jones A (2013) Physiotherapy alignment with guidelines for the management of stroke in the inpatient setting New Zealand Journal of Physiotherapy 41(3): 102-111.
... No obstante, la existencia de las GPC no garantiza su implementación, por lo que se han desarrollado múltiples métodos para asegurar la utilización de las mismas en la práctica clínica 5 . La realización de auditorías periódicas que registren la incorporación de recomendaciones específicas de una GPC y la comunicación activa de sus resultados son algunos de los métodos propuestos 6,7 . Diversas experiencias pueden servir de referencia, como el programa Get With The Guidelines-Stroke (GWTG-stroke), para la mejora de la adherencia a determinados estándares de calidad en los EUA 8 , o el National Sentinel Audit of Stroke que periódicamente evalúa la calidad de la atención hospitalaria del paciente con ictus en Gran Bretaña 9 . ...
Objectives
To define a core set of evidence-based performance indicators (PIs) for the assessment of in-hospital stroke care quality by means of consensus prioritisation by a panel of experts representing stroke care professionals in three Autonomous Communities (Catalonia, Aragon and Balearic Islands).
... Facilitation of improvements. A national clinical audit should adopt and implement a framework for spread of good practice [72,73], identify what works best among improvement initiatives and encourage the rapid adoption of those initiatives [13,54,55,74]. The national audit should create and market practical tools to help healthcare organizations improve their performance [13,28,75]. ...
Purpose:
The purposes were to find and synthesize available literature on explicit or implicit standards for the design and conduct of a national activity that involves measuring and facilitating improvement of the quality of patient care, such as a national clinical audit or a quality improvement (QI) study, and to develop proposed standards for the design and conduct of the national activity. DATA SOURCES, SELECTION AND ANALYSIS: The literature was searched to identify key aspects of good practice in the conduct of national or international clinical audits, QI studies, performance or quality indicator measurements or equivalent national initiatives that have the purpose of driving improvement in the quality of care provided in a healthcare system. Key aspects of good practice in design or operation of these activities were abstracted from the literature, and organized logically into standard statements according to the stages in the design or conduct of such an activity.
Results:
Thirty standards for the design and conduct of a national clinical audit or QI study were derived from the published literature. The standards are on structural, process and outcome aspects of any national activity that involves measuring and improving healthcare services. Most of the standards focus on measurement processes.
Conclusion:
It is hoped that these proposed standards for a national clinical audit or QI study will facilitate debate on how to assure the quality of these national activities. Activities that meet accepted standards may be more effective in influencing participating sites to achieve improvements in the quality of care.
... In this paper we describe the design of the first ever national clinical audits of occupational health (OH) care for National Health Service (NHS) staff in England. Some of the methodology builds on that used in the more established clinical specialties, such as stroke [3], and some we developed specifically to address the complexities of OH service design and case management. ...
Rationale, aims and objectives:
Little is known about the quality of occupational health care provided to National Health Service (NHS) staff. We designed the first national clinical audits of occupational health care in England. We chose to audit depression and back pain as health care workers have high levels of both conditions compared with other employment sectors. The aim of the audits was to drive up quality of care for staff with these conditions. The object of this paper is to describe how we developed an audit methodology and overcame challenges presented by the organization and delivery of occupational health care for NHS staff.
Methods:
We designed two retrospective case note audits which ran simultaneously. Sites submitted up to 40 cases for each audit. We used duplicate case entry to test inter-rater reliability and performed selection bias checks. Participants received their site's audit results, benchmarked against the national average, within 4 months of the end of the data entry period. We used electronic voting at a results dissemination conference to inform implementation activities.
Results:
Occupational Health departments providing services to 278 (83%) trusts in England participated in one or both audits. Median kappa scores were above 0.7 for both pilot and full audits, indicating 'good' levels of inter-rater reliability. In total, 79% of participants at a dissemination conference said that they had changed their clinical practice either during data collection (52%) or following receipt of their audit results (27%).
Conclusions:
Clinical audit can be conducted successfully in the occupational health setting. We obtained meaningful data that have stimulated local and national quality improvement activities. Our methodology would be transferable to occupational health settings outside the NHS and in other countries.
... These have been used to identify substantial variations in organisation and clinical care between hospitals. 12 However, criterion-based review has been criticised as being insensitive 15 and may not identify unexpected factors influencing outcomes of care. 16 Mixed methods are an alternative, 17 18 whereby nurses use criterion-based review to identify a subset of problematic cases for subsequent holistic review by doctors; however, prior selection may lead to hindsight bias among the physician reviewers who may judge selected cases more harshly. ...
To determine which of the two methods of case note review provide the most useful and reliable information for reviewing quality of care.
Retrospective, multiple reviews of 692 case notes were undertaken using both holistic (implicit) and criterion-based (explicit) review methods. Quality measures were evidence-based review criteria and a quality of care rating scale.
Nine randomly selected acute hospitals in England.
Sixteen doctors, 11 specialist nurses and three clinically trained audit staff, and eight non-clinical audit staff. ANALYSIS METHODS: Intrarater consistency, inter-rater reliability between pairs of staff using intraclass correlation coefficients (ICCs), completeness of criterion data capture and between-staff group comparison.
A total of 1473 holistic reviews and 1389 criterion-based reviews were undertaken. When the three same staff types reviewed the same record, holistic scale score inter-rater reliability was moderate within each group (ICC 0.46 to 0.52). Inter-rater reliability for criterion-based scores was moderate to good (ICC 0.61 to 0.88). Comparison of holistic review score and criterion-based score of case notes reviewed by doctors and by non-clinical audit staff showed a reasonable level of agreement between the two methods.
Using a holistic approach to review case notes, same staff groups can achieve reasonable repeatability within their professional groups. When the same clinical record was reviewed twice by the doctors, and by the non-clinical audit staff, using both holistic and criterion-based methods, there are close similarities between the quality of care scores generated by the two methods. When using retrospective review of case notes to examine quality of care, a clear view is required of the purpose and the expected outputs of the project.
... A good example of this is the UK initiative of monitoring the quality of stroke care and services through a series of national audits commissioned by the National Health System. [1][2][3][4][5] In line with the UK stroke audits, other experiences have been reported. 6 -8 In addition to the need of monitoring quality of stroke services, it is crucial to ensure that knowledge from recent research studies is made available to everybody and is definitely translated into clinical practice. ...
Evidence-based standards are used worldwide to determine quality of care. We assessed quality of in-hospital stroke care in all acute-care hospitals in Catalonia by determining adherence to 13 evidence-based performance measures (PMs) of process of care.
Data on PMs were collected by retrospective review of medical records of consecutive stroke admissions (January to June, 2005). Compliance with PMs was calculated according to 3 hospital levels determined by their annual stroke case-load (level 1, <150 admissions/yr; level 2, 150 to 350; and level 3, >350). We defined sampling weights that represented each patient's inverse probability of inclusion in the study sample. Sampling weights were applied to produce estimates of compliance. Factors that predicted good/bad compliance were determined by multivariate weighted logistic regression models. An external monitoring of 10% of cases recruited at each hospital was undertaken, after random selection, to assess quality of data.
We analyzed data from 1791 stroke cases (17% of all stroke admissions). Global interobserver agreement was 0.7. Eight PMs achieved compliances >or=75%, 4 of which were more than 90%, and the remaining showed adherences <or=62%. Analysis of compliance across hospital levels displayed some significant differences that persisted after multivariate analysis. We observed lower adherences to "early mobilization," "assessment of rehabilitation needs," and "prescription of anticoagulants for atrial fibrillation" in females and in the elderly.
In 2005, in-hospital stroke care in Catalonia was heterogeneous across hospital levels. Rehabilitation-related measures showed poor compliances compared to acute care-related ones, which achieved more satisfactory adherences.
... To try to avoid the failure of this policy, at the very least, it is necessary to build effective methods for monitoring the quality of care into service development. They could use the National Sentinel audit for stroke care as an example [9], which has been helpful in developing local standards [10] and for making national comparisons of care [11]. But more than this is needed. ...
Health care systems of today did not evolve to provide optimum care to an ageing population. The philosophies that shaped the United Kingdom's (UK's) response to disease drew on the perceived health care needs in the 19th and early 20th century, and were crystalised into the formation of the UK National Health Service (NHS) in the mid-20th century. In those days, life was reletavely brutish and often quite short, illness was acute, severe and potentially life threatening.
