All Wales Profession Specific Audit of Stroke - psa - all wales tools and guida… · The PSAG, in the light of feedback from the pilot, reviewed and revised the PSA audit tools and

All Wales

Profession Specific Audit of Stroke

Audit Tools and Protocol

2008

Stroke Services Improvement Project nww.stroke.wales.nhs.uk

Stroke - PSA - All Wales Tools and Guidance 2008

JMS Oct 2008 1

Contents

1. Background ……………………………………………………..

2

2. First National Profession Specific Audit Pilot …………….

2

3. Revised PSA …………………………………….……………...

2

4. Second PSA Pilot - All Wales ………………………………..

3

5. PSA Protocol - All Wales ……………………………………..

3

5.1 Scope …………………………………………………

4

5.2 Localities …………………………………………….

4

5.3 Local Audit Teams …………………………………

4

5.4 PSA - Organisational Audit ……………………….

4

5.5 PSA – Clinical Audit ……………………………….

4

5.6 Submission of Audit Data ………………………...

5

Appendices

1 Localities and Locality Identification Codes …………. 6

2 Definitions …………………………………………………... 7

3 Case List Pro Forma ………………………………………. 8

4 Organisational Audit Tool ………………………………... 9

5 Clinical Audit Tool - Nutrition and Dietetics ………….. 14

6 Clinical Audit Tool - Occupational Therapy …………... 16

7 Clinical Audit Tool – Physiotherapy ……………………. 20

8 Clinical Audit Tool - Speech and Language Therapy... 23

9 Clinical Audit Tool – Nursing ……………………………. 26

10 Clinical Audit Tool - Clinical Psychology ……………... 28

11 Clinical Audit Tool – Podiatry/Orthotics (not yet available)

--


JMS Oct 2008 2

1. Background

Every year in the UK an estimated 150,000 people suffer a stroke and one in ten people in the UK will die from a stroke. There are 250,000 people living with severe disabilities caused by stroke, the third largest cause of severe disability.

Timely and appropriate treatment of stroke has shown to be effective in reducing deaths and improving recovery. Standards for stroke management are set out in the National Service Frameworks for Older People and the National Clinical Guidelines for Stroke.

In 1998 The Royal College of Physicians (RCP), under the guidance of an Intercollegiate Working Party, established a bi-annual National Sentinel Audit of Stroke. The audit, comprised of two parts - an organisational audit and a clinical audit, enables the assessment of multi-disciplinary inpatient stroke services in England, Wales and Northern Ireland.

Five rounds of the National Sentinel Audit of Stroke have been completed since 1998. The 6th organisational audit was undertaken in April 2008 and the 6th Clinical Audit will be conducted in October 2008. The most recent published audit can be found on http://www.rcplondon.ac.uk/pubs/books/strokeaudit/

2. First National Profession Specific Audit Pilot

The first profession specific audit (PSA) for stroke was piloted across England, Wales and Northern Ireland in 2006. The audit was developed, co-ordinated and analysed by the Profession Specific Audit Group (PSAG) on behalf of the RCP Intercollegiate Working Party for Stroke and encompassed the services provided by:- • Nutrition and Dietetics • Occupational Therapy • Physiotherapy • Speech and Language Therapy • Nursing Each discipline had a separate audit tool consisting of two parts, an organisational audit and a clinical audit.

The results were published in May 2007. The report can be found on the National library for health web-site:- Profession specific audit of stroke 2006: a multidisciplinary pilot study

3. Revised PSA

The PSAG, in the light of feedback from the pilot, reviewed and revised the PSA audit tools and in November 2007 produced 2nd Edition tools consisting of:- • a single organisational audit tool common to all five professions , and • five profession specific clinical audit tools.


JMS Oct 2008 3

The clinical audits do not cover all aspects of care included in uni-professional standards but have been designed to identify key areas of intervention pertinent to the evaluation of the quality of stroke services.

Participation in the audits should enable local teams to:- • benchmark the quality of their stroke services against the audit standards • provide detail to support practice development • evaluate the progress of implementation of the National Clinical Guidelines for

Stroke for each profession

4. Second PSA Pilot - All Wales

Within the Programme of Work for Stroke for Wales, WHC (2007) 082, there are two actions relating to audit of nursing and therapy services for stroke patients. These are to:- • Undertake Profession Specific Audits of nursing, physiotherapy, occupational

therapy, speech and language therapy and dietetic provision using Royal College of Physicians/professional colleges audit tools (piloted in 2006).

