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National Stroke Register Report 2017

National Stroke Programme

August 2018

2

Executive Summary

Introduction

The 2017 National Stroke Register Annual Report is the sixth report since its inception in 2012 and it

continues to reflect the increased commitment to data collection and reporting. The data used for this

analysis is based on routinely collected HIPE data and on additional data inputted onto the stroke portal

by individual hospitals. We remain thankful for the on-going support of the Clinical Nurse Specialists and

Advanced Nurse Practitioners who continue to collect and report data on stroke patients. The National

Stroke Register remains under the governance of a National Stroke Register Steering Group, however, it

remains without any data analytic or research support and the National Stroke Programme continues to

work towards finding a solution for the long term governance of the register. We strongly recommend

that the governance of the National Stroke Register sits within a Quality Improvement framework and

are working with NOCA to support us in this endeavour.

Results

This report presents an analysis of all cases that were discharged from acute public hospitals between

January 1st and December 31st 2017 with a principal diagnosis of Intracerebral Haemorrhage (i61) or

Cerebral Infarction (i63) that have additional stroke register data recorded in >80% of cases .

19 acute public hospitals met this criteria and the sample size obtained for analysis is 3,481 which is

similar to 2015 and 2016. Of those hospitals, HIPE data identified a total of 4205 cases of Cerebral

Infarction or Intracerebral Haemorrhage, of these, 3726 were entered into the National Stroke Register

in 2017 which gives a coverage rate of 89% across all 19 hospitals. As in previous reports there remains

concerns around the completeness of the data and this is reflected in the reduced cohort for analysis in

some areas e.g. onset times and medical review times.

Demographics

The demographic data reported is consistent by and large with that found in the 2015 Irish Heart

foundation / HSE National Stroke Audit (McElwaine et al 2015) with 75% of strokes occurring in over

65s. The proportion of strokes occurring in men of working age rose slightly from 26% in 2016 to 28%.

Data recorded on time of onset suggests high levels of ‘wake-up’ or unwitnessed stroke with time of

onset recorded as ‘unknown’ in 40% of cases. The date and time of stroke onset was only recorded in

3

54% of cases therefore caution is advised when reviewing onset to admission results, however, there is

a trend towards delayed hospital arrival in rural areas, >3hrs in eight hospitals. This would support the

need for increased public awareness campaigns such as the FAST campaign. The UK SSNAP 2017 report

have a known time of onset in 68% of cases with a median time to hospital arrival of 2hrs 50 mins (IQR

1:28-8:46) slightly increased on Irish results of 2hrs 36mins (IQR 1:28-8:46).

Acute Stroke Treatment

Hospital arrival date and time was available in 95% of cases which is a good sample to allow analysis of

acute stroke treatment.

In terms of delivery of acute treatment, 69% of patients were seen by the stroke team within 3hrs of

admission increased from 54% in 2016.

Data on thrombolysis was available in 98% of ischaemic stroke (i63, i64) cases. Thrombolysis was

administered in 11.9 % of cases of cerebral infarction in this stroke population. 271 patients received

endovascular thrombectomy in either Beaumont Hospital or Cork University Hospital.

Data on antithrombotic therapy and atrial fibrillation (AF) is reported in 92% of cases. Of those with

known AF 47% were not on anticoagulation pre-stroke. On discharge, inclusive of pre-existing and new

diagnosis AF, 93% of patients were anticoagulated. There appears to be a strong preference (17:1) for

non-vitamin K antagonist oral anticoagulants (NOACs).

70.6 % of patients were admitted to an acute stroke unit and spent a median of 9 days in a stroke unit.

Data on stroke severity and intensity of rehabilitation is not captured so comparisons about stroke unit

length of stay cannot be made. However, data that suggests the quality of care in stroke units is higher

given that patients are three times more likely to have a swallow screen and a mood screen compared

to those who do not access stroke unit care. 81% of stroke patients are reviewed by the multidisciplinary

team, similar to 2016, however, the data does not interrogate the intensity of therapy. The new HSCP

dataset commenced in 2018 will record more detail in this domain.

Outcomes

This is the first report where we have outcome data based on the Modified Rankin Score (MRS). 71% of

cases have a pre-stroke and discharge MRS and results will be monitored over time.

Challenges remain in our definition of mortality when comparing to other European figures where 30-

day mortality or standardised mortality ratios are often used. In-hospital mortality, in this sample,

without a standardised mortality ratio is 14.2%. When mortality is reported by stroke type, ischaemic

stroke mortality is 10.8% and haemorrhagic stroke is 36.2%. This is comparative to HIPE data for 2017.