... Unexpectedly, functional recovery was quicker and quality of life better in the group of patients receiving conventional care. The National Sentinel Stroke Audit has shown that patients managed on stroke units are more likely to receive beneficial interventions than those on general wards [11]. In this issue of Age and Ageing, Sulch and colleagues speculate that this improved outcome relates to better processes of care [12]. ...
... The serial national audits of stroke care have shown that hospital staff are rarely aware of the problems identified, but once alerted are keen to improve and prove that improvement is possible. 27 If this study could be repeated across multiple sites to yield some benchmark figures, it would add more objective data against which changes in organisation could be planned and assessed. ...
In this retrospective pilot study we examine the feasibility of establishing a confidential enquiry into why some patients die after emergency admission to hospital. After excluding those who died in the first hour or who were admitted for palliative care, pairs of physicians were able to collect quantitative and qualitative data on 200 consecutive deaths. Both physicians reported shortfalls of care in 14 patients and one of the pair in 25 patients whose deaths would not have been the expected outcome. In 25, the shortfalls of care may have contributed to their deaths. Major problems were delays in seeing doctors, inaccurate diagnoses, delays in investigations and initiation of treatment. They occurred mostly in those admitted at night. It is possible that establishing the correct diagnosis and starting appropriate treatment may have been delayed in 64% of the 200 patients. The headline figures appear worse than some previous external assessment studies but this study did concentrate on those in whom problems were more likely. Nevertheless, the frequency is too high to be overlooked. In this feasibility study we have demonstrated that it is practicable for local staff to collect and assess data in hospitals and that the types of problems identified are relevant to anyone planning how to organise emergency care. A larger definitive study should be performed.
... The hospital trust responsible for the stroke unit was rated in the top third of the three National Sentinel Audits for Stroke in 1998, 1999 and 2001 . 18,19 Ethical approval for the trial was obtained from the local research ethics committee. ...
Objectives: To evaluate the effectiveness of an education programme for patients and carers recovering from stroke.
Design: Randomized controlled trial.
Subjects and setting: One hundred and seventy patients admitted to a stroke rehabilitation unit and 97 carers of these patients.
Interventions: The intervention group received a specifically designed stroke information manual and were invited to attend education meetings every two weeks with members of their multidisciplinary team. The control group received usual practice.
Measures: Primary outcome was knowledge of stroke and stroke services. Secondary outcomes were handicap (London Handicap Scale), physical function (Barthel Index), social function (Frenchay Activities Index), mood (Hospital Anxiety and Depression Scale) and satisfaction (Pound Scale). Carer mood was measured by the General Health Questionnaire-28.
Results: There was no statistical evidence for a treatment effect on knowledge but there were trends that favoured the intervention. The education programme was associated with a significantly greater reduction in patient anxiety score at both three months (p=0.034) and six months (p=0.021) and consequently fewer ‘cases’ (Hospital Anxiety and Depression Scale anxiety subscale score ≥ 11). There were no other significant statistical differences between the patient or carer groups for other outcomes, although there were trends in favour of the education programme.
Conclusion: An education programme delivered within a stroke unit did not result in improved knowledge about stroke and stroke services but there was a significant reduction in patient anxiety at six months post stroke onset.
Background
Despite advances in the quality of acute stroke management, there are gaps in knowledge about effective support interventions to better manage the transition of care to home for patients with this complex condition. The goal of this systematic review is to explore the literature around support interventions available for patients as they navigate from acute hospital, rehabilitation or early supported discharge (ESD) services to independent living at home; and to establish if, in comparison with usual care or other comparative active interventions, support services offered to patients as they transition from acute hospital, inpatient rehabilitation/ESD to home, can achieve better patient and / or process outcomes.
Protocol
In June 2021, we will carry out, on electronic peer-reviewed databases, a comprehensive literature search based on a pre-defined search strategy, developed and conducted in collaboration with an Information Specialist. In an effort to identify all published trials we will perform citation tracking of included studies, check reference lists of relevant articles, review grey literature, and extend our search to google scholar.
We will include randomised controlled trials (including cluster and quasi-randomisation) recruiting stroke patients transitioning to home, to receive either usual care or any support intervention designed to improve outcomes after stroke.
The primary clinical outcome will be functional status. Two review authors will scrutinise trials, categorise them on their eligibility, and extract data. We will analyse the results for all trials and perform meta-analyses where possible. We will assess risk of bias for the included trials and use GRADE to assess the quality of the body of evidence.
Patient and public involvement (PPI) engaged in the development of the research questions, and will participate in co-design of a strategy for dissemination of findings.
Conclusions: The findings from this review will be used to identify knowledge gaps to direct future research.
Background
Despite advances in the quality of acute stroke management, there are gaps in knowledge about effective support interventions to better manage the transition of care to home for patients with this complex condition. The goal of this systematic review is to explore the literature around support interventions available for patients as they navigate from acute hospital, rehabilitation or early supported discharge (ESD) services to independent living at home; and to establish if, in comparison with usual care or other comparative active interventions, support services offered to patients as they transition from acute hospital, inpatient rehabilitation/ESD to home, can achieve better patient and / or process outcomes.
Protocol
In September 2021, we will carry out, on electronic peer-reviewed databases, a comprehensive literature search based on a pre-defined search strategy, developed and conducted in collaboration with an Information Specialist. In an effort to identify all published trials we will perform citation tracking of included studies, check reference lists of relevant articles, review grey literature, and extend our search to google scholar.
We will include randomised controlled trials (including cluster and quasi-randomisation) recruiting stroke patients transitioning to home, to receive either usual care or any support intervention designed to improve outcomes after stroke.
The primary clinical outcome will be functional status. Two review authors will scrutinise trials, categorise them on their eligibility, and extract data. We will analyse the results for all trials and perform meta-analyses where possible. We will assess risk of bias for the included trials and use GRADE to assess the quality of the body of evidence.
Patient and public involvement (PPI) engaged in the development of the research questions, and will participate in co-design of a strategy for dissemination of findings.
Conclusions: The findings from this review will be used to identify knowledge gaps to direct future research.
This chapter discusses a dissemination and sustainability strategy for the Liverpool Care Pathway for the Dying Patient (LCP) programme in incorporating a model for national audit for care of the dying. It first takes the national clinical audit in context before considering the impact of national clinical audit. It shows that the measurement of quality to drive sustained improvement is important for a high-performing healthcare system, and that data can be a powerful tool for improving quality of care.
The known early intervention opportunities in cerebrovascular events (CVE), not only from the medical point of view but from rehabilitation, create the necessity of moving forward in the formulation of clinical performance indicators in the hospitalary physiotherapeutic management of a person with a CVE. Objective: to identify the physiotherapeutic clinical performance indicators in the early hospitalary management of people surviving CVE. Materials and methods: this is about a descriptive exploratory study investigating about the existing physiotherapeutic tests and practices, the scientific evidence about clinical indicators in CVE, the standard indicators and the possible clinical indicators in this setting. We conducted systematic review of descriptive studies, clinical practice guidelines, systematic reviews, clinical case study in evidence-based databases such as Pubmed, Proquest, Peter and electronic journals, plus analysis of data epidemiological
prevalence of stroke in Colombia and Chile, on websites of the World Health Organization, Ministry of Health and National Bureau of each country respectively. Results: the
evidence points out that early rehabilitation of CVE should be initiated during hospitalization, as soon as the diagnosis is made and the life threatening issues are controlled. Priorities in the CVE therapeutic interventions are to prevent: complications (venous thrombosis, infections and pain) and to facilitate the early mobilization. The latest updates to these directives include early rehabilitation, particularly mobilization within 24 hours after the CVE occurrence. Proves supporting performance indicators in rehabilitation for the assistance in the sub-acute stage of CVE are limited. Conclusions: it is evident the importance of early intervention physical therapy in the acute process of patients with stroke as the evidence stands a better prognosis for patients who are operated on by the area within the first 24 hours after the event and the importance of patient care indicators such as quality of care, attention span, timing and use of intervention within the time window acute recovery.
