In the UK, an estimated 150,000 people have a stroke annually (1). Mortality and morbidity are high. 67,000 deaths occur annually (2) and many of those who survive are left with moderate or severe disabilities (3).

Specialist stroke units have been shown to improve outcome in patients presenting with stroke by concentrating patients in a unit with appropriate expertise (4). Early initiation of treatment for transient ischaemic attacks (TIAs) has been shown to reduce the incidence of stroke (5).

Despite stroke being a major health problem, the National Sentinel Stroke Audit has shown that the quality of stroke services varies in the UK (6, 7).

The Commissioning for Quality Improvement and Innovation (CQUIN) framework was introduced in April 2009 as a result of the High Quality Care for All report (8).

The framework is designed to encourage and stretch continuous improvements in the quality of patient care, ensuring better outcomes. Working alongside other financial levers, the framework includes a commitment to make a modest proportion of providers’ income conditional on quality and innovation.

The Pennine Acute Trust (PAHNT), collaborating with partner primary care trusts, introduced a CQUIN scheme in 2009 to achieve agreed goals to improve local stroke services. Local CQUIN schemes are required to include goals in the three domains of quality: safety, effectiveness and patient experience; and to reflect innovation. When achieved, it enables the provider to earn its full CQUIN payment. For PAHNT, this works out at 1.5 per cent of the contract value in 2010/11(9, 10).

PAHNT comprises four district general hospitals - Fairfield General Hospital, Rochdale Infirmary, Royal Oldham Hospital and North Manchester General Hospital - all of which provide outpatient stroke services. Fairfield is a primary stroke centre providing hyperacute stroke care across the trust and acute stroke service for both Fairfield and Rochdale. The two other sites act as district stroke centres providing acute stroke care for patients not suitable for thrombolysis as well as repatriated patients post-thrombolysis (11).

To ensure adequate standards in quality of care, our trust implemented the following CQUIN clinical indicators:

1. Two components of stroke vital sign indicators (in-line with Department of Health targets for 2009-2010 (10)):

            - 70 per cent of people with stroke spend at least 90 per cent of their time on a stroke unit.

- 45 per cent of higher risk TIA cases should be treated within 24 hours.

2. Nine performance indicators from the National Sentinel Stroke Audit (6, 7)

            - Swallowing assessment within 12 hours of admission

            - Brain scan (CT or MRI) within 24 hours of presentation

            - Aspirin commenced within 48 hours after stroke

            - Physiotherapy assessment within 72 hours of admission

            - Rehabilitation goals agreed by the multidisciplinary team

            - Weight measured at least once during admission

            - Occupational therapy assessment within four days of admission

            - Mean of the above indicators

            - Mean score of above indicators and 90 per cent of time spent on acute stroke unit

3) An additional indicator in line with the Greater Manchester Integrated Stroke Service Pathway:

            - Nutrition assessment using the MUST tool within 24 hours

4) Annual patient survey using the questionnaire used by the Healthcare Commission in their national stroke patient survey in 2005 (12).

A target of a mean of 80 per cent for each of the nine performance indicators and the MUST screening was set.

Methods

All patients with stroke who were in-patients in the acute stroke and rehab units in our Trust between 1 September 2009 and 31 March 2010 were included. Data was collected on all the above clinical indicators. Data was collected for high risk TIA patients (defined as those with an ABCD2 score of 4 or above (13)) between 1 January 2010 and 31 March 2010.

At the end of each month, data was analysed for each stroke unit and performance assessed. Problem areas were identified and an action plan created for the following month. This process was repeated at the end of each calendar month.

A pilot patient survey was sent to 33 per cent of patients (30 per cent was required) were inpatients on a PAHNT Acute stroke/Rehab unit between 1 March 2009 and 30 June 2009.

Results

588 stroke patients were inpatients on an acute stroke unit during the study period.

Vital Sign Indicators

Stroke Units

The percentage of stroke patients who spent 90 per cent of their admission on a stroke unit is shown in Table 1.

 NMGH(DSC)ROH(DSC)FGH/RI(PSC)
Sept 2009March 2010Sept 2009March 2010Sept 2009March 2010
Percentage of patients spending 90% of admission on a stroke unit53%57%61%65%60%98%

Table 1 – Time spent on a stroke unit

High Risk TIAs

While no data was collected for high risk TIAs between September and December 2009, quarterly data from 1 January 2010 to 31 March 2010 are shown in Table 2.

