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Improving clinical practice in stroke through audit: results of three rounds of National Stroke Audit
1Stroke Programme Co-ordinator, Clinical Effectiveness and Evaluation Unit, Royal College of Physicians London, London NW1 4LE, UK. penny.irwin@rcplondon.ac.uk
Insights
National Stroke Audits reveal improved stroke care standards, with mortality decreasing and stroke unit care rising. Further improvements require more patients managed in specialized stroke units.
Area of Science:
- Neurology
- Public Health
- Healthcare Management
Background:
- Three rounds of the National Stroke Audit in England, Wales, and Northern Ireland were conducted.
- The audits assessed stroke service organization and patient case notes.
Purpose of the Study:
- To compare the results of three National Stroke Audits.
- To analyze changes in organizational, case-mix, and process outcomes over time.
- To evaluate the impact of stroke unit care on patient outcomes and standards.
Main Methods:
- A retrospective case-note audit of up to 40 consecutive stroke cases per hospital.
- Audits conducted in 1998, 1999, and 2001/02, involving eligible trusts across England, Wales, and Northern Ireland.
- Analysis focused on hospitals participating in all three audit rounds.
Main Results:
- Mortality at 7 and 30 days decreased by 3% and 5%, respectively.
- The proportion of hospitals with dedicated stroke units increased from 48% to 77%.
- Care standards on stroke units were consistently higher than on general wards, though improvement slowed by 2001/02.
Conclusions:
- Stroke units demonstrate notably higher standards of care compared to general wards.
- Slower improvements in national care standards correlate with a slower increase in stroke unit management.
- Increased patient management within stroke units is crucial for further improving stroke care outcomes.
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.