Hyper-acute stroke units (HASUs) admit all stroke patients across London. As a novel London stroke model, the integration of thrombolysis in acute ischaemic stroke is an important element of hyper-acute stroke care for patients. In this model, nurses working in a hyper-acute stroke unit are involved in the delivery of thrombolysis treatment. By use of a phenomenological approach, the study investigates the 'lived experiences' of nurses' preparation for their role and explores any factors that affect nurses' participation in thrombolysis treatment. The nurses' roles-which facilitate, support, monitor, anticipate and result in prevention-are central to effective thrombolysis treatment. However, factors such as communication, teamwork, clinical decision, training, staffing and safety affect their thrombolysis roles. Addressing factors that affect nurses' thrombolysis roles could lead to improved communication, collaborative teamwork and better patient outcomes.
Stroke is a common and devastating disease and, until very recently, was largely unrecognised as a -preventable or treatable condition. Between 1998 and 2010, the National Sentinel Stroke Audit (NSSA) achieved 100% voluntary participation, collecting data on more than 60,000 patients from stroke services within England, Wales and Northern Ireland and becoming a benchmark for hospital stroke services. In this way it has informed stroke improvement at the local, regional and national levels and has overseen a radical change in stroke care within the NHS. This article describes the achievements of the NSSA and the -lessons learned.
What is high-quality healthcare? And how can we distinguish between
hospitals that perform well and those that do not?
Over recent years, the urgency of such questions has increased. Only two
decades ago, physicians had a social mandate to judge and manage quality
of care. But the new quest for transparency means that medical practice is
now scrutinised critically by a wide range of stakeholders.
So how should quality of care be evaluated? As better patient outcomes are
the ultimate aim of quality-of-care measurements, outcome measures (such
as hospital mortality) are attractive. But they are complicated by two
major methodological problems: statistical uncertainty and differences in
patient population between hospitals.
This thesis presents methods to tackle these problems, applying them to
acute neurological diseases, including traumatic brain injury, stroke,
Guilllain-Barre syndrome, and subarachnoid haemorrhage.
Clinical audit is defined the quality assurance method that aims to improve the delivery of health care. During the systematic review of the provided heath care, specific criteria may guide the process of reflection. Structures, processes and intervention outcomes, in their vary ing forms, are evaluated and examined in relation to chosen criteria and standards of care. The mechanism and the philosophy of clinical audit were developed in a wider spectrum of reforms for a better and more reliable National System of Health (NHS) in the UK. The audit cycle has been described as a process that may answer questions such as the following: what should be happening? what actually happens? what changes are indicated? It is apparent that it is essential to adopt a structured and objective
assessment of clinical practice. Indeed, clinical audit facilitates this sort of evaluation and may contribute to the improvement in service delivery of health care. The environment is highlighted as instrumental in the success of clinical audit. Clinical audit facilitates the objective review of the quality of the delivery of health care, through a process that is both encouraging and developmental.
Resumen
Objetivo
Analizar la calidad de la atención hospitalaria al paciente con ictus en los hospitales públicos catalanes antes de la difusión de la Guía de Práctica Clínica (GPC) del ictus, estudiando el grado de adhesión a determinadas recomendaciones de la GPC.
Métodos
Mediante revisión retrospectiva de historias clínicas de pacientes con ictus definidos mediante los códigos CIE-9 431, 433.×1, 434.×1, 436, e ingresados consecutivamente en 48 hospitales públicos catalanes en el primer semestre de 2005, se recogió información sobre distintos indicadores del proceso asistencial al ictus seleccionados según su evidencia científica o su importancia clínica. Los hospitales participantes reclutaron 20, 40 o 60 casos, según el número de ingresos/ año. Se llevó a cabo una auditoría externa en el 9,3% de los casos reclutados en cada centro, tras selección aleatoria, para determinar la calidad de los datos recogidos. Los indicadores se agruparon en 6 perfiles relacionados con diferentes aspectos de la práctica clínica.
Resultados
Se incluyeron 1.791 casos, un 53,9% hombres, con una media (desviación estándar) de edad de 75,6 (12,4) años. La concordancia global entre observadores fue de 0,7. El cumplimiento de los perfiles asistenciales (porcentaje medio [intervalo de confianza del 95%]) fue: calidad de la historia clínica, 78,5% (77,5-79,4); estándares de atención básica, 92,4% (91,5-93,2); evaluación neurológica, 38,3% (37,3-39,3); medidas iniciales del tratamiento rehabilitador, 44,9% (43,2-46,7); prevención y manejo de complicaciones, 68,4% (66,9-70), y medidas preventivas iniciales, 78,9% (77,3-80,4).
Conclusiones
En 2005 la atención hospitalaria al ictus era mejorable, sobre todo los aspectos relacionados con la evaluación y el seguimiento neurológico del paciente y la rehabilitación.
Hintergrund und Zielsetzung: Bislang gibt es in Deutschland nur wenige Vergleiche bezüglich der Unterschiede in der Schlaganfallbehandlung zwischen verschiedenen Fachrichtungen. Das Ziel der vorliegenden Studie war deshalb die Untersuchung von Art und Umfang der eingesetzten Diagnostik bei der Akutbehandlung von Schlaganfallpatienten in neurologischen, internistischen und geriatrischen Abteilungen. Methodik: In den Analysen wurden alle Schlaganfallpatienten berücksichtigt, die zwischen 1. Januar 2000 und 31. Dezember 2001 innerhalb des Schlaganfallregisters Westfalen-Lippe dokumentiert wurden. Insgesamt nahmen an der Studie 42 Kliniken teil, darunter 24 neurologische, 13 internistische und fünf geriatrische Abteilungen. Klinische und soziodemographische Merkmale, durchgeführte Diagnostik und Therapie, aufgetretene Komplikationen sowie der Entlassungsstatus wurden standardisiert dokumentiert. Als diagnostischer Standard, der die Diagnose und ätiologische Klärung eines Hirninfarktes erlaubt, wurde die Durchführung eines bildgebenden Verfahrens des Gehirns, einer transthorakalen oder transösophagealen Echokardiographie sowie einer dopplersonographischen Untersuchung der hirnversorgenden Gefäße definiert. Ergebnisse: Insgesamt wurden 12 232 Schlaganfallpatienten in die Analysen einbezogen, das Durchschnittsalter betrug im Median 72 Jahre, 49 % waren Männer. Die Mehrzahl der untersuchten diagnostischen Methoden wurde häufiger in neurologischen, verglichen mit internistischen bzw. geriatrischen Abteilungen angewandt. Insgesamt wurden in allen Kliniken mit zunehmenden Alter der Patienten weniger diagnostische Untersuchungen durchgeführt. In neurologischen Abteilungen mit einer Stroke Unit erhielten Patienten nach Hirninfarkt häufiger den von uns definierten diagnostischen Standard verglichen mit Einrichtungen ohne Stroke Unit. Schlussfolgerung: In unserer Studie zeigten sich Unterschiede in Art und Umfang diagnostischer Maßnahmen nach Hirninfarkt zwischen verschiedenen Fachrichtungen. Ob eine häufigere Anwendung diagnostischer Maßnahmen auch relevante therapeutische Konsequenzen nach sich zieht, muss allerdings in weiteren Studien geklärt werden.
Background:
The results of three rounds of National Stroke Audit in England, Wales and Northern Ireland are compared.
Methods:
Audit of the organization of stroke services and retrospective case-note audit of up to 40 consecutive cases admitted per hospital over a 3-month period was conducted in each of 1998, 1999 and 2001/02. The changes in the organizational, case-mix and process results of the hospitals that had participated in all three rounds were analysed.
Results:
60% of all eligible trusts from England, Wales and Northern Ireland took part in all three audits in 1998, 1999 and 2001/02. Total numbers of cases were 4996, 4841 and 5152, respectively. Case-mix variables were similar over the three rounds. Mortality at 7 and 30 days fell by 3% and 5%, respectively. The proportion of hospitals with a stroke unit rose from 48% to 77%. The proportion of patients spending most of their stay in a stroke unit rose from 17% in 1998 to 26% in 1999 and 29% in 2001/02. Improvements achieved in process standards of care between 1998 and 1999 (median change was a gain of 9%) failed to improve further by 2001/02 (median change was 0%). In all three rounds process standards of care tended to be better in stroke units.
Conclusions:
Three rounds of national audit of stroke care have shown standards of care on stroke units were notably higher than on general wards. Slowing in the rise of the proportion managed on stroke units mirrors the slow down in improvement to overall national standards of care. To further improve outcomes and national standards of stroke care a much higher proportion of patients needs to be managed in stroke units.