• Develop audit tools and undertake Profession Specific audits for clinical

psychology and orthotics

To enable these two actions to be achieved the Welsh Assembly Government has agreed with the RCP that a second PSA pilot will be undertaken in Wales using the 2nd Edition audit tools. This second pilot will be co-ordinated and analysed by the National Public Health Service for Wales (NPHS) on behalf of the Stroke Services Improvement Project. The 2008 All Wales audit will include the in-patient stroke centres in Wales and encompass the period from acute admission to discharge from that continuous in-patient stay, regardless of number of ward areas involved. While the 2nd Edition tools will be used for the All Wales audit a number of additional data items, considered to be of significance in Wales, have been added by members of the Welsh Stroke Alliance Rehabilitation Sub-group. Of particular note is the addition of:-

• co-located beds and out-patient* sections to the organisational audit; • psychology, social work and podiatry staffing to the organisational audit; • psychology clinical audits tools**

*out-patient data will be collected by the organisational audit only, this round of clinical audit will not cover the outpatient component of the patient pathway. ** a clinical audit for podiatry is under development.

5. PSA Protocol - All Wales

The audit comprises two parts:- • An Organisational Audit • Six Profession Specific Clinical Audits


JMS Oct 2008 4

5.1 Scope The Organisational Audit is intended to capture data on aspect of acute/rehab/ combined stroke units; co-located beds; community stroke teams; and outpatients. The Clinical Audits are intended to capture data on the acute part of the patient pathway only. This is defined as commencing from the point of admission to and discharge from a hospital bed and should include any transfers between wards. 5.2 Localities The audits will be undertaken in localities across Wales that align to those participating in the Stroke Sentinel Audit. These are given in Appendix 1 together with PSA locality identification codes. 5.3 Local Audit Teams Each locality should establish a local Profession Specific Audit Team (PSAT) that includes, as far as is practicable, at least one member from each of the professions listed below. The team should work closely with the Local Stroke Sentinel Audit team to co-ordinate the audits and avoid duplication of effort. The PSAT should identify a key contact person responsible for linking with the Stroke Services Improvement Project and the NPHS and who will be responsible for co-ordinating the audits and submitting data via the Stroke in Wales web-site. 5.4 PSA - Organisational Audit One PSA Organisational Audit Tool (Appendix 4) should be completed for each location and must include data on the following disciplines:- • Nutrition and Dietetics • Occupational Therapy • Physiotherapy • Speech and Language Therapy • Nursing • Clinical Psychology • Social Worker • Podiatry For the All Wales 2008 PSA Organisational Audit the data provided should relate to the period April to June 2008.

5.5 PSA - Clinical Audits The profession specific clinical audits should be completed retrospectively for each of the following disciplines from the records of consecutive patients admitted to each Stroke Unit/team within a three month period. • Nutrition and Dietetics (appendix 5) • Occupational Therapy (appendix 6) • Physiotherapy (appendix 7) • Speech and Language Therapy (appendix 8) • Nursing (appendix 9) • Clinical Psychology (appendix 10)


JMS Oct 2008 5

All clinical records relating to the cohort of patients should be examined in the audit. This may include the ‘medical notes’ and a range of profession specific notes dependant on the local record keeping practices. For the All Wales 2008 PSA Clinical audit the start and finish dates will align with that for the 2008 Stroke Sentinel Audit i.e. all consecutive admissions from:- 1st April 2008 to 30th June 2008. Collection of each set of profession specific audit data should cease when:- • the number of cases reaches 20 for the discipline, or • all cases admitted within the three month time frame have been used It is acknowledged that for smaller centres there may not be 20 admissions within the 3 month time frame. It is also acknowledged that, while all patients will be seen by nursing staff, not all will be seen by all other disciplines. While the aim is to collect clinical audit data for 20 cases per discipline it is accepted that this may not be achieved in all centres. A sample case list pro forma is provided at Appendix 3 to support the tracking of progress. 5.6 Submission of Audit Data The audit tools are appended to this guidance in word format, with an online format provided on the Stroke in Wales web-site nww.stroke.wales.nhs.uk or nww.nphs.wales.nhs.uk/stroke. Submissions of completed audits to the NPHS must be made via this on-line facility. To access the online facility each PSA Team should contact Dr S Jones in the NPHS to obtain a secure password [email protected] The online version of the Organisational Audit is shorter than the word version. For this audit only PSA Teams are required to also submit a word version of the full Organisational Audit to Dr Jones by e-mail. All completed audits should be submitted by 30th November 2008.