The accuracy of the data related to discharge to nursing home remains a concern. An analysis of HIPE

discharge destination to nursing home (15.8%) compared to the discharge destination recorded in the

stroke portal (7.5%) is conflictual and could be explained to some extent by discharge to non-acute

hospital. The NSP will continue to work with the Health Pricing Office in this matter.

4

Recommendations

This registry report highlights that patient presentation times to hospital after symptom onset

remain poor and the need for a sustained public health campaign on stroke.

Door to CT remains challenging and needs ongoing Quality Improvement (QI) focus in hospitals.

Thrombolysis rates remain low in some hospitals although this is also impacted by delayed

presentations.

Admission rates to an acute stroke unit are inadequate against a national target of 90% and

highlights the need for both a stroke unit capacity review and a stroke unit accreditation

process.

Overall the data coverage of the national register continues to improve but work remains to

ensure a more complete capture particularly from large centres missing in this report, and to

understand the gap between registry and HIPE stroke case finding.

Definition of stroke and stroke mortality need universal agreement.

While reassuringly the 2017 data seems consistent with previous reports and the findings of the

2015 Irish Heart Foundation /HSE National Stroke Audit, the National Stroke Register now needs

appropriate professional governance structures to ensure it is GDPR compliant and can become

a sustainable professional audit responsive to the data needs of individual stroke services and

the country to monitor trends, highlight service needs, effect change and allow for international

comparison.

Ronan Collins, Clinical Lead, National Stroke Programme

Joan McCormack, Programme Manager, National Stroke Programme

25/9/18

5

Table of Contents

EXECUTIVE SUMMARY ........................................................................................................................................... 2

INTRODUCTION ..................................................................................................................................................... 6

METHOD ................................................................................................................................................................ 7

RESULTS ................................................................................................................................................................. 9

DEMOGRAPHICS ............................................................................................................................................................. 9

ADMISSION/DISCHARGE DATA........................................................................................................................................ 11

Admission Type ................................................................................................................................................... 11

Admission Source and Discharge Destination ..................................................................................................... 11

Stroke Onset and Admission ............................................................................................................................... 13

Hospital Length of Stay ....................................................................................................................................... 15

STROKE CARE .............................................................................................................................................................. 15

Assessment by Stroke Team ................................................................................................................................ 15

Brain Scanning (CT or MRI) ................................................................................................................................. 16

Thrombolysis ....................................................................................................................................................... 17

Thrombectomy .................................................................................................................................................... 19

Antithrombotic therapy ...................................................................................................................................... 19

Atrial Fibrillation ................................................................................................................................................. 20

ADMISSION TO STROKE UNIT .......................................................................................................................................... 21

Swallow Screening in Stroke Units ...................................................................................................................... 22

Mood Screening .................................................................................................................................................. 23

Stroke Unit Length of Stay (LOS) ......................................................................................................................... 23

OUTCOMES ................................................................................................................................................................. 24

MRS and Stroke Type .......................................................................................................................................... 24

Multidisciplinary Team Assessment .................................................................................................................... 25

APPENDICES......................................................................................................................................................... 27

APPENDIX 1. NATIONAL STROKE REGISTER STEERING GROUP MEMBERS................................................................................. 27

APPENDIX 2. NATIONAL STROKE REGISTER DATASET ........................................................................................................... 28

REFERENCES ......................................................................................................................................................... 33

6

Introduction The National Clinical Programme for Stroke was launched in 2010 and included nine different work

streams, one of which was the development of a National Stroke Register. The National Stroke Register

was developed in partnership with the Health, Research and Information Division at the Economic and

Social Research Institute (ESRI)1. The Register is considered a fundamental component of integrated

stroke services being developed by the National Clinical Programme for Stroke project team. It is essential

to measure the effect of the implementation of the National Clinical Programme for Stroke, in addition to

providing data for planning and estimation of resource requirements for stroke services, evaluation and

clinical audits, and hospital accreditation. The Register was developed and is governed by a Steering Group

derived from the project team, together with expert input from the Healthcare Pricing Office, clinical

practitioners, coding managers and the Irish Heart Foundation Council on Stroke (Appendix 1).

The National Stroke Register was developed within the existing HIPE data collection system. The

Healthcare Pricing Office provides an ‘add-on screen’ to HIPE where the stroke team enters the data

(Appendix 2) while the patient is still in hospital. This is merged automatically with the HIPE discharge

record to provide enhanced information on the hospital care of the stroke patient.