Rationale, aims and objectives The randomized controlled trial (RCT) is considered the gold standard methodology for determining the efficacy and tolerability of new treatments. However, RCTs cannot provide information on the effectiveness of interventions as they are used in real life. This study was conducted to investigate the effectiveness of montelukast, a leukotriene receptor antagonist, in the real-world management of asthma, through a large-scale, retrospective, observational study: the National Montelukast Survey.
Methods In order to ensure a robust methodology for the National Montelukast Survey we performed three pilot studies involving a total of almost 400 patients. During the pilots, the design of the study was extensively modified from a simple prescriber questionnaire used in the first pilot to the ‘triangulated’ methodology encompassing the perspectives of patient, prescriber and independent observer used in the National Montelukast Survey. Good levels of interobserver agreement confirmed the robustness of the final methodology.
Conclusions Achieving a robust methodology was dependent on the extensive piloting. It is possible to collect reliable observational data relating to treatment outcomes. We believe our methods are likely to have more widespread applicability and offer a potential improvement over postmarketing surveillance.
Rationale, aims and objectives Service provision and clinical outcomes for patients admitted with chronic obstructive pulmonary disease remain unacceptably variable despite guidelines and performance feedback of national audit, data. This study aims to assess the impact of mutual peer review on service improvement. The initial phase of this study was to assess the feasibility and determine the practicalities of delivering such a peer review programme on a large scale.
Methods All UK acute hospitals were invited to participate in a reciprocal peer review programme administered by a central team from three UK health organizations. Hospitals with the most resources were paired with those with the least (as defined in a baseline survey) and pairs randomized on a 3:2 basis into intervention or control groups. A number of key quality indicators were derived to measure service levels at the beginning and end of the study. Peer review teams included clinicians and managers from acute and primary care organizations and when possible a patient representative. Visits were focussed on four key areas of chronic obstructive pulmonary disease service. Teams were to agree service improvements and submit plans signed off by participants. Monthly change diaries were to be used to record progress towards agreed goals.
Results A total of 100 hospitals participated in the programme. Overall, 52 of 54 peer review visits took place within a 4-week time frame and all units submitted service improvement plans within an agreed time frame. Secondary care representatives participated in all visits, primary care in 30 but patients in only 17. The mean number of diaries returned was 2, but 94% of units returned initial and final versions.
Conclusions It is possible to deliver successful large-scale mutual peer review using a limited but focussed programme. Participation of patients and use of change diaries requires further evaluation.
Patient safety concerns have focused attention on organisational and safety cultures, in turn directing attention to the measurement of organisational and safety climates.
First, to compare levels of agreement between survey- and observation-based measures of organisational and safety climates/cultures and to compare both measures with criterion-based audits of the quality of care, using evidence-based markers drawn from national care standards relating to six common clinical conditions. (This required development of an observation-based instrument.) Second, to examine whether observation-based evaluations could replace or augment survey measurements to mitigate concerns about declining response rates and increasing social desirability bias. Third, to examine mediating factors in safety and organisational climate scores.
The study had three strands: (A) a postal questionnaire survey to elicit staff perceptions of organisational and safety climates, using six prevalidated scales; (B) semistructured non-participant observation of clinical teams; and (C) a retrospective criterion-based audit carried out by non-clinical auditors to minimise hindsight bias. Standardised summary scores were created for each strand, and pairs of measurements were compared (strand A with strand B, strand A with strand C, and strand B with strand C) using Bland-Altman plots to evaluate agreement. Correlations were also examined. Multilevel modelling of Strand A scores explored mediating factors.
Eight emergency departments and eight maternity units in England, UK.
None.
Examination of feasibility, correlation and agreement.
Strand A: the overall response rate was 27.6%, whereas site-specific rates ranged from 9% to 47%. We identified more mediating factors than previous studies; variable response rates had little effect on the results. Organisational and safety climate scores were strongly correlated (r = 0.845) and exhibited good agreement [standard deviation (SD) differences 0.449; 14 (88%) within ± 0.5; one large difference]. Two commonly used scales had high levels of positive responses, suggesting positive climates or social desirability bias. Strand B: scoring on a four-point scale was feasible. Observational evaluation of teamwork culture was good but too limited for evaluating organisational culture. Strand C: a total of 359-399 cases were audited per condition. The results varied widely between different markers for the same condition, so selection matters. Each site performed well on some markers but not others, with few consistent patterns. Some national guidelines were contested. Comparisons: the comparison of safety climate (survey) and teamwork culture (observation) revealed a moderately low correlation (r = 0.316) and good agreement [SD differences 1.082; 7 (44%) within ±0.5; one large difference]. The comparison of safety climate (survey) and performance (audit) revealed lower correlation (r = 0.150, i.e. relationship not linear) but reasonably good agreement [SD differences 0.992; 9 (56%) within ± 0.5; two large differences]. Comparisons between performance (audit) and both organisational climate (survey) and teamwork culture (observation) showed negligible correlations (< 0.1) but moderately good agreement [SD differences 1.058 and 1.241; 6 (38%) and 7 (44%) within ± 0.5; each with two large differences (at different sites)]. Field notes illuminated large differences.
Climate scores from staff surveys are not unduly affected by survey response rates, but increasing use risks social desirability bias. Safety climate provides a partial indicator of performance, but qualitative data are needed to understand discrepant results. Safety climate (surveys) and, to a lesser degree, teamwork culture (observations) are better indicators of performance than organisational climate (surveys) or attempts to evaluate organisational culture from time-limited observations. Scoring unobtrusive, time-limited observations to evaluate teamwork culture is feasible, but the instrument developed for this study needs further testing. A refined observation-based measure would be useful to augment or replace surveys.
The National Institute for Health Research Health Technology Assessment programme.
ObjectivesTo evaluate the use of a combined strategy (a nurse opinion-leader; evidence-based guidelines; a staff education programme and a new recording system) for the implementation of multidisciplinary stroke assessment in an acute hospital setting as measured by the compliance of different professional groups.DesignA quasi-experimental study design utilising a pre-test/post-test group.SettingNine medical wards in a 600 bedded outer London Acute NHS Trust (without a stroke unit).Participants190 stroke patients (n = 98 pre-test vs n = 92 post-test).Main outcome measuresProfessional compliance with assessment guidelines documented in the new recording system.ResultsPre-test compliance with guidelines (n40) ranged from 0% to 100% and post-test ranged from 23–100%. Significant improvements (p < .05) in compliance were found in relation to 25 guidelines and a significant decline was documented in four others. Comparison of pre vs post-test values demonstrated variable changes in compliance with guidelines across professional groups: medical (range −64–+23%); nursing (range +2–+74%); physiotherapy (range −15–+69%); occupational therapy (range 0–+34%).ConclusionThe combined use of an opinion leader, guidelines, education and a recording system had a variable affect on compliance with guidelines; opinion-leadership appeared to have the most influence over compliance. The study design, and guideline specific features may have constrained changes in practice.
Self-audit involves self-collection of personal performance data, reflection on gaps between performance and standards, and development and implementation of learning or quality improvement plans by individual care providers. It appears to stimulate learning and quality improvement, but few physicians engage in self-audit. The purpose of this study was to identify how self-audit has been operationalized; factors influencing self-audit conduct and outcomes, including program design; and issues warranting further research.
A systematic review of quantitative and qualitative studies was undertaken. Two individuals independently reviewed searches of indexed literature databases, tables of contents, and references of eligible studies. Data were extracted and tabulated to describe the nature and impact of self-audit programs.
Six studies evaluated the impact of self-audit programs. No program was based on a model or theory that informed its design. All studies showed improved compliance with care delivery guidelines and/or improved patient outcomes, although these findings were largely self-reported. Programs varied so features associated with benefit could not be identified.
Overall there is a need for guidance on all aspects of self-audit for both participants and leaders. This guidance would be useful to educators, professional associations, and medical certification bodies to plan, develop, implement, evaluate, and support self-audit programs. Further research should aim at developing training programs and tools that address and evaluate a variety of competencies across different disciplines using more rigorous research designs, including both quantitative and qualitative approaches.