JMS Oct 2008 6

Appendix 1

Profession Specific Audit for Stroke – All Wales Pilot 2008 Localities and Identification Codes

PSA Locality Trust

PSA Locality Hospital

PSA Locality Code

Mid & West Wales ABM University NHS Trust Neath Port Talbot MW 001 Morriston MW 002 Princess of Wales MW 003 Singleton MW 004 Hywel Dda NHS Trust Bronglais MW 005 Prince Philip MW 006 West Wales General MW 007 Withybush MW 008 Other MW 100 South East Wales Cardiff and Vale NHS Trust Llandough SE 001 University Hospital Wales SE 002 Cwm Taf NHS Trust Prince Charles SE 003 Royal Glamorgan SE 004 Gwent Healthcare NHS Trust Caerphilly Miner's SE 005 Nevill Hall SE 006 St Woolos/Royal Gwent SE 007 Other SE 100 North Wales Conwy & Denbighshire NHS Trust Glan Clwyd NW 001 North West Wales NHS Trust Bangor NW 002 Llandudno NW 003 North East Wales Wrexham Maelor NW 004 Other NW 100


JMS Oct 2008 7

Appendix 2

Definitions 1. Stroke units The definition of a stroke unit used in this audit is based on that of the NSAS (2006) which defines a stroke unit as:

A multidisciplinary team including specialist nursing staff in a discrete ward designated for stroke patients

This category includes the following:

a. Acute stroke units - accept patients acutely but discharge early (usually within 7 days).

b. Rehabilitation stroke units - accept patients after a delay of usually 7 days or

more and focus on rehabilitation.

c. Combined stroke units - no separation between acute and rehab beds - that accept patients acutely but also provide rehab for at least several weeks as necessary.

2. Co-Located Stroke Beds The 2008/9 Annual Operating Framework Target required that ‘by March 2009, each patient suspected of or confirmed as having had a stroke must be admitted to dedicated and co-located acute stroke beds staffed by a specialist multi-disciplinary medical and acute rehabilitation stroke team’. The definition used in this audit is:-

Dedicated Co-Located Stroke Beds are hospital beds in a ward or part of a ward that are located very near one another (subject to issues of dignity and gender) and are guaranteed for admitting stroke patients who should have access to high quality specialist acute medical and rehabilitation stroke care.

3. Community Stroke Teams There is no formally agreed definition as to the constitution of a Community Stroke Team. For the purposes of this audit the following working definition should be adopted. A Community Stroke Team consists of a team of specialist therapists and nurses established to provide dedicated support for stroke patients in the community, with access to stroke physician for medical input as needed. 4. Out-patients For the purposes of this audit out-patients is defined as any out-patient setting providing rehabilitation or maintenance services for stroke patients. This may be uni or multi professional e.g. physiotherapy rehab, MDT Rehab, Day Hospital etc.


JMS Oct 2008 8

Appendix 3 Case List Pro Forma Locality …………… Locality Code ………… Key Use for:- P Seen by; audited Í Not seen by; not audited ¡ Palliative care � Patient died

Nurse

Physio

OT

Diet

SLT Social Work

Clin Psych

Pod

Pt No

Unique

Identifier (for local use only)

Seen

by

Au

dited

Seen

by

Au

dited

Seen

by

Au

dited

Seen

by

Au

dited

Seen

by

Au

dited

Seen

by

Au

dited

Seen

by

Au

dited

Seen

by

Au

dited

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30


JMS Oct 2008 9

Appendix 4

ALL WALES - PROFESSION SPECIFIC STROKE AUDIT

ORGANISATIONAL AUDIT

NB text and data fields in blue have been added for use in the All Wales audits

Complete one organisation audit for each locality Name of Service …………….. Locality Identification Code ………….… Date: …………………..……… Type of service*: (See appendix 2 for definitions) Acute beds o Rehab beds o Combined acute/rehab stroke unit o Co-located beds o Community stroke team o Outpatients o * please tick all that are appropriate 1. On your stroke unit/service, what are your current staffing establishments in whole

time equivalents?

Band Acute Stroke Unit 1 2 3 4 5 6 7 8

Nursing Physiotherapy Occupational Therapy Speech & Language Therapy Nutrition and Dietetics Podiatry Psychology CCA/

SWA Social Worker

Senior SW SW Practitioner

Principal SW

Social Work

Band Rehabilitation Stroke Unit 1 2 3 4 5 6 7 8


SWA Social Worker


Principal SW

Social Work Band


JMS Oct 2008 10

Combined Stroke Unit 1 2 3 4 5 6 7 8 Nursing Physiotherapy Occupational Therapy Speech & Language Therapy Nutrition and Dietetics Podiatry Psychology CCA/

SWA Social Worker


Principal SW

Social Work

Band Co-located beds 1 2 3 4 5 6 7 8


SWA Social Worker


Principal SW

Social Work

Band Community Stroke Team 1 2 3 4 5 6 7 8


SWA Social Worker


Principal SW

Social Work

Band Outpatients 1 2 3 4 5 6 7 8


SWA Social Worker


Principal SW

Social Work


JMS Oct 2008 11

2. How many beds are there on your unit? Number of beds Acute Stroke Unit Rehabilitation Stroke Unit Combined Stroke Unit Co-located beds

3. Which disciplines in your team are actively participating in research?

Research activity is defined as taking part in a project e.g. screening, outcome assessment etc or designing or leading projects.

