Irish National Audit of Stroke organisational audit report 2021

This is the third national audit of the organisation of acute hospital stroke services in Ireland and the first under the governance of the National Office of Clinical Audit. The first audit examining the organisation of stroke care took place in 2006 and it found that only one hospital had a stroke unit, that access to acute treatments such as thrombolysis  was very limited, and that the patient journey was fragmented and poorly organised.</p

Hospital size, remoteness and stroke outcome

Introduction: Previous studies have shown an association between number of stroke admissions and outcomes. Small hospitals often support more remote areas and we studied national data to determine if an association exists between hospital remoteness and stroke care. Methods: Data from the Irish National Audit of Stroke (INAS) on average stroke admissions, adjusted mortality for ischaemic stroke, thrombolysis rate and proportion with door to needle (DTN) ≤45 min were analysed. Hospital remoteness was quantified by distance to the next hospital, nearest neurointerventional centre and location within 10 km of the national motorway network. Results: Data for 23 of 24 stroke services were evaluated. Median number of strokes admitted per year was 186 (range 84-497). Nine hospitals (39%) admitted ≥200 stroke patients per year (mean 332). Average adjusted mortality (7.0 vs. 7.3, P = 0.67 t-test), mean thrombolysis rate (12.1% vs. 9.2%, P = 0.09) and mean proportion of patients treated ≤45 min (40.4% vs. 31.3%, P = 0.2) did not differ significantly between higher and lower volume hospitals.Hospitals close to the motorway network (n = 15) had a higher mean thrombolysis rate (11.9% vs. 7.5%, P = 0.01 t-test) and proportion DTN ≤45 min (43.7-18.4%, P Conclusion: Remoteness of hospitals is associated with worse measures of stroke outcome and management.</p

Response to: Relationship between hospital size, remoteness and stroke outcome

We thank Dr Liu and Dr Wang for their consideration of our paper. In response to some of their comments, as the paper makes clear, the study was conducted in only Ischaemic strokes (1). Because of the small size of some of the participating hospitals and the smaller proportion of haemorrhagic strokes calculations of adjusted mortality rate are less precise in the haemorrhagic stroke population. There are also fewer effective acute interventions for intracerebral haemorrhage thus measures of process such as thrombolysis rate and door to needle time would not be pertinent to them. Subsequent analyses of the data have found that in fact Remote hospitals in Ireland see a lower proportion of haemorrhagic strokes and care for a slightly older population (2) but both of these factors were controlled for in the study.</p

Profiling the characteristics of people after stroke in Ireland discharged home with and without Early Supported Discharge: analysis of a nationally representative cohort study [version 1; peer review: awaiting peer review]

Background: Early Supported Discharge (ESD) after stroke has demonstrated cost savings, reducing hospital length of stay (LOS) and long-term dependency. ESD discharges people after stroke from hospital earlier than conventional care with rehabilitation continuing at home. The Irish National Stroke Strategy 2022–2027 aims for ESD to be available to 92% of the stroke inpatient population. This study aims to profile the clinical characteristics and rehabilitation needs of those referred to ESD on discharge versus those discharged home without it in Ireland. Methods: This study represents secondary analysis of an anonymised nationally representative prospective cohort study; the Irish National Audit of Stroke (INAS). Data were retrieved for 2018–2020 inclusive. A subset of 20 variables were used to profile the clinical characteristics and rehabilitation needs of those referred to ESD on discharge versus those discharged home without it. Data were analysed descriptively. Results: In 2018, 139 people were discharged home with ESD, representing 3.8% of all people after stroke discharged home. This increased to 207 (4.9%) in 2019 and to 325 (6.6%) in 2020. More men were discharged home with and without ESD. Those aged 65–79 years represented the largest proportion of those discharged home with and without ESD. For those discharged with ESD, the mean LOS reduced each year from 17 days (SD=20) in 2018, 16 days (SD=16) in 2019 to 13 days (SD=13) in 2020. Those with a modified Rankin Scale score of 1, 2 at discharge represented the highest proportion of those returning home with ESD (59.3%) and without ESD (40.8%). Of those returning home with ESD, 10.8% were seen by a psychologist. Conclusions: There is a need for significant scale-up of ESD to meet National Stroke Strategy targets. Consensus on ESD eligibility criteria nationally needs to be established and access to psychology services for people after stroke needs expansion. </p

Major Trauma Audit national report 2019 and 2020

The Major Trauma Audit (MTA) is a clinically led audit established by the National Office of Clinical Audit (NOCA) in 2013. This audit focuses on the care of the more severely injured trauma patients in Ireland’s healthcare system. The methodological approach for the MTA is provided by the Trauma Audit and Research Network (TARN), based in the University of Manchester, United Kingdom (UK). In 2016, the MTA became the first national clinical audit endorsed by the National Clinical Effectiveness Committee (NCEC) and mandated by the Minister for Health. </p

Major Trauma Audit paediatric report 2014-2019

This report provides the first comprehensive analysis of paediatric major trauma in the Irish population. This is timely, given the opportunities for improving care for traumatically injured children throughout Ireland presented by the new children’s hospital, as this will be the single paediatric major trauma centre for the State. The report highlights that paediatric major trauma is of low frequency, at 5% of the overall trauma caseload for the 26 participating Irish hospitals. This represents a challenge in ensuring that healthcare institutions have the required expertise, preparedness and practice for presentations and procedures that happen relatively infrequently. The report also highlights the volume of major trauma patients attending model 3 and level 4 hospitals outside of Dublin and the need for on-site expertise and rapid transport services to get critically injured children to the right place at the right time. The MTA will continue to inform the reconfiguration of the Irish trauma system so that it is continuously modifying and improving, driven by the data and outcomes of MTA reports, in order to ensure equity of access to efficient and high-quality care for the children and adults of Ireland. A key finding from this report has been the many preventable mechanisms of injury leading to major trauma in children. Disseminating injury prevention messages to key groups and programmes will be a key focus for the audit. Moving forward, the MTA will work to support hospital MTA governance committees to use the data to identify areas of variation and develop QIPs to improve care

