Acute Stroke Care in Ireland - The Role of a National Audit in Improving Care

Abstract

Background: The 2008 Irish national audit of stroke service (INASC) showed large deficits in service provision and access. A national stroke programme emerged to develop services and address these deficits. The country suffered a severe economic recession with a 23% reduction in health funding between 2008-2014. We undertook a second national audit to reassess the impact of the national stroke programme. Methodology: Twenty-seven hospital sites participated in the audit consisting of: -An audit of the organisational aspects of stroke care in acute hospitals. -A clinical audit of stroke care involved the review of clinical case notes (874 cases) for a selected national sample of patients with stroke. The results were compared against the findings of INASC 2008 and the Sentinel Stroke National Audit Programme (SSNAP) UK 2014, and in particular Northern Ireland. Results: In the 2015 audit 27 hospitals admitted acute stroke patients compared with 37 hospitals in 2008. 21 sites (78%) provided stroke unit care, compared with 1 unit (3%) in 2008 (p<0.001, Chi square). Only 29% of patients were admitted directly to a stroke unit and 54% spent some time in a unit during their admission. The number of stroke unit beds available nationally at the time of the audit was 150. However, 61% of inpatients with a stroke at the time of the audit were being managed on a ward other than a stroke unit. 24/7 access to CT was available in all hospitals (78%, 2008 p<0.05). Specialist physicians and nurses in 23 sites (85%) increased from 14% in 2008 (p<0.001). 11% of nonhaemorrhagic strokes were thrombolysed compared with 1% in 2008 (p<0.001). Average length of stay reduced from 30 days to 22 days, with a reduction in newly institutionalised patients to residential care down from 15% to 8% (p<0.001). Inpatient mortality rate dropped from 19% to 14% (p<0.01). A deficit in the availability of rehabilitative therapists exists, with deficits of 61%, 50%, and 31% for OT, physiotherapy and SLT respectively when compared to recent guidelines. Conclusion: The National Stroke Audit 2015 provided a snapshot of the acute service available in Ireland. It provides vital information for planning and development both at local and national level. Overall, the audit found reorganisation of services, and recruitment and training of specialist staff improved service provision and outcomes for stroke patients in Ireland.