Samandrag Masteroppgåva er ein del av prosjektet ”Bruk av Marevan (warfarin) i klinisk praksis”. Tidlegare er det gjennomført pilotstudie og spørjeundersøking blant pasientar som henta Marevan® frå apotek i Tromsø. Det er under utvikling eit verktøy (Anticoagulation Tool warfarin, ATw) der det blir vurdert om behandlinga av kvar einskild pasient oppfyller visse kriterier. Verktøyet skal kunne brukast til evaluering av warfarinbehandling og skal prøvast ut på profilar for pasientar som tok del i spørjeundersøkinga. Formål Det overordna formålet med studien ”Bruk av Marevan (warfarin) i klinisk praksis” var å kartleggje klinisk praksis for oppstart og gjennomføring av warfarinbehandling i Tromsø, gjere synleg kvar det eventuelt skjer svikt og fremje forslag til betre gjennomføring av behandlinga. Hensikta med masteroppgåva var å byggje opp ein database med relevante journaldata, og bruke denne som grunnlag for utprøving av eit verktøy (ATw) for evaluering av warfarinbehandling under norske forhold. Material og metode Studiepopulasjonen i masteroppgåva var 65 apotekkundar i Tromsø som brukte Marevan® på det tidspunktet dei vart spurt om å ta del i studien. Pasientane som tok del i journalstudien har i ei tidlegare undersøking svara på spørjeskjema om bruk av Marevan. Ein database for journaldata vart opparbeidd av masterstudenten. Informasjon samla frå spørjeundersøking og journalar vart overført til eit verktøy (ATw) for evaluering av antikoagulasjons¬behandling. Verktøyet vart evaluert i forhold til kor enkelt det var å forstå og bruke, og om nødvendig informasjon kunne finnast i det tilgjengelege datamaterialet som første ledd i valideringa av verktøyet. Det vart kalkulert score for dei ulike svaralternativa og appliseringsgrad og svarprosent for kvart enkelt kriterium. Som mål på behandlingskvalitet i pasientgruppa vart det brukt prosentdel oppfylte kriterier for god behandling i forhold til appliserbare kriterier. For å kunne identifisere ”care issues” vart tal på ikkje oppfylte kriterier brukt. Resultat Databasen inneheldt ved registreringsstans journaldata for 65 pasientar. Fire kriterier vart endra før verktøyet vart tatt i bruk. Det vart fremja forslag for fleire endringar i verktøy, rettleiing og journaldatabase. Tre kriterier var det vanskeleg å finne tilstrekkelege data for i journal. Det foreløpige datamaterialet viste at prosentdel oppfylte kriterier var på 62,5 % for journaldelen og for spørjeundersøkingsdelen 45,4 %. I gjennom¬snitt var 26,8 % av appliserbare kriterier svara med Nei for journaldelen og 44,9 % for spørjeundersøkingsdelen. Få pasientar hadde meir enn 12 veker mellom INR-målingane. Det var sjeldan notert i journal at informasjon var gitt til pasienten. Mange epikriser mangla viktige opplysingar om oppstart av behandling. INR-mål vart ofte funne i AK-journal. Ved INR > 4,5 vart det i dei fleste tilfella målt ny INR etter 1-2 veker. For 10 av 17 episodar med INR > 4,5 var det ikkje notert at warfarin var midlertidig seponert. Konklusjon Verktøyet ATw kan brukast til å kartleggje warfarinbruk ut frå spørjeundersøking og informasjon frå journalar i ein database, men utvida validering må utførast før det er pålitelig nok til evaulering av warfarinbehandling. I gjennomsnitt var 54 % av anvendte kriterier oppfylt (svara med Ja). Databasen fungerer tilstrekkeleg for datamateriale av moderat storleik. Det kan bli enklare å bruke verktøyet med ein betre tilpassa journal¬database.
Stroke is a leading cause of disease burden. The quality of care provided in hospitals can affect outcome. Therefore, examining adherence to clinically important processes of care can help improve care delivery and patient outcomes. However, knowing which process indicators to measure is essential.
Systematically review process indicators used to evaluate acute stroke services, including early rehabilitation interventions, and assess whether published indicators conform to clinical guidelines.
Publications (1985-2006) were identified by systematically searching databases (e.g. Medline and Cochrane Library), and the internet using free text terms: 'stroke unit', 'process', 'quality', 'mobilisation', 'acute', and 'early rehabilitation'. Publications describing process indicators relating to the first 2 weeks of in-patient stroke care were included. Process indicators were categorised according to six clinical process domains covering the acute stroke admission. Commonly cited indicators (>or=6 publications) were then mapped to the 2003 Australian clinical guidelines.
Sixty potential studies were found from title and abstract. Following full text review, 32 publications were retained. Of the 161 process indicators identified, 43 were commonly cited. Seventy-nine per cent of commonly cited indicators were found in the guidelines. The level of evidence underpinning each indicator ranged from low 'expert opinion' (59%), to high, 'level 1' (12%) evidence. Indicators related to rehabilitation were rare.
Many acute stroke process indicators have been published. However, a quarter did not align with current clinical guidelines. Developing an 'ideal set' of process indicators to reflect the evidence base seems sensible and should include rehabilitation interventions.
To determine the quality of in-hospital stroke care in public acute care hospitals in Catalonia before the implementation of a clinical practice guideline (CPG) on stroke by determining adherence to specific recommendations of the CPG.
We retrospectively reviewed the case notes of consecutive patients with stroke (defined with ICD-9 codes: 431, 433.x1, 434.x1, and 436) admitted to 48 Catalan hospitals within the first half of 2005. Data were collected on indicators of the healthcare process selected on the basis of their scientific evidence and/or clinical relevance. The participating hospitals included 20, 40 or 60 stroke cases according to their annual stroke caseload. After random selection, up to 9.3% of all cases recruited at each study center were externally monitored to assess the quality of the data gathered. Indicators were grouped into six different dimensions related to distinct aspects of clinical practice.
We analyzed data from 1,791 stroke cases (53.9% men, mean age: 75.6 [12.4] years). Overall inter-observer agreement was 0.7. Compliance with the six dimensions was as follows (mean percentage [95%CI]): quality of medical records, 78.5% (77.5-79.4); initial interventions, 92.4% (91.5-93.2); neurological assessment, 38.3% (37.3-39.3); assessment of rehabilitation needs, 44.9% (43.2-46.7); prevention and management of medical complications, 68.4% (66.9-70), and initial preventive measures, 78.9% (77.3-80.4).
In the first half of 2005, in-hospital stroke care in Catalonia showed room for improvement particularly in aspects related to the neurological assessment and follow-up of patients and their rehabilitation process.
Robust international data support the effectiveness of stroke unit (SU) care. Despite this, most stroke care in Ireland are provided outside of this setting. Limited data currently exist on the quality of care provided.
The aim of this study is to examine the quality of care for patients with stroke in two care settings-Regional General Hospital (RGH) and Stroke Rehabilitation Unit (SRU).
A retrospective analysis of the stroke records of consecutive patients admitted to the SRU between May-November 2002 and April-November 2004 was performed applying the UK National Sentinel Audit of Stroke (NSAS) tool.
The results of the study reveal that while SRU processes of care was 74% compliant with standards; compliance with stroke service organisational standards was only 15 and 43% in the RGH and SRU, respectively.
The quality of stroke care in our area is deficient. Comprehensive reorganisation of stroke services is imperative.
Healthcare payers make decisions on funding for treatments for diseases, such as chronic obstructive pulmonary disease (COPD), on a population level, so require evidence of treatment success in appropriate populations, using usual routine care as the comparison for alternative management approaches. Such health outcomes evidence can be obtained from a number of sources. The 'gold standard' method for obtaining evidence of treatment success is usually taken as the randomized controlled prospective clinical trial. Yet the value of such studies in providing evidence for decision-makers can be questioned due to the restricted entry criteria limiting the ability to generalize to real life populations, narrow focus on individual parameters, use of placebo for comparison rather than usual therapy and unrealistic intense monitoring of patients. Evidence obtained from retrospective and observational studies can supplement that from randomized clinical trials, providing that care is taken to guard against bias and confounders. However, very large numbers of patients must be investigated if small differences between drugs and treatment approaches are to be detected. Administrative databases from healthcare systems provide an opportunity to obtain observational data on large numbers of patients. Such databases have shown that high healthcare costs in patients with COPD are associated with co-morbid conditions and current smoking status. Analysis of an administrative database has also shown that elderly patients with COPD who received inhaled corticosteroids within 90 days of discharge from hospital had 24% fewer repeat hospitalizations for COPD and were 29% less likely to die during the 1-year follow-up period. In conclusion, there are a number of sources of meaningful evidence of the health outcomes arising from different therapeutic approaches that should be of value to healthcare payers making decisions on resource allocation.