Yes No Nursing Physiotherapy Occupational Therapy Speech and Language Therapy Nutrition and Dietetics Psychology Podiatry Social Work

4. Does your service offer multidisciplinary stroke in-service training?

Yes No

5. Where required, can your patients access the following?

Yes No Bladder scanning on the unit Videofluoroscopy Fiberoptic Endoscopic Evaluation of Swallowing (FEES) Home enteral feeding support via a Dietitian Botulinum Toxin for post-stroke spasticity Functional Electrical Stimulation (FES ) Full neuropsychological assessment Vascular assessment of lower limb Social Work Services

6. Does your dietetic service accept referrals for the following?

Yes No Enteral feeding? Oral nutritional support? All patients on modified consistency diets? Diabetes? Weight management? Dietary secondary prevention of stroke?

7. Is a choice of modified consistency foods available at each meal?

Yes No


JMS Oct 2008 12

8. Are there written protocols for the following?

Yes No Self Medication? Stroke Specific Moving, Handling and Positioning? Promotion of Continence/ Management of Incontinence? Dysphagia? Nutrition Management? Enteral Feeding? Carer Support? Patient Centred Approach/goal planning meetings? Pressure Area Care? Assessment of mood? Therapeutic Handling? Assessment of Cognition? Where in place are these integrated into a written Operational Plan for the unit?

9. Do you have a multidisciplinary stroke strategy group that covers acute and

community services?

Yes No Partial

10. Does your service offer a Stroke Specific Early Supported Discharge Scheme?

Yes No Partial 11. Does your service have access to a generic Early Supported Discharge Scheme?

Yes No Partial 12. Does your service offer a Stroke Outreach Team Service?

Yes No Partial 13. Does your service have access to a generic community follow up service?

Yes No Partial 14. Does your service provide patients and carers with information on stroke

prevention?

Yes No 15. Do you refer patients to the Stroke Association?

Yes No

16. Does your service have a Social Worker attached to it? Yes No


JMS Oct 2008 13

If ‘No’, are social care assessments undertaken? Yes No If ‘Yes’, are these incorporated into discharge planning? Yes No


JMS Oct 2008 14

Appendix 5 PSA Stroke Clinical Audit Nutrition and Dietetics NB text and data fields in blue have been added for use in the All Wales audits Locality Code ……… Patient ID…………… Age…………. years Gender M / F Location of service - please tick all that are appropriate Acute beds o Rehab beds o Combined acute/rehab stroke unit o Co-located beds o Date of Admission to Hospital …………………………… Date of referral received by Dietitian................................. Date first seen by Dietitian ……………………………… Process of Care Please tick the appropriate column for ‘Yes’, ‘No’ or ‘No but…’ (If answering ‘no but…’ please see definitions of ‘no but..’) Audit Question

Referral & Assessment

Yes

No

No, but…. 1 Has an initial screening tool been completed by the

nursing staff within 48 hours of admission and/or transfer?

2 Has the patient been weighed or a Mid Upper Arm Circumference (MUAC) been recorded weekly during their hospital stay? (Answer ‘No, but....’ if patient is for palliative care etc Please detail)

3 Is there evidence that the initial assessment by the Dietitian has been completed and documented within two working days of referral?

4 Does the initial assessment include: a) Initial BMI b) Weight history / usual weight c) Diet history d) Able to self feed or not (No, but…if patient

NBM) e) Estimation of nutritional requirements (Answer

‘No, but’ if this information is Not Applicable) f) Are there enough staff with appropriate skills to

assist with eating and drinking Number of Nurses per meal ________________Number Patients needing assistance ________

g) Who else is available to assist at meal times? i) Volunteers ii) Family iii) Dietetic Assistants iv) Specifically trained feeding assistants

v) Other, please specify..............................


JMS Oct 2008 15

Goal Setting & intervention

Yes

No

No, but….

5 Is there evidence of a documented nutritional care plan in medical / multidisciplinary notes?

6 Is there documented evidence of a review for the nutritional care plan?

7 Is there evidence of a target weight or weight maintenance?

8 Is there evidence of weight being reviewed weekly? 9 Is there evidence of a review of the patients’ nutritional

assessment regularly according to Trust specific protocol?

