P Irwin’s research while affiliated with Royal College of Physicians and other places

the Department of Health report 'Good practice in continence services' highlights the need for proper assessment and management of urinary incontinence. The National Service Framework for Older People required service providers to establish integrated continence services by April 2004. A national audit was conducted to assess the quality of continence care for older people and whether these requirements have been met. the audit studied incontinent individuals of 65 years and over. Each site returned data on organisational structure and the process of 20 patients' care. Data were submitted via the internet, and all were anonymous. the national audit was conducted across England, Wales and Northern Ireland. Data on the care of patients/residents with bladder problems were returned by 141/326 (43%) of primary care trusts (PCT), by 159/196 (81%) of secondary care trusts (involving 198 hospitals) and by 29/309 (9%) of invited care homes. In all 58% of PCT, 48% of hospitals and 74% of care homes reported that integrated continence services existed in their area. Whilst basic provision of care appeared to be in place, the audit identified deficiencies in the organisation of services, and in the assessment and management of urinary incontinence in the elderly. the results of this audit indicate that the requirement for integrated continence services has not yet been met. Assessment and care by professionals directly looking after the older person were often lacking. There is an urgent need to re-establish the fundamentals of continence care into the practice of medical and nursing staff and action needs to be taken with regard to the establishment of truly integrated, quality services in this neglected area of practice.

Faecal incontinence in older people is associated with considerable morbidity but is amenable to successful management. Quality standards in this area were previously subject to a pilot audit in primary, secondary care and care homes to allow providers to compare the care delivered by their service to others and to monitor the development of integrated continence services as set out in the National Service Framework for Older People. This study reports the results of the national audit. Data were returned by 141 primary care sites, 159 secondary care trusts (involving 198 hospitals) and 29 care homes. Data on the care of 3,059 patients/residents with bowel problems were analysed. Fifty-eight per cent of Primary Care Trusts (PCTs), 48% of hospitals and 74% of care homes reported that integrated continence services existed in their areas. Whilst basic provision of care appeared to be in place, the audit identified deficiencies in the organisation of services and in the assessment and management of faecal incontinence. The results of this audit indicate that the requirement for integrated continence services contained within the National Service Framework for Older People has not yet been met. Basic assessment and care by the professionals directly looking after older persons is often lacking. There is an urgent need to re-establish the fundamentals of continence care into the daily practice of medical and nursing staff, and undoubtedly, action needs to be taken with regard to the establishment of truly integrated, quality services in this neglected area of practice.

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.

Background: The National Clinical Guidelines for Stroke (NCGS) were produced and three rounds of the National Sentinel Audit of Stroke conducted to improve the quality of stroke care in the UK. Objective: To compare the results of the occupational therapy and physiotherapy elements of the most recent national sentinel audit with the occupational therapy-and physiotherapy-specific recommendations of the NCGS. Methods: Retrospective case-note audit. Results: Over 95% of hospitals/sites who manage stroke in England, Wales and Northern Ireland took part in the most recent round of the sentinel audit. The clinical audit took place from 1 April to 30 June 2001 and incorporated 235 hospitals/sites. The organizational audit took place in January 2002 and incorporated 240 hospitals/sites. Data are presented from the 235 with both clinical and organizational data, under the headings of: approaches to rehabilitation; carers/families; rehabilitation interventions; and transfer to the community. Low rates of compliance with national standards were observed for all domains. Conclusion: Our findings suggest that occupational therapists and physiotherapists are not fully complying with the national standards for stroke care.

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 and purpose: There are widespread regional variations in the institutionalization rate after stroke. This study sought to identify the factors that predict institutionalization after a primary diagnosis of stroke and determine whether institutionalization rate could be used to assess the quality of hospital care. Methods: A retrospective case note audit of 2778 consecutive admissions with stroke, between 1 September and 31 October 2000 from a randomly selected sample of 79 hospitals in England, Wales and Northern Ireland. Data were collected on demographics, case-mix, clinical outcome, organization of discharge, and place of residence at discharge and at three and six months. The figures from this audit were validated using data from the 1998 National Sentinel Audit of Stroke. Results: Overall 14% of patients previously living at home were discharged to nursing or residential homes. Using logistic regression, Barthel Index score at discharge accounted for 40% of variation. Two-thirds of patients with a discharge Barthel score of B=5 were institutionalized. Age alone explained 14% and when taken together with discharge Barthel and length of stay it accounted for 54% of variation. On admission 22% of the variation in institutionalization rate could be accounted for by total Glasgow Coma Score (15, B=15), age and ability to walk unaided. Regional variations in institutionalization rates are evident and may in part be explained by differences in ease of access to the institutions. Conclusions: Discharge disability and older age were the dominant factors determining admission to nursing and residential homes. It is not possible to predict sufficiently reliably for an individual patient the likelihood of institutionalization at admission or at 72 h after admission, to justify early resource allocation decisions.

Stroke unit care is one of the most powerful interventions available to help stroke patients. There are limited data available to assess the impact of stroke units in routine clinical practice outside randomized clinical trials. This article uses data from the 2001 to 2002 National Stroke Audit to assess the effectiveness of stroke unit care in England, Wales, and Northern Ireland in delivering effective processes of care and in reducing case fatality and disability. An observational study of the organization, structure, process of care, and outcomes for stroke in 2001. Case fatality after stroke in England was compared using data from the audit and routinely collected data from the Department of Health. 240 hospitals (196 Trusts) from England, Wales, and Northern Ireland took part in the 2001 to 2002 National Stroke Audit, a response rate of >95%. These sites assessed a total of 8200 patients using the Royal College of Physicians Intercollegiate Working Party Stroke Audit Tool. The availability of stroke unit care varies hugely across the country. Case fatality after stroke was higher in Trusts with least availability of stroke unit care. These differences persisted after control for case mix. The process of care was better for patients managed on stroke units compared with other settings. Overall, the risk of death for patients who received stroke unit care was estimated to be approximately 75% that of the risk for those having no stroke unit care (95% CI, 60 to 90). Stroke unit care as provided in routine clinical practice in England, Wales, and Northern Ireland reduces case fatality by approximately 25%, which is in line with the figures obtained from systematic analysis of stroke unit trial data.

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.

Building on earlier work, this paper describes a coordinated and systematic method for identifying priorities for nursing development within a field of practice. The nursing contribution in stroke care serves as a case study, the primary aim of which was to establish priorities for research and development in stroke care from a nursing perspective. The initiative was a partnership between the Royal College of Nursing and the Stroke Association, supported by the Royal College of Physicians.

To identify the variations between regions in England, Wales and Northern Ireland in the case-mix, organization and process of care for stroke. Retrospective audit of case notes and service organization. Two hundred and ten Trust sites from 197 Trusts in 10 Health Regions in England, Wales and Northern Ireland. The 6894 consecutive stroke patients admitted between 1 January and 31 March 1998 (up to 40 per Trust). Audit tool: The Intercollegiate Stroke Audit. 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. 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.