To measure performance on the basis of generic (non-diagnoses related) standards of care developed in a national Danish quality improvement programme in departments of internal medicine, and to determine the power of repetitive national audits to increase levels of performance.
Multifaceted intervention: national audits in 2001 and 2002 based on the standards of the program, combined with direct contact with heads of departments and a national conference to discuss audit results.
Seventy-nine and 82 wards in 2001 and 2002, respectively, covering 71% of Danish hospitals receiving medical emergencies. The wards participated on a voluntary basis.
In the first audit round, 3950 patients were admitted as emergencies, while 4068 patients were admitted as emergencies in the second audit. Patients were included without reference to diagnoses.
Correct initial diagnostic assessment, early interdisciplinary action plans, correct drug prescriptions, waiting times for examinations, documented patient information, readmissions, and content and processing time for discharge letters.
For the 70 wards participating in both rounds, the general level of performance improved significantly between the two audits: the proportion of patients with correct initial diagnostic assessment increased from 75.9% to 79.4%, the proportion of patients with correct drug prescriptions increased from 83.8% to 85.9%, and the proportion of sufficiently informed patients increased from 32.4% to 36.2% (P < 0.05). The proportion of medical records containing action plans for selected clinical problems (nutritional and functional problems, fever, and treatment of pain) increased from 72.8% to 75.9% (P < 0.05). Length of stay in hospital was significantly related to a correct initial assessment and to waiting time for examinations. Wards with a common medication chart for physicians and nurses had significantly more correct drug prescriptions than wards that did not use a medication chart. Fifty-four (75%) of the participating departments indicated that the result of the first audit round had led to organizational changes in the department.
Professional self-regulation guided by a multidisciplinary audit tool developed in cooperation with professionals can improve quality of care. It is possible to conduct and repeat a national audit on a voluntary basis.
To measure the quality of secondary prevention of stroke provided to patients in England, Wales and Northern Ireland.
Retrospective case note analysis.
235 hospitals (95% of all such hospitals), providing care for acute stroke patients in England, Wales and Northern Ireland and primary health care for follow-up data.
8,200 patients admitted with stroke between 1(st) April and 30(th) June 2001. Data on up to 40 consecutive cases submitted by each hospital. AUDIT TOOL: Royal College of Physicians Intercollegiate Stroke Working Party Stroke Audit.
24% of patients with previous cerebrovascular disease were not on anti-thrombotic medication at the time of admission. Nine percent of appropriate patients were not taking anti-thrombotic medication at discharge. Patients left with moderate to very severe disability (Barthel scores 14 or less) compared with those independent with mild disability (Barthel score 15-20) were more likely not to have anti-thrombotic treatment (18% versus 8%). Fifty-four percent of patients with known hyperlipidaemia and 21% of those with previous ischaemic heart disease were on lipid lowering therapy on admission. Sixty-four percent of patients had lipids measured during their hospital stay and of those with high total cholesterol or LDL the rate of non-treatment was 36%. Older patients (75+ years) were less likely to be treated (54%) than those <65 years (71%). Seventy-nine percent of known patients with hypertension were on treatment at admission, with 78% being treated by discharge from hospital. At 6 months after stroke a systolic blood pressure of 140 mmHg or less, and a diastolic of 85 mmHg or less, was achieved in 41% of known pre-stroke hypertensives on treatment, 31% of previously untreated hyper-tensives but on treatment at follow-up and 40% of patients not previously labelled as hypertensive.
Major deficiencies in delivery of secondary prevention after stroke have been demonstrated. Services need reorganisation to prevent unnecessary mortality and morbidity in this group of patients.
To audit the performance of hospitals in evidence-based prescribing.
All hospitals in England were invited to participate. The audit was completed in 62 hospitals.
Prescribing and clinical data were collected on 100 consecutive medical inpatients aged >/= 65 years at each site, enabling evaluation of eight prescribing indicators before and after intervention. The data were collected using a specifically designed database.
The results of the first audit were available immediately from the software and a national report with locally identifiable information was returned to hospitals. Hospitals were encouraged to design and deliver their own intervention strategy. A questionnaire was sent to all hospitals to document prioritization of indicators.
Generic names were used for 36 061 (82.6%) in 1999 and 39 188 (86.4)% in 2000. In 1999, 50% (3074) of patients had documentation of allergy status. This increased to 60% (3684) in 2000. For 21.2% of patients prescribed paracetamol in 1999 and 18.1% in 2000, the prescription was written such that it was possible to exceed the maximum recommended dose of 4 g in 24 hours. Long-acting hypoglycaemic drugs were prescribed to 29 patients in 1999 and 20 patients in 2000. Anti-thrombotics were used appropriately for 54% (520/966) of patients in atrial fibrillation in the first audit and 57% (579/1019) in the second audit. The appropriate use of aspirin increased from 91% (595/651) to 94% (725/772) and the appropriate use of benzodiazepines dropped from 49% (537/1088) to 47% (460/966) between the audits. For three indicators, the allocating of a high priority translated into a bigger improvement between the audits.
Local ownership of data and the quality improvement process, and provision of national benchmarking data did not result in a significant improvement in prescribing in the second audit.
To use data from the 2001-2 National Stroke Audit to describe the organisation of stroke units in England, Wales and Northern Ireland, and to see if key characteristics deemed effective from the research literature were present.
Data were collected as part of the National Sentinel Audit of Stroke in 2001, both on the organisation and structure of inpatient stroke care and the process of care to hospitals managing stroke patients.
240 hospitals from England, Wales and Northern Ireland took part in the 2001-2 National Stroke Audit, a response rate of over 95%. These sites audited a total of 8200 patients. AUDIT TOOL: Royal College of Physicians Intercollegiate Working Party Stroke Audit Tool.
73% of hospitals participating in the audit had a stroke unit but only 36% of stroke admissions spent any time on one. Only 46% of all units describing themselves as stroke units had all five organisational characteristics that previous research literature had identified as being key features, while 26% had four and 28% had three or less. Better organisation was associated with better process of care for patients, with patients managed on stroke units receiving better care than those managed in other settings.
The National Service Framework for Older People set a target for all hospitals treating stroke patients to have a stroke unit by April 2004. This study suggests that in many hospitals this is being achieved without adequate resource and expertise.
Background: The UK National Clinical Guidelines for Stroke (2000) include recommendations on psychological services. The third National Sentinel Audit of Stroke was completed in 2001-2002.
Objectives: To examine the extent to which UK stroke services complied with the national guidelines.
Design: Use of three retrospective case note audits of hospital admissions, covering the period from admission to six months after discharge, and audits of how stroke services were organized.
Setting: Hospitals within England, Wales, Northern Ireland, the Channel Islands and the Isle of Man.
Subjects: Stroke patients admitted consecutively within a three-month time frame.
Main measures: Compliance with the guidelines on mood disorders and cognitive impairments, and changes between audits.
Results: The 2001-2002 audit provided data on 60% of possible participants, from 145 hospitals and 5152 patients. Compliance with the guideline to screen for mood disturbance was poor; the median patient compliance rate of hospitals was 50%. More hospitals (88%) had a locally agreed cognitive assessment protocol in 2001-2002 than in 1998 (68%) and in 1999 (82%). However, actual rates of screening for cognitive difficulties were lower than implied by the existence of a local protocol. There were no strong case-mix associates of mood and cognitive screening. Access to clinical psychologists was poor. Mood and cognitive assessment rates were not much better for stroke units with access to clinical psychologists than for units without access (mood: p = 0.6, cognition: p = 0.09).
Conclusions: Although compliance with some of the guidelines has improved, many areas in current psychological services for stroke urgently need attention.
National audit provides a basis for establishing performance against national standards, benchmarking against other service providers and improving standards of care. For effective audit, clinical indicators are required that are valid, feasible to apply and reliable. This study describes the methods used to develop clinical indicators of continence care in preparation for a national audit.
To describe the methods used to develop and test clinical indicators of continence care with regard to validity, feasibility and reliability.
A multidisciplinary working group developed clinical indicators that measured the structure, process and outcome of care as well as case-mix variables. Literature searching, consensus workshops and a Delphi process were used to develop the indicators. The indicators were tested in 15 secondary care sites, 15 primary care sites and 15 long-term care settings.