Team Working

Yes

No

No, but….

10. Is there evidence this care plan has been shared with the multidisciplinary team at a patient review meeting?

Evaluation/transfer of care/discharged

Yes

No

No, but….

11 Is there evidence that the patient and / or their carers have been advised about their nutritional needs? (No, but …if no specific nutritional needs or patient died)

12 Is a nutrition and dietetic summary written, either for the multidisciplinary discharge report or a stand alone dietetic summary? (‘No But’ if patient died or no specific nutritional needs)

13 Has any follow up been agreed? (‘No But’ if no specific nutritional needs at discharge)

14 If yes to Q 13 What follow up Dietetic services is available to the patient:

a. Domicillary/community services b. Outpatient clinics c. Early supported discharge scheme d. Stroke outreach service e. Home enteral feeding team f. Other, eg; Day Hospital, please specify................................


JMS Oct 2008 16

Appendix 6

PSA Stroke Clinical Audit Occupational Therapy NB text and data fields in blue have been added for use in the All Wales audits

Locality Code ……… Patient ID…………… Age…………. years Gender M / F Location of service - please tick all that are appropriate Acute beds o Rehab beds o Combined acute/rehab stroke unit o Co-located beds o Date of Admission to Hospital …………………………… Date first seen by an Occupational Therapist ……………………………… Process of Care Please tick the appropriate column for ‘Yes’, ‘No’ or ‘No but…’ (If answering ‘no but…’ please see definitions of ‘no but..’)

QUESTION YES NO NO, BUT

NO, BUT…. EXPLANATION

Referral and Assessment

1 Is there evidence that the stroke survivor was interviewed within the agreed time frame? (5 days from admission)

i.e. patient unconscious, died, palliative care, unwell

Is there information on the following: a) Home situation (physical

environment)?

b) Home situation (socio-cultural)? c) Pre-stroke level of self-care? d) Pre-stroke employment? e) Pre-stroke domestic responsibilities? f) Pre-stroke leisure activities? g) Pre-stroke driving status?

2

h) Concerns of the stroke survivor? Is there evidence that: a) The family / carers were contacted

by the occupational therapist within seven days of initial contact with the stroke survivor?

i.e. no relatives / carers involved

3

b) There was discussion on the concerns of the family / carers?

4 Is there evidence of occupational therapy assessment within the agreed time frame? (5 days from admission)


Does the assessment include:

a) Lifestyle issues? b) Employment issues?

5

c) Positioning and support?


JMS Oct 2008 17

d) Visual disturbance? e) Mood disturbance? f) Cognitive / perceptual function? g) Motor control? h) Need for orthotics? i) Tone disturbance? j) Sensory disturbance? k) Activities of daily living? i Personal Care Assessment within 5 working days

ii Feeding assessments within 5 working days

iii Domestic ADL assessment completed

iv Life skills assessed e.g. money, telephone use

Transfers:- v. Bed

vi. Chair

vii Toilet/commode

viii Bath/shower

ix Car

l) Home visit assessment completed

m) Driving advice given

Goal Setting and Intervention

Is there evidence that occupational therapy goals were discussed with:

a) The stroke survivor?

6

b) The stroke survivor’s family / carers?

i.e. no relatives / carers involved

7

Is there evidence that the intervention plan is initiated within 5 days of admission

Based on the occupational therapy assessment and intervention do the goals set include: a) Lifestyle advice? i.e. no intervention

req’d b) Needs of younger stroke survivors?

c) Positioning and support?

d) Visual disturbance?

e) Mood disturbance?

f) Cognitive / perceptual function?

8

g) Motor control?


JMS Oct 2008 18

h) Orthotics?

i) Tone disturbance?

j) Sensory disturbance?

k) Activities of daily living?

i Personal Care interventions undertaken

ii Feeding equipment supplied iii Domestic ADL interventions undertaken

iv Life skills practised Transfer practices undertaken:- v Bed

vi Chair vii Toilet/ commode viii Bath/shower ix Car

9 Has the patient received daily OT Intervention (Monday-Friday); (recommended level of 45 mins per session)

No because e.g. • patient unable to

tolerate /not needed/ insufficient resource

10 Is there evidence that advice was given to the stroke survivor or their family / carers regarding the use, fitting and care of equipment?

Team working

11 Is there evidence that the occupational therapist participated in team meetings?

Evaluation / Transfer / Discharge

12 Is there a transfer / discharge summary? (see attached example)

i.e. patient died

If there is a transfer / discharge summary, does it include:

a) Present level of disability in self-care?

b) Present level of disability in work?

c) Present level of disability in leisure?

d) Interventions?

e) Whether goals have been achieved?

f) Equipment supplied? i.e. patient died, no intervention required

g) Driving regulations recommendations given?