Major Trauma Audit national report 2021

This is the seventh national report from the Major Trauma Audit (MTA). Since 2016, 26 eligible hospitals have been participating in the MTA and data have been collected on almost 33,500 major trauma patients. This report focuses on processes that impact outcomes for patients who sustained major trauma during 2021. Chapter 6, The Patient Journey, includes a focus on major trauma patients who required blood products between 2017 and 2021. The process of reconfiguring Ireland’s trauma system began while this report was being written, following the publication of A Trauma System for Ireland: Report of the Trauma Steering Group (Department of Health, 2018). The commitment to developing an integrated trauma system is welcomed by the MTA. The ongoing work to ensure that facilities and services are coordinated for the delivery of care of major trauma patients in Ireland within standardised pathways is acknowledged.  This report includes data from only 22 of the 26 participating hospitals. The effects of redeployment when contending with a fourth and fifth wave of a global pandemic alongside further disruption associated with the cyberattack on the Health Service Executive (HSE) and vacant posts left unfilled have resulted in data coverage which is below the optimum standard of 80%. The data coverage for all 26 hospitals was 68%, which represents a further reduction from 73% in 2020 and 83% in 2019 (NOCA, 2022). As four hospitals had no data entered for 2021, the data coverage for the 22 hospitals is 76%. The goal for future reports is to provide hospital-level reporting in MTA to drive quality through enabling hospitals to benchmark against peer hospitals.  The MTA has consistently shown that injuries in the home, especially low falls, comprise the most common cause of major injuries. More needs to be done to keep our population safe; therefore, we continue to advocate the use of public health messages on this issue, which can be obtained via the website of the National Office of Clinical Audit (NOCA). The hyperlinked documents are highlighted in blue throughout the text. The Major Trauma Audit National Report 2018, (NOCA, 2020) featured a home safety infographic, the Major Trauma Audit Paediatric Report 2014–2019 (NOCA, 2021) featured an injury prevention infographic for children and the Major Trauma Audit National Report 2019 and 2020 (NOCA, 2021) featured a home safety checklist.  Each hospital is encouraged to use MTA reports for continuous quality improvement. Without the constant leadership provided by the hospital clinical leads for the MTA and the dedication and hard work of the audit coordinators, this audit would not be possible. The NOCA Executive Team and the MTA Governance Committee wish to thank the clinical leads, audit coordinators and staff in the participating hospitals for their continued commitment to, and engagement with, this audit.</p

Irish National Audit of Stroke: a critical review of national stroke data for Ireland from 2013 to 2021

In the European Union (EU) stroke is the second most common  cause of death and a leading cause of adult disability. As populations continue to grow and live to an older age, stroke and the long-term sequelae, along with the corresponding costs, are expected to increase dramatically (The Stroke Alliance for Europe, 2020; Bennett et al., 2014). Treatment for stroke has advanced greatly since the 1990s, and there is strong evidence that stroke unit care with multidisciplinary team input will reduce disability and mortality and will benefit all patients with a stroke. Patients with ischaemic stroke who present early after symptom  onset will benefit from emergency  treatments such as thrombolysis and thrombectomy (Organisation for Economic Co-operation and Development, 2015). </p

Irish National Audit of Stroke National Report 2020

Stroke remains the third leading cause of death in Ireland and Western Europe, and the leading cause of severe, adult-onset physical disability. We report on patients aged 17 years and over who were treated in the 24 public hospitals that provide acute stroke care in Ireland and that admit more than 25 stroke cases annually. Data are typically collected by stroke services on behalf of the participating hospitals. In order to be included in the audit report, hospitals must have collected data on more than 80% of patients with a stroke. This year’s report incorporates data from the 23 participating hospitals that met the mandatory 80% coverage threshold; overall, despite the effects of the coronavirus disease 2019 (COVID-19) pandemic, coverage improved from 83% to 93% across the hospital system for patients with a stroke identified through the Hospital In-Patient Enquiry (HIPE) system as having been admitted with acute stroke, either ischaemic or haemorrhagic. The audit does not currently collect data on subarachnoid haemorrhage; however, we are exploring how these data may be effectively incorporated in future years’ audits. Because of the increased coverage, the number of individuals on whom data have been collected increased by more than 20% in 2020 from 2019. This important increase in coverage does appear to have led to substantial changes in proportional outcomes for most variables, but caution should be exercised in interpretation of minor changes from previous years.</div

Irish Heart Attack Audit national report 2021

The Irish Heart Attack Audit National Report 2021 includes data from 1,491 patients with an ST elevation myocardial infarction (STEMI) who received treatment in a percutaneous coronary intervention (PCI) centre during 2021. STEMI was more common in males (n=1154, 77%), with females presenting at an older median age (67 years versus 61 years in males) and with a higher burden of comorbidities. The data provide detailed information about the care, processes and outcomes received by patients with a STEMI, and enable each participating hospital to benchmark itself against comparable hospitals in Ireland. The quality of care delivered is measured against national and international key quality indicators (KQIs), and opportunities for quality improvement (QI) are identified. </p