The process of development produced indicators that received a high degree of consensus within the Delphi process. Testing of the indicators demonstrated an internal reliability of 0.7 and an external reliability of 0.6. Data collection required significant investment in terms of staff time and training.
The method used produced indicators that achieved a high degree of acceptance from health care professionals. The reliability of data collection was high for this audit and was similar to the level seen in other successful national audits. Data collection for the indicators was feasible to collect, however, issues of time and staffing were identified as limitations to such data collection. The study has described a systematic method for developing clinical indicators for national audit. The indicators proved robust and reliable in primary and secondary care as well as long-term care settings.
Bladder and bowel problems are common in the elderly and are associated with a considerable morbidity and impact on quality of life. Inequalities in service provision and access to services have been recognized but there has been no systematic approach to measuring the quality of continence care for older people. This study aimed to develop quality standards, to assess the reliability and utility of the resulting audit package and to report on the standards of care provided in primary care, secondary care and care home setting.
Fifteen sites in secondary care, primary care and in long-term care settings were randomly selected to pilot the audit package. Data collectors completed audit questionnaires relating to the structure [organization] of care, the outcomes of care, and the process of care for 20 subjects with urinary incontinence and 10 subjects with faecal or double incontinence.
The audit tool was reliable (median kappa score of 0.7). Access to integrated continence services, as defined by Good Practice in Continence Services was inadequate. Eighty-five per cent of hospitals had no written policy for continence care. There were deficiencies in obtaining information, in carrying out basic and specialist examinations and investigations and in determining the cause of incontinence. There was a high prevalence of catheter use in secondary care settings.
The pilot has indicated significant inadequacies in continence care and demonstrates that in many sites the National Service Framework milestone for integrated continence services has not been met. A national audit of continence care is required to determine the extent of inadequate continence care.
Study objective: To identify the variations between regions in England, Wales and Northern Ireland in the case-mix, organization and process of care for stroke.
Design: Retrospective audit of case notes and service organization.
Setting: Two hundred and ten Trust sites from 197 Trusts in 10 Health Regions in England, Wales and Northern Ireland.
Patients: The 6894 consecutive stroke patients admitted between 1 January and 31 March 1998 (up to 40 per Trust).
Audit tool: The Intercollegiate Stroke Audit.
Results: There are significant differences in stroke care between regions that cannot be explained by known case-mix or clinical variables. The proportion of patients spending more than half their hospital stay in stroke unit care varied between regions from 10% to 27%. Thirty-day mortality in different regions ranged between 21% and 33%. Institutionalization rates for those admitted from home varied between 6% and 19%. Similar variations existed in discharge disability and length of stay.
Conclusions: There were widespread variations in specialist service provision for stroke in different regions. Regional variation in 30-day mortality and in institutionalization after stroke is not explained by clinical factors and therefore may represent different local health care policies and expectations.
• Research Problem and Methods.
—There are currently 1.5 million stroke survivors in the United States. More than half of these individuals have significant residual physical disability and functional impairment. Survivors of stroke constitute the largest group of patients receiving rehabilitation services in this country. We examined existing clinical trials investigating the effectiveness of stroke rehabilitation programs to improve functional outcomes and discharge destination. One hundred twenty-four research reports were initially identified. From this sample, 36 trials meeting selected criteria were evaluated by the methods of meta-analysis.
Results.
—A total of 3717 patients participated in the 36 clinical trials included in the meta-analysis. The results revealed a mean d-index of 0.40±0.33. This effect size index was converted to a U3 value of 65.5, indicating that the average patient receiving a program of focused stroke rehabilitation performed better than approximately 65.5% of those patients in comparison groups (95% confidence interval, 63.6% to 67.3%). The results also revealed a significant interaction between type of research design and method of recording the outcome of a clinical trial. Blind recording of the outcome measure appears to be an essential design characteristic in clinical trials that do not randomize patients to conditions.
Conclusions.
—Programs of focused stroke rehabilitation may improve functional performance for some patients who have experienced a stroke. The improvement in performance appears related to early initiation of treatment, but not to the duration of intervention. Improvements are also associated with the patient's age and the type of design. Research design should be considered an important moderator variable in planning and interpreting future clinical trials of treatment effectiveness in stroke rehabilitation.
The emphasis on outcomes measurement requires that casemix is considered in any comparative studies. In 1996 the Intercollegiate Working Party for Stroke agreed a minimum data set to measure the severity of casemix in stroke. The reasons for its development, the evidence base supporting the items included and the possible uses of the data set are described. It is currently being evaluated in national outcome and process audits to be reported at a later date.
There are significant variations in mortality rates from stroke in Europe. A European Union BIOMED Concerted Action was established to assess and determine the reasons for the variations in case fatality and disability after stroke.
Hospital-based stroke registers were established in 12 centers in 7 western and central European countries to collect demographic, clinical, and resource use details at the time of first-ever stroke during 1993-1994. At 3 months, details of survival, activity of daily living score, and use of health services were recorded. Multinomial logistic regression was used to estimate the relationship between centers and outcome (dead, functionally independent, functionally dependent), with adjustment for case mix and resource use variables, and to predict outcomes for the full cohort. This should minimize the bias due to loss to follow-up.
A total of 4534 stroke events were registered. The mean age was 71.9 years (SD, 12.53). There were significant differences between centers for all case mix and resource use variables (P<0. 001). Multinomial logistic regression modeling of outcome indicated that for those patients initially unconscious (588), center was not significantly related to outcome (P=0.427). For those initially conscious, there were wide variations in death and dependency between centers after adjustment for case mix, type of bed, and use of CT scan. The predicted proportion dead at 3 months ranged from 42% (95% CI, 35% to 49%) in one UK center to 19% (95% CI, 14% to 24%) in France.
Areas with high mortality rates within western and central Europe have been identified for stroke outcome, and there appears to be opportunity for considerable health gain in certain centers. Adjustment for case mix and health service resource use does not explain these differences in outcome. Although there are true differences in outcome, the aspects of care that need to be altered to improve outcome remain unclear despite detailed data collection. Comparisons of outcome of the same design used in the present study do not allow rational policy decisions to be made.
To assess the quality of inpatient care and follow-up for stroke in England, Wales and Northern Ireland.
Retrospective audit of case notes and service organisation.
197 trust (80% of eligible trusts in England, Wales and Northern Ireland).
6,894 consecutive stroke patients admitted between 1 January 1998 and 31 March 1998 (up to 40 per trust). AUDIT TOOL: The Intercollegiate Stroke Audit.
Most patients were admitted to acute hospitals with access to the appropriate acute investigations and treatments. Only 64% of trusts had a physician with responsibility for stroke and only 50% had a stroke team. Involvement of different members of the multidisciplinary team within appropriate time-frames varied from 37% to 61%. Assessment of impairments specific to stroke was inadequate (screening for swallowing disorders in only 55%, cognitive function tests in 23% and visual field examination in 44%). Rehabilitation goals were agreed by the multidisciplinary team in only 55% of eligible cases. 41% of patients were contacted by their GP within 3 days of discharge. The best compliance with standards was achieved for the 18% of patients who spent at least 50% of their time in a stroke unit.
This national audit demonstrates that care is suboptimal in many areas, and that there is wide variation in standards for the management of stroke across the country. This may have implications for clinical governance.
To investigate the ability of a bedside swallowing assessment to reliably exclude aspiration following acute stroke.
Consecutive patients admitted within 24 h of stroke onset to two hospitals.
A prospective study. Where possible, all patients had their ability to swallow assessed on the day of admission by both a doctor and a speech and language therapist using a standardized proforma. A videofluoroscopy examination was conducted within 3 days of admission.
94 patients underwent videofluoroscopy; 20 (21%) were seen to be aspirating, although this was not detected at the bedside in 10. In 18 (22%) of the patients the speech and language therapist considered the swallow to be unsafe. In the medical assessment, 39 patients (41%) had an unsafe swallow. Bedside assessment by a speech and language therapist gave a sensitivity of 47%, a specificity of 86%, positive predictive value (PPV) of 50% and a negative predictive value (NPV) of 85% for the presence of aspiration. Multiple logistic regression was used to identify the optimum elements of the bedside assessments for predicting the presence of aspiration. A weak voluntary cough and any alteration in conscious level gave a sensitivity of 75%, specificity of 72%, PPV of 41% and NPV of 91% for aspiration.