13

h) Referral to other voluntary or statutory organisations?


JMS Oct 2008 19

i) Plans for review?

14 Is there evidence that information was given regarding future access to the occupational therapy service?

15 Is there evidence that the outcome of occupational therapy interventions were recorded?

16 Is there evidence that a measure that is recognised to be reliable and valid was used to record outcome?

17 Is the stroke survivor in a rehabilitation research project where they (or a relative) gave written consent / assent?


JMS Oct 2008 20

Appendix 7

PSA Stroke Clinical Audit Physiotherapy NB text and data fields in blue have been added for use in the All Wales audits

Locality Code ……… Patient ID…………… Age…………. years Gender M / F Location of service - please tick all that are appropriate Acute beds o Rehab beds o Combined acute/rehab stroke unit o Co-located beds o Date of Admission to Hospital …………………………… Date of referral received by Physiotherapy................................. Date first seen by a physiotherapist ……………………………… Process of Care Please tick the appropriate column for ‘Yes’, ‘No’ or ‘No but…’ (If answering ‘no but…’ please see definitions of ‘no but..’) QUESTION YES NO NO,

BUT.. NO, BUT.. EXPLANATION

Referral and Assessment

1 Is there evidence that the stroke survivor was assessed within the agreed time frame? Within 72 hours of referral for inpatients Within 3 weeks for community/outpatient referrals


Does the assessment include information on the following:

a. pre-stroke mobility i.e. patient unconscious, died, palliative care, unwell

b. respiratory function i.e. patient unconscious, died, palliative care, unwell

c. posture i.e. patient unconscious, died, palliative care, unwell

d. balance i.e. patient unconscious, died, palliative care, unwell

e. abnormal tone i.e. patient unconscious, died, palliative care, unwell

f. volitional movement i.e. patient unconscious, died, palliative care, unwell

g. functional mobility i.e. patient unconscious, died, palliative care, unwell

2

h. problems according to the stroke survivor

i.e. patient unconscious, died, unwell, or has communication issues.


JMS Oct 2008 21

3 Is there evidence that:

a) The family / carers were contacted by the physiotherapist within 2 weeks of initial contact with the stroke survivor?

i.e. no relatives / carers involved, pt died

b) There was discussion about the concerns of the family / carers?

i.e. no relatives / carers involved, pt died

Goal Setting and Intervention

4 Is there a treatment plan?

5 Are there goals with a time frame or date set for achievement?

i.e. patient unconscious, died, on palliative care, unwell, or only multidisciplinary goals are set

Is there evidence that therapy goals were discussed with:

a) The stroke survivor? i.e. patient unconscious, died, on palliative care, unwell, or has communication issues.

6

b) The stroke survivor’s family / carers?

i.e. no relatives / carers involved, patient died, or it is documented that the carer is not participating in the patient’s care.

7 Is there evidence that the family/carer were taught the skills required to care for the patient at home?

i.e. no relatives / carers involved, patient died, pt is self caring or it is documented that the carer is not participating in the patient’s care.

8 Has the Patient received the desired frequency of physiotherapy intervention?

i.e. illness, unavailable or not appropriate and reason why. No because e.g.

• patient unable to tolerate /not needed

insufficient resource Team working

9 Is there evidence that the physiotherapist participated in team meetings?

i.e the pt died

Evaluation / Transfer / Discharge

10 Is there a transfer / discharge summary?

i.e the pt died

11 If there is a transfer / discharge summary, does it include:

i.e the pt died

a. Interventions provided? i.e. patient died b. Whether goals have been i.e. patient died


JMS Oct 2008 22

achieved? c. Equipment supplied? i.e. patient died, or not

required d. Home programme? e.g.

exercises &/or advice provided i.e. patient died, or not

required e. Plans for review? i.e. patient died, no

intervention required, or reviewed by another member of the team

12 Is a standardised measure of impairment recorded?

i.e. patient died

13 Is a standardised measure of functional activity recorded?

i.e. patient died


JMS Oct 2008 23

Appendix 8

PSA Stroke Clinical Audit Speech and Language Therapy NB text and data fields in blue have been added for use in the All Wales audits Locality Code ……… Patient ID…………… Age…………. years Gender M / F Location of service - please tick all that are appropriate Acute beds o Rehab beds o Combined acute/rehab stroke unit o Co-located beds o Date of Admission to Hospital …………………………… Date referral received by Speech and Language Therapy................................. Date first seen by a Speech and Language Therapist ……………………………… Process of Care Please tick the appropriate column for ‘Yes’, ‘No’ or ‘No but…’ (If answering ‘no but…’ please see definitions of ‘no but..’)

