The two major pieces of work being undertaken currently are the National Clinical Guidelines for Stroke, and the fourth edition was published last year, and the Sentinel Stroke National Audit Programme (SSNAP).
The next edition of the National Clinical Guidelines is likely to be published in 2016; the National Audit Programme (SSNAP) was initiated in January of this year, and is very active. My update today will mainly focus on SSNAP and the noteworthy data that has emerged from everyone’s hard work to date.
The Sentinel Stroke National Audit Programme (SSNAP) is an audit funded nationally by the Health Quality Improvement Programme (HQIP), and run through the Royal College of Physicians.
The aim is that every person who has a stroke in England and Wales will be registered and that data will be collected on structure, process and outcome for every patient and for all services involved over the first six months of the stroke patient’s journey.
Although the audit started about 12 years ago with a focus on acute hospital care (SYNAPE), from the outset it considered disability and rehabilitation. It is now starting to consider rehabilitation and care in much more detail. Consequently input from non acute sector is vital, both in helping design and develop the audit and in terms of collaborating and encouraging participation by the Trusts and services involved, and by all staff involved.
Recently a bid was submitted to the Health Quality Improvement Programme (HQIP) to take responsibility for collecting outcome data on all patients at six months after stroke as part of SSNAP. This is a national goal, and it is likely that someone will be funded to undertake it. However to ensure that successful data collection occurs at six months post stroke, it is Imperative that local and regional stroke rehabilitation services work together to maximise data collection in order to ensure the meaningful results for all in the future.
For all those already collecting data we must remember that this is a developmental and pilot phase and there are opportunities to improve the data collected by removing items and replacing them with others. To date the dataset remains large and it is not feasible to greatly increase it any further.
One particular area of concern relates to data is on the amount of therapy a patient receives. The standard is 45 minutes each day for any therapy needed. Two issues concern therapists in particular:
1. The first is that there is no clear way to identify which patients need what therapy. In speech and language therapy there is an additional concern that the nature of the therapy(swallowing/language/communication) is hidden.
2. The second issue is that some patients may need only a little therapy (less than 45 minutes daily) and/or they may only need therapy for a short time (therapy time delivered in measured over the whole episode and is averaged per working day).
One partial solution suggested by the medical rehabilitation expert would be to use the Rehabilitation Complexity Scale and it extended it over a seven day period, either using the whole scale or simply using the Therapy Intensity subscale for each therapy. What do people think? Comments on the identification and recording of need would be welcome via twitter or email NSNF.
We all need to remember that the audit will only truly succeed in the future if we collect data along the whole of the patient pathway over the first six months; including especially the services provided once the patient has left acute inpatient services. Local plans with your commissioners will need to be put in place to support and assist inpatient, out-patient or outreach (domiciliary) services, commissioners will also need to be aware of all services in their locality that treat stroke patients This will also need to include voluntary, third sector, social, jointly funded services and those provided by other commercial organisations.
The data that will be collected will reach an extraordinary size, scope, and detail. There will be enough data to keep all members busy in research for years! If members have ideas on data analysis that they would like to pursue, they should contact SSNAP with a proposal, or discuss ideas with NSNF via email. Following data input, clinical services will start to see the output three months later, which will help support future service development.
Currently audits are also being proposed for acute trauma and other disciplines, which will create a future opportunity for shared learning.
The biggest piece of information to take away from everyone’s hard work to date is that there is evidence emerging that patient improved outcome is positively correlated with high nurse staffing levels on a stroke unit. Interestingly the data has not yet shown the same correlation for medical staff. As the RCN and the NSNF are both engaged in the debate for minimum nurse staffing levels and this information echoes the staffing findings of the Francis Report, there is an opportunity here to use this data to push forward the work on minimum staffing levels especially on stroke units.
Diana Day
Stroke Consultant Nurse Cambridge University Hospitals NHS Foundation Trust | Addenbrooke's Hospital
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