Variation in quality of acute stroke care by day and time of admission: prospective cohort study of weekday and weekend centralised hyperacute stroke unit care and non-centralised services

Abstract

ObjectiveTo investigate variations in quality of acute stroke care and outcomes by day and time of admission in London hyperacute stroke units compared with the rest of England.DesignProspective cohort study using anonymised patient-level data from the Sentinel Stroke National Audit Programme.SettingAcute stroke services in London hyperacute stroke units and the rest of England.Participants68 239 patients with a primary diagnosis of stroke admitted between January and December 2014.InterventionsHub-and-spoke model for care of suspected acute stroke patients in London with performance standards designed to deliver uniform access to high-quality hyperacute stroke unit care across the week.Main outcome measures16 indicators of quality of acute stroke care, mortality at 3 days after admission to the hospital, disability at the end of the inpatient spell, length of stay.ResultsThere was no variation in quality of care by day and time of admission to the hospital across the week in terms of stroke nursing assessment, brain scanning and thrombolysis in London hyperacute stroke units, nor was there variation in 3-day mortality or disability at hospital discharge (all p values>0.05). Other quality of care measures significantly varied by day and time of admission across the week in London (all p values<0.01). In the rest of England there was variation in all measures by day and time of admission across the week (all p values<0.01), except for mortality at 3 days (p value>0.05).ConclusionsThe London hyperacute stroke unit model achieved performance standards for ‘front door’ stroke care across the week. The same benefits were not achieved by other models of care in the rest of England. There was no weekend effect for mortality in London or the rest of the England. Other aspects of care were not constant across the week in London hyperacute stroke units, indicating some performance standards were perceived to be more important than others.

What does it take to provide clinical interventions with temporal consistency? A qualitative study of London hyperacute stroke units

“…To our knowledge, this is the first qualitative study about the organisation of stroke care with respect to temporal variation. This study reports qualitative data that help explain the findings presented in Melnychuk et al 24. Consistent provision of clinical interventions was underpinned by: (1) junior nursing and medical staff extending their in-hours responsibilities to cover key decision-making roles, such as that of the thrombolysis nurse; (2) intervening to bridge potential gaps caused by shift-working (staggering rotas, holding meetings to share information) and (3) HASU leadership building trust and respect across staff both within HASUs and within key specialties elsewhere in the hospital (such as ED and neuroradiology).…”

“…London HASUs deliver ‘front door’ clinical interventions, including brain scans, thrombolysis and swallow assessment without significant temporal variation 24. Length of stay showed significant variation without a clear temporal trend, assessment by a stroke physician within 12 or 24 hours varied by time of day and assessments by therapists varied by the day of the week.…”

“…Staff were sampled purposively to ensure coverage of a range of professional roles within all eight HASUs, with perspectives on the clinical interventions analysed in our accompanying paper in this issue24 (eg, interpreting brain scans, thrombolysis, therapy assessments) including medical, nursing, therapy and administrative or managerial staff (table 2).…”

“…The third phase developed iteratively by group interpretation of the coded data, focusing on the research questions and unexpected findings. Finally, we mapped the results against the variations in practice across the 7-day week found in our analysis of the performance data for care provision in London HASUs set out in Melnychuk et al ,24 in particular the distinction between ‘front door’ clinical interventions (which were provided consistently) and other interventions (which were not).…”

“…The model is governed by the London Stroke Strategy which imposes tariff-linked requirements for staff level consistency and sufficient evidence-based care at all times; this strategy may have facilitated better outcomes 22. We show in a companion paper24 that in the London HASUs, there was:No variation by day/time of admission in 3-day mortality or disability at hospital discharge.No variation by day/time of admission in delivery of ‘front door’ interventions, such as stroke nursing assessment, brain scanning and thrombolysis measures.Significant variations by day/time of admission in other interventions (including timely consultations and assessments with stroke specialists and therapies, and length of hospital stay).…”