Referral and assessment Yes

No

No But…

1 Does the referral response time fall within RCSLT agreed timescales? ie within 2 working days if extremely high risk of choking, within 10 working days if high risk of dysphagia or psychosoc ial impact and within 13 weeks for all others. Answer ‘no but’ if the client was unavailable, unconscious, too unwell to be seen, or refused appointment.

2 Is there evidence of assessment of: a) pre-morbid communication function? Answer ‘no but’ if there is no evidence of a communication problem, or if the client was unconscious, too unwell to be seen, refused to participate, or no carer to contact.

b) comprehension? Answer ‘no but’ if there is no evidence of a communication problem, or if the client was unconscious, too unwell to be seen, refused to participate.

c) oromotor skills? Answer ‘no but’ if there is no evidence of a communication problem, or if the client was unconscious, too unwell to be seen, refused to participate.

3 Is there evidence of assessment of: a) pre-morbid swallowing ability? Answer ‘no but’ if there is no evidence of a swallowing problem, or if the client was unconscious, too unwell to be seen, refused to participate, or no carer to contact.


JMS Oct 2008 24

b) oral function? Answer ‘no but’ if there is no evidence of a swallowing problem, or if the client was unconscious, too unwell to be seen, or refused to participate.

c) Pharyngeal function? Answer ‘no but’ if there is no evidence of a swallowing problem, or if the client was unconscious, too unwell to be seen, or refused to participate.

4 Is there evidence that assessment results were communicated by the SLT to the client? Answer ‘no but’ if assessment could not be completed because client was unconscious, too unwell, refused to participate, or had very severe communication/cognitive impairment and lacked capacity.

Goal setting & Intervention Yes

No

No But…

5 Is there evidence of a SLT management plan specifying type of intervention? Answer ‘no but’ if intervention not indicated or refused.

6 Is there evidence of a SLT management plan specifying goals of intervention? Answer ‘no but’ if intervention not indicated or refused.

7 Is there evidence that the management plan has been agreed with the client? Answer ‘no but’ if intervention not indicated or refused, client unconscious, too unwell, or unable to participate owing to very severe communication/cognitive problems.

Teamworking Yes

No

No But…

8 Is there evidence of SLT liaison with MDT eg attendance at MDT meetings, or similar forum? Answer ‘no but’ if no other member of MDT involved or client refused consent to discuss with MDT.

Evaluation/transfer of care/discharge Yes

No

No But…

9 Is there evidence of discussion of outcome with the client? Answer ‘no but’ if client unable to participate owing to very severe comprehension/ cognitive problems, or no intervention given.

10 Is there evidence of discussion of outcome with the carer? Answer ’no but’ if the client does not have any carers involved, client refused consent to discuss with carer(s), no need to discuss with a carer, or no intervention given.


JMS Oct 2008 25

11 Is there evidence of discussion of outcome with other professionals? (e.g. to GP, other SLT, intermediate care team)? Answer ‘no but’ if client refused discussion with other professionals or ongoing care not needed.

12 Is there evidence that the client/carer was given a named SLT contact on discharge? Answer ‘no but’ if not discharged.

13 Is there evidence that a discharge report was given to the client/carer on discharge? Answer ‘no but’ if client not discharged, died before discharge, or if client an inpatient or been transferred on within the service.


JMS Oct 2008 26

Appendix 9

PSA Stroke Clinical Audit Nursing NB text and data fields in blue have been added for use in the All Wales audits

Locality Code ……… Patient ID…………… Age…………. years Gender M / F Location of service - please tick all that are appropriate Acute beds o Rehab beds o Combined acute/rehab stroke unit o Co-located beds o Date of admission to hospital: ………….…………... Date first seen by a nurse: …………..………………

QUESTION Yes

No

No but ..

Referral and Assessment 1 Is there evidence of initial screening/assessment within 24

hours of admission to the hospital of:

a) Swallowing ability? (no but would be when patient was drowsy or unconscious)

b) Nutritional status/risk? (no but would be for patients receiving palliative care)

c) Conscious level e.g. Glasgow Coma Score? d) Oxygen saturation? e) Blood sugar?

(no but would be for patients receiving palliative care)

f) Tissue viability/pressure damage risk? g) Communication? (no but would be when patient was

drowsy, unconscious or receiving palliative care)

h) Moving and handling? i) Falls risk? Within 7 days of admission j) Mood?