Bedside assessment of swallowing lacks the necessary sensitivity to be used as a screening instrument in acute stroke, but there are concerns about the use of videofluoroscopy as a gold standard. The relative importance of aspiration and bedside assessment in predicting complications and outcome needs to be studied.
Objectives:
To define the characteristics and determine the effectiveness of organised inpatient (stroke unit) care compared with conventional care in reducing death, dependency, and the requirement for long term institutional care after stroke.
Design:
Systematic review of all randomised trials which compared organised inpatient stroke care with the contemporary conventional care. Specialist stroke unit interventions were defined as either a ward or team exclusively managing stroke (dedicated stroke unit) or a ward or team specialising in the management of disabling illnesses, which include stroke (mixed assessment/rehabilitation unit). Conventional care was usually provided in a general medical ward.
Setting:
19 trials (of which three had two treatment arms). 12 trials randomised a total of 2060 patients to a dedicated stroke unit or a general medical ward, six trials (647 patients) compared a mixed assessment/rehabilitation unit with a general medical ward, and four trials (542 patients) compared a dedicated stroke unit with a mixed assessment/rehabilitation unit.
Main outcome measures:
Death, institutionalisation, and dependency.
Results:
Organised inpatient (stroke unit) care, when compared with conventional care, was best characterised by coordinated multidisciplinary rehabilitation, programmes of education and training in stroke, and specialisation of medical and nursing staff. The stroke unit care was usually housed in a geographically discrete ward. Stroke unit care was associated with a long term (median one year follow up) reduction of death (odds ratio 0.83, 95% confidence interval 0.69 to 0.98; P < 0.05) and of the combined poor outcomes of death or dependency (0.69, 0.59 to 0.82; P < 0.0001) and death or institutionalisation (0.75, 0.65 to 0.87; P < 0.0001). Beneficial effects were independent of patients' age, sex, or stroke severity and of variations in stroke unit organisation. Length of stay in a hospital or institution was reduced by 8% (95% confidence interval 3% to 13%) compared with conventional care but there was considerable heterogeneity of results.
Conclusions:
Organised stroke unit care resulted in long term reductions in death, dependency, and the need for institutional care. The observed benefits were not restricted to any particular subgroup of patients or model of stroke unit care. No systematic increase in the use of resources (in terms of length of stay) was apparent.
The published data on the relationship between dysphagia and both outcome and complications after acute stroke have been inconclusive. We examined the relationship between these, using bedside assessment and videofluoroscopic examination.
We prospectively studied 121 consecutive patients admitted with acute stroke. A standardized bedside assessment was performed by a physician. We performed videofluoroscopy blinded to this assessment within 3 days of stroke onset and within a median time of 24 hours of the bedside evaluations. The presence of aspiration was recorded. Mortality, functional outcome, lengthy of stay, place of discharge, occurrence of chest infection, nutritional status, and hydration were the main outcome measures.
Patients with an abnormal swallow (dysphagia) on bedside assessment had a higher risk of chest infection (P=.05) and a poor nutritional state (P=.001). The presence of dysphagia was associated with an increased risk of death (P=.001), disability (P=.02), length of hospital stay (P<.001), and institutional care (P<.05). When other factors were taken into account, dysphagia remained as an independent predictor of outcome only with regard to mortality. The use of videofluoroscopy in detecting aspiration did not add to the value of bedside assessment.
Bedside assessment of swallowing is of use in identifying patients at risk of developing complications. The value of routine screening with videofluoroscopy to detect aspiration is questioned.
Reports on an audit of service organizations, clinical care and casemix. The sample included up to 40 consecutive cases of acute stroke (1CD10 161-164) from each trust, admitted from 1 January to 31 March 1998 and 1 August to 31 October 1999. Feedback consisted of individualized reports showing participants’ own results compared to the national data, and regional multidisciplinary workshops between audit rounds. A total of 197 (81 per cent) trusts (6,894 cases) in England, Wales and Northern Ireland participated in the first round, and 175 (72 per cent) (5,823 cases) in the second. Of the 38 organisational standards, 29 improved between 1998 and 1999 (range 1-20 per cent, median 5 per cent); 64 of the 71 process standards improved (range 1-20 per cent, median 8 per cent). Inter-rater reliability was good with kappa scores of 0.49 to 0.87. National multidisciplinary, cross sector audit is feasible and can promote service improvements. Comparison of participants’ results to national data is a useful way of identifying areas needing change at local level.
Among 47 patients with stroke evaluated clinically and videofluoroscopically, one-half aspirated. Patients with combined cerebral-brainstem strokes with bilateral cranial nerve signs were at greatest risk, but aspiration also occurred in the context of unilateral signs. Dysphonia was the common clinical characteristic of aspirating patients. Single chest roentgenograms were of limited value in predicting aspiration. Outcome was favorable following compensatory oral feeding programs.
Management of stroke patients in specialist stroke units hastens recovery but is not believed to influence mortality. We did a statistical overview of randomised controlled trials reported between 1962 and 1993 in which the management of stroke patients in a specialist unit was compared with that in general wards. We identified 10 trials, 8 of which used a strict randomisation procedure. 1586 stroke patients were included; 766 were allocated to a stroke unit and 820 to general wards. The odds ratio (stroke unit vs general wards) for mortality within the first 4 months (median follow-up 3 months) after the stroke was 0.72 (95% CI 0.56-0.92), consistent with a reduction in mortality of 28% (2p < 0.01). This reduction persisted (odds ratio 0.79, 95% CI 0.63-0.99, 2p < 0.05) when calculated for mortality during the first 12 months. The findings were not significantly altered if the analysis was limited to studies that used a formal randomisation procedure. We conclude that management of stroke patients in a stroke unit is associated with a sustained reduction in mortality.
This paper presents findings from a study of the nursing role in rehabilitation hospital wards for elderly people and focuses on early morning dressing; this is a microcosm of service delivery but it illustrates the way in which institutional practices impinge on patient experiences and highlights areas which warrant attention for the future development of rehabilitation services for elderly people in hospital. The reported findings are drawn from a non-participant structured observational study of 'early morning rising' on rehabilitation wards for elderly people.
It is assumed that individualised patient care (IPC) benefits both patients and nurses. This study set out to clarify what IPC means to nurses and how they practise it, as well as how it is experienced by patients. With some exceptions, IPC was not practised widely in the seven wards used as case studies. Even in the wards where it was more common, there were some examples of bad practice. Factors that facilitated IPC were: the personal qualities of the nurses; a shared understanding among the ward team of the goals of nursing care and what constitutes good practice; levels of staffing and skill mix; effective leadership and management of nursing work.
The increasing need to adopt evidence-based practice places large information demands on health professionals. This paper draws on the experience of the information team of the NHS Centre for Reviews and Dissemination to examine opportunities for information workers to assist researchers and health professionals in the move to more evidence-based care. The importance of research reviews for the development of evidence-based practice and the process of conducting overviews are discussed. The Centre for Reviews and Dissemination is disseminating the results of reviews and developing information services for information professionals, health practitioners and health service managers. The services include databases of structured abstracts of quality reviews and economic evaluations and an enquiry service.
The aim of this study was to assure the validity and reliability of the Intercollegiate Stroke Audit Package as used in the National Sentinel Audit of Stroke. The Intercollegiate Working Party for Stroke, which included most stakeholders, including patients, devised the audit standards. These were submitted to a formal consensus (modified Delphi) survey before the audit questions were developed and piloted for validity and reliability. Following the pilot, Help Booklets were developed to promote the involvement of all disciplines as auditors in the national sentinel audit of stroke and ensure inter-rater reliability. During the national audit each Trust was asked to double rate the first five cases with auditors of different disciplines working independently. A total of 886 case notes were double-rated in 184 separate sites (median 5, range 1-5 per site). Trusts used auditors from different disciplines in 77% of cases. After excluding the 'No answer' cases the kappa score for items ranged from 0.49 to 0.87 (median 0.70, IQR 0.63-0.78). Very good agreement was found for seven of the 45 items, good agreement for 30 items, and moderate agreement for eight items. This large study, across a range of hospital sites and involving many disciplines, demonstrates that careful piloting of audit tools, with use of clear instructions to auditors, promotes the reliability of data.
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