stop stroke. save lives. end suffering. why patients are not receiving stroke unit care: barriers...
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Stop stroke. Save lives. End suffering.
www.strokefoundation.com.au
Why patients are not receiving stroke unit care: Barriers and facilitators to stroke unit access?
BackgroundStroke unit care (SUC) significantly reduces death and disability after stroke compared with conventional care in general wards for all people with stroke (odds ratio [OR] 0.82, 95% CI 0.73–0.92)1.The 2009 National Audit of Acute Stroke Services reported an increase from 2007 in the number of stroke units (SUs) (36 in 2007 to 54 in 2009) and SU beds (391 in 2007 to 534 in 2009). However only 49% of patients received care on a SU (all hospitals) and 74% received care on a SU (stroke unit hospitals) .
The Australian Stroke Coalition (ASC)# identified two priorities: the need to increase the number of SUs and to improve access to existing stroke units.
AimTo identify the barriers and facilitators to SU access in Australia.
DiscussionThis survey has shown there are a number of reasons why stroke patients do not get access to SUC: • Lack of resources (bed availability, poor stroke unit staffing, appropriate discharge facilities) • poor use of existing resources (bed management, Hospital ED “access block”, ED culture, Colleagues ('SU consultants')
practice/application of guidelines) • poor systems (bed management, Hospital ED “access block policy”, lack of a formal process to identify stroke patients, hospital
stroke admission policy, SU admission policy/exclusion criteria).
Hospitals with good SUA state the following reasons:• appropriate resourcing (Registrar with responsibility for stroke, stroke coordinator, bed availability, staff resources) • good use of existing resources (pro-active staff, hospital policy/culture, education) • good systems (stroke guidelines, hospital policy/culture, ED protocols).
While the survey results provide an excellent view of SUs in Australia, they must be interpreted with caution. The self-reported survey was completed by a representative from the participating hospital and may be subject to individual and systems knowledge bias. These sites may also be subject to selection bias as those participating are likely to be actively involved in improving their stroke services.
ConclusionThe Australian Stroke Coalition has identified access to SUC as a priority. There are numerous barriers and enablers identified by this survey. A systematic, evidence-based quality improvement approach to identifying and resolving barriers to SU access is clearly required to maximise the benefits of SUC.
AcknowledgementsMembers of the Australian Stroke Coalition Access to Stroke Unit Working Group:Greg Cadigan Principal Project Officer, Queensland Statewide Stroke Clinical Network; Assoc Prof Dominique Cadilhac Head, Public Health Division NSRI; Dr Helen Castley Neurologist Royal Hobart Hospital; Ms Sonia Denisenko Manager, Victorian Stroke Clinical Network; Ms Pip Galland Stroke Liaison Officer, Westmead Hospital; Dr Erin Godecke (Chair)Post Doctoral Research Fellow, Edith Cowan University; Dr Andrew Granger Geriatrician WA Stroke Unit Network; Prof Christopher Levi Director, Acute Stroke Services Hunter Stroke Service; Dr James Leyden Consultant Neurologist Queen Elizabeth Hospital; Mr Mark Longworth Manager, Statewide Stroke Services NSW Agency for Clinical Innovation; Mr Michael Pollack Rehabilitation Medicine John Hunter Hospital; Mr Chris Price Divisional Director, Stroke Services NSF; Ms Rebecca Smith A/Research and Quality Officer, Internal Medicine Services The Prince Charles Hospital; Ms Leah Wright Senior Project Officer, Stroke Services NSF
MethodsThe ASC Access to Stroke Unit working group (WG) reviewed de-identified national audit data 2, 3 to determine which hospitals had “high” access rates to their SU’s and which had “low” rates of access. The WG developed a 12-question online survey to explore the barriers and facilitators to SU access. All 68 stroke unit hospitals across Australia were invited to participate. The survey aimed to better understand the processes that support good access and other processes that may relate to access issues, e.g. emergency department protocols, staffing levels, bed numbers, etc. The survey included closed and opened questions. The survey results were collated and the findings were then compared to SU access figures.
ResultsIn total, 56 identified hospitals and 2 unidentified hospitals responded to the survey. 50 hospitals (89%) had SUs and 6 hospitals did not.
Barriers
L Wright1, E Godecke2, C Price1 for the Australian Stroke Coalition Access to Stroke Unit Working Group
“Currently we are having more trouble getting people out of the stroke room in order to let a new stroke in. We have a policy for this, but further education is
needed. Case conferencing usually helps identify when pts are ready to leave and therefore frees up beds.”
Facilitators
“I believe we have a supportive ED who are trying their best to support the quick assessment and management of stroke presentations. We are working to improve out clinical pathways with ED. As education increases amongst the nurses in ED, the time it takes for the stroke page to be activated
decreases. Having close contact with the bed manager and the ward case manager also facilitates good planning for bed movements and can aide in quicker admission to the SU.”
# The Australian Stroke Coalition was established by the National Stroke Foundation and Stroke Society of Australasia on 11 July, 2008. The Coalition brings together representatives from groups and organisations working in the stroke field, such as clinical networks and professional associations/colleges. This group works together to tackle agreed priorities to improve stroke care, reduce duplication amongst groups and strengthen the voice for stroke care at a national and state level.
Figure 1. Current barriers to stroke unit access
Figure 2. Facilitators to stroke unit access
ED pro
toco
ls
Educa
tion
Regist
rar w
ith re
spon
sibilit
y for
stro
ke
SU guid
eline
s
Hospit
al po
licy/
cultu
re
Case
findin
g an
d m
oving
of s
troke
s to
SU p
ost a
dmiss
ion
Bed a
vaila
bility
Pro-a
ctive
sta
ff
Staff
reso
urce
s
Stroke
Coo
rdina
tor
Oth
er (p
lease
spe
cify)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
56.1%
83.3%
65.2% 65.2%71.2%
53.0%48.5%
89.4%
31.8%
62.1%
13.6%
Lack o
f ED g
uidelin
es
ED cultu
re
Hospita
l stro
ke a
dmiss
ion p
olicy
SU adm
issio
n polic
y / e
xclu
sion c
riteria
Colleagues
('SU c
onsulta
nts')
pract
ice /
applicatio
n of g
uidelin
es
Access
to c
ompute
rs
Lack o
f a fo
rmal p
roce
ss to
identify
stro
ke p
atients
Lack o
f ele
ctro
nic data
base
sys
tem
to id
entify p
atients
Lack o
f knowle
dge to u
se IT
sys
tem
s
Bed ava
ilabilit
y
Bed Managem
ent
Poor SU s
taffin
g
Hospita
l ED "a
ccess
blo
ck" p
olicy
Oth
er0%
10%
20%
30%
40%
50%
60%
70%
80%
23.8%
33.3%
22.2%17.5%
31.7%
1.6%
17.5%14.3%
4.8%
77.8%
57.1%
30.2%
6.3%11.1%
1National Stroke Foundation, Melbourne, Victoria, Australia2Edith Cowan University, Western Australia, Australia