(no but would be when patient was drowsy, unconscious or receiving palliative care within 7 days of admission)

k) Continence? (no but would be when patient was drowsy, unconscious or receiving palliative care/dying or died within 7 days)

l) Social situation? (‘no but..’ would be when patient was drowsy, unconscious or receiving palliative care within 7 days of admission)

m) Carer support? (‘no but..’ would be when patient was drowsy, unconscious or receiving palliative care within 7 days of admission)

Does nursing documentation take account of: 2 a) If the patient was hypoxic (O2 saturations below 95%), is

there evidence of oxygen being given. (‘no but..’ would be when patient is not hypoxic)


JMS Oct 2008 27

b) If the patient was pyrexial, have they been given

antipyretics e.g. paracetamol (‘no but..’ would be when patient is not pyrexial)

c) If the patient was hypertensive does the care plan include education on diet and medications (‘no but..’ would be when patient was not antihypertensive drowsy, unconscious or receiving palliative care /dying or died)

d) If the patient was smoking up to the stroke, is there documentation that a smoking cessation service had been offered (‘no but..’ would be when patient was drowsy, unconscious or receiving palliative care or died)

3 Does the nursing documentation include nursing actions to prevent the following post-stroke complications:

a) Chest infection/aspiration? b) Constipation? c) Incontinence? d) Dehydration? e) Shoulder pain? 4 Is there evidence of assessment of carers’ needs prior to

stroke patients’ discharge? (‘no but..’ would be used where the patient had no carers, patient did not want them involved or the patient died)

Goal Setting and Intervention 5 Is there evidence that the patient has been assessed safe to

dispense their own medications prior to discharge? (Only use the ‘no but..’ option if the patient died or when the patient would not dispense their medications, i.e. carer dispenses medication)

Evaluation / Transfer / Discharge 6 Is there evidence that the patient has been given information

about their medication management prior to discharge? (‘no but..’ would be used if the patient died or they had severe cognitive impairment)

7 Is patient progress evaluated and documented on the target dates specified on each of the nursing care plans?

8 Is there documented evidence of information regarding transfer of care arrangements being given to the: Primary Care Team/GP? Patient Carer? (Carer could be a family member/significant other/NOK) (‘no but..’ would be used if the patient died or they did not have a carer/family member)


JMS Oct 2008 28

Appendix 10

PSA Stroke Clinical Audit Clinical Psychology

Locality Code ……… Patient ID…………… Age…………. years Gender M / F Location of service - please tick all that are appropriate Acute beds o Rehab beds o Combined acute/rehab stroke unit o Co-located beds o Date of Admission to Hospital …………………………… Date first seen a Clinical Psychologist: …………..……… Question Yes No Details N/A Screening 1 Is there evidence of screening (by any member of the MDT)

for:

(a) Cognitive function? (b) Mood, anxiety or emotional adjustment? (c) Behavioural problems?

2 If problem identified, is there evidence of referral to a psychologist?

Referral and assessment 3 Is there evidence of involvement of psychology service with

either the patient or the family/carer? If ‘no’ then discontinue If ‘yes’ then:

4 Is the psychologist part of the specialist MDT? 5 If ‘no’ is there evidence of psychology input provided by

another service?

6 Is there evidence of assessment by the psychologist of: (a) Cognitive function (b) Mood, anxiety or emotional adjustment? (c) Behaviour?

7

Is there evidence that the outcome of the assessment, when undertaken, has been communicated to the patient?

8 Is there evidence that the outcome of the assessment, when undertaken, has been communicated to the family/carer (where consent has been obtained)?

9 Is there evidence of identification of need for assessment of family/carers emotional adjustment? (from any member of the MDT)

10 If ‘yes’, is there evidence of assessment by the psychologist of family/carers emotional adjustment?

11 Is there evidence of an assessment made of Mental Capacity?

12 If ‘yes’, is there evidence that a psychologist was involved?


JMS Oct 2008 29

Therapeutic Intervention & Goal Setting 13 Is there evidence of psychological intervention with the

patient for cognitive rehabilitation?

14 Is there evidence of psychological intervention with the patient for mood, anxiety or emotional adjustment?

15 Is there evidence of psychological intervention with the family/carer?

16 Is there evidence of psychology involvement in goal planning/setting?

Teamworking 17 Is there evidence of psychology attendance/contribution to

MDT meetings, goal planning meetings, etc.?

18 Is there evidence of communication with the team about the outcome of the psychological assessment and intervention?

19 Is there evidence of a psychologist engaging in MDT working?

Evaluation/transfer of care/discharge 20 Is there evidence of discharge documentation? 21 If ‘yes’, does it include reference to involvement of the

psychologist?

Documents

All Wales Profession Specific Audit of Stroke - psa - all wales tools and guida… · The PSAG, in the light of feedback from the pilot, reviewed and revised the PSA audit tools and