 NMGHROHRIFGH
Percentage of high risk TIAs treated within 24 hours50%38%100%92%

Table 2 - Percentage of High risk TIAs Treated within 24 Hours

Clinical Indicators

 NMGH(DSC)ROH(DSC)FGH/RI(PSC)
Sept 2009March 2010Sept 2009March 2010Sept 2009March 2010
Swallow Assessment within 12 hours (%)206033604088
Brain scan within 24 hours (%)787582908097
Aspirin within 48 hours (%)7090821008591
Physiotherapy assessment within 72 hours (%)7892961008597
Rehabilitation goals agreed (%)888695928591
Weight measured during admission (%)9010095100100100
Occupational Therapy assessment within 4 days (%)9095851004094
MUST nutritional screen within 24 hours (%)407346647885

The overall performance improved across the trust from 71 per cent in September 2009 to 86 per cent in March 2010.

Patient Survey

119 patients completed the pilot patient questionnaire (45.1 per cent return rate). 87 per cent of respondents rated their inpatient care as good or excellent. However, post-discharge care was often considered to be fragmented and some patients felt they were not given adequate psychological support or information regarding lifestyle changes

Discussion

Prior to introduction of the CQUIN scheme, stroke data was only collected bi-annually in PAHNT as part of the National Sentinel Stroke Audit. Slow progress was achieved in improving quality of care through data collection, analysis and interpretation of this audit. However with monthly data collection, problems were identified early and specific action plans were drafted. Changes instituted brought about improvement in quality month after month.  

Areas that showed marked improvement were timely swallow and nutritional assessments, early administration of aspirin and early physiotherapy and occupational therapy assessments. The performance by the PSC was better. This might suggest a higher proportion of resources being distributed to hyperacute care with better application which in turn contributed to significant improvement. A high proportion of high risk TIAs were seen and treated within 24 hours. With centralisation of TIA referrals and initiation of TIA clinics across all sites, it is likely that in the near future all patients with TIAs will be seen within 24 hours, irrespective of risk.

Although the pilot patient questionnaire showed that the majority of patients were happy with the quality of care they received, there were several areas highlighted as requiring improvement. Since then, an information pack containing individualised information on lifestyle advice and medications has been produced and is now given to every patient and the community stroke support team have been given a larger role. More information will be gained from the patient survey which is due to be rolled out in July 2010.

Conclusions

The CQUIN framework has had a positive impact in improving quality of stroke care in PAHNT. There is, however, still scope for improvement in many areas – in particular in ensuring all stroke patients get adequate stroke unit care through rapid access pathways to acute stroke units.

Although introduced to improve quality of care rather than as a financial lever, it is likely that CQUIN parameters for stroke will become more stringent in the future and failure to achieve targets could result in financial penalties for acute trusts.

While there is uncertainty on the financial budget over the coming years, introduction of locally agreed CQUIN schemes could improve care quality and patient safety in other areas of healthcare without an increase in cost.

References

1. The Stroke Association.  www.stroke.org.uk/ information/ what _ is _a _stroke/index.html (last accessed 29-4-10)

2. Coronary Heart Disease Statistics, 2005. (www.heartstats.org, accessed 1/05/10)

3. Adamson J, Beswick A and Ebrahim S. ‘Reducing Brain Damage: Faster access to better stroke care.’ Stroke and Disability Journal of Stroke and Cerebrovascular Diseases 2004; 13(4)

4. Department of Health, Older people’s NSF standards, Standard five- Stroke, 2008 (http://www.dh.gov.uk/en/Healthcare/Longtermconditions/Vascular/Stroke/DH_075730), accessed 01/05/10.

5. Stroke-Diagnosis and initial management of Transient Ischaemic attack(TIA) National Institute for health and clinical excellence guideline ,2008

6. Royal College of Physicians, National Sentinel Stroke Audit (Clinical Audit), 2008

http://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Documents/stroke-audit-report-2008.pdf (last accessed 29-4-10)

7. Royal College of Physicians, National Sentinel Stroke Audit (Organisational audit), 2008  http://www.nelm.nhs.uk/en/NeLM-Area/News/2008—-September/15/National-Sentinel-Stroke-Audit-results-of-organisational-audit-2008/ (last accessed 29-4-10)

8. Department of Health, Commissioning for Quality Improvement and Innovation, 2008(accessed 2/05/10).

9. Department Of health. Publication Policy and Guidance, Using the Commissioning for Quality and Innovation (CQUIN) payment framework (with addendum for 2010/11), 2009.

10. Pennine Acute Hospitals NHS Trust, Stroke CQUIN Indicator Implementation Roll Out Project Initiation Document, 2009.

11. Greater Manchester Integrated Stroke Service, Establishing the governance framework to support integrated Acute Stroke care, 2008

 http://www.gmccsn.nhs.uk/cmsupload/Stroke_Governance_Framework_Final.pdf

( last accessed 10/05/10)

12. Stroke Follow-Up Survey 2005, http://www.nhssurveys.org/publications (last accessed 27/04/10)

13. Johnston SC, Rothwell PM, Nguyen-Huynh MN et al. ‘Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack.’ The Lancet 2007; 369: 283-292.

Acknowledgements: Julie Smith, Robert Barrow, Richard Klimiuk and Louise Williams.