Hospitals commenced participation in the National Stroke Register on a phased basis, with 24 hospitals

currently participating out of the 27 that were provided with access to the Stroke Register. It is noted that

some hospitals are not yet entering data on all acute stroke patients although this is improving over time.

While there is no clear evidence of bias, i.e. hospitals submitting data on patients with the mildest or most

severe strokes, an element of caution is advised in interpreting the data. In 2017, both Connolly Hospital

and Kerry University Hospital commenced data entry and full year data will be presented for both services

in 2018.

1 From January 1st 2014 the National Casemix Programme and the Health Research & Information

Division at the ESRI became the Healthcare Pricing Office (HPO

7

Method

Coverage is the term used to describe the proportion of stroke patients discharged from a hospital with

an ICD 10 code of i61, i63 or i64 that have additional data inputted onto the National Stroke Register.

Table 1. Identifies all HIPE cases that were discharged from acute public hospitals between January 1st

and December 31st 2017 and the cases with additional stroke register data.

Table 1. 2017 HIPE i61, i63, i64 cases with additional NSR data.

This report presents an analysis of all National Stroke Register cases that were discharged from acute

public hospitals between January 1st and December 31st 2017, with approximately 80% coverage, with a

principal diagnosis of Intracerebral Haemorrhage or Cerebral Infarction. Analysis is based on the

aggregate data of these 19 hospitals and measured against previous annual reports and comparative data

from the UK SSNAP 2017 results. For the purposes of this annual report, as was the case for the all previous

reports data are presented on Intracerebral Haemorrhage and Cerebral Infarction patients, based on the

cohort of patients that have been assigned a principal diagnosis in HIPE of Intracerebral Haemorrhage

(ICD-10 I61) or Cerebral Infarction (ICD-10 I63), table 2.

Hospital HIPE Cases i61, i63, i64

Registered Cases i61, i63, i64 Coverage

St Luke’s Hospital Kilkenny 114 114 100%

Cavan General Hospital 166 165 99%

Letterkenny University Hospital 194 192 99%

Bantry General Hospital 57 54 98%

Our Lady of Lourdes Drogheda 194 188 97%

University Hospital Waterford 132 126 95%

University Hospital Galway 318 300 94%

Mercy University Hospital 111 103 93%

Mayo University Hospital 203 185 91%

Tallaght University Hospital 257 233 91%

St Vincent’s University Hospital 339 302 89%

Beaumont Hospital 641 556 87%

Midland Regional Hospital Mullingar 133 116 87%

Wexford General Hospital 157 135 86%

Sligo University Hospital 179 153 85%

Naas General Hospital 174 143 82%

St James’s Hospital 268 217 81%

Portiuncula Hospital 82 66 80%

Cork University Hospital 486 378 78%

South Tipperary General Hospital Clonmel 124 80 65%

Our Lady’s Hospital Navan 81 31 38%

Mater Misericordiae University Hospital 357 94 27%

University Hospital Limerick 359 35 10%

Grand Total 5126 3966 77%

8

Table 2. 2017 NSR data i61, i63, i64 cases

*Beaumont Hospital had 174 cases recorded within HIPE and the NSR that were admitted for thrombectomy

and were transferred back to the referring hospital without admission. These cases have been excluded from

this analysis.

For the time period in question, there

were 4, 784 discharges recorded in the

National Stroke Register across the 19

hospitals. However, not all of the 4,784

cases recorded on the National Stroke

Register were ultimately assigned a

principal diagnosis of Intracerebral

Haemorrhage or Cerebral Infarction in

HIPE. When cases coded as TIA or

recorded as in-patient strokes are

excluded it is found that 10.9% of cases

recorded on the stroke register did not

have a primary diagnosis of stroke (figure

1). The i64 Cerebral Infarction

Undifferentiated was recorded in 114

(4%) of cases. Figure 1. Stroke Register Case

Hospital Total

Registered Cases

I61, i63, i64

Registered Cases

Final Dataset for analysis Registered

Cases i61, i63 St Luke’s Hospital Kilkenny 126 114 114

Cavan General Hospital 182 165 153

Letterkenny University Hospital 374 192 191

Bantry General Hospital 61 56 56

Our Lady of Lourdes Drogheda 201 188 185

University Hospital Waterford 148 126 121

University Hospital Galway 464 313 312

Mercy University Hospital 123 103 96

Mayo University Hospital 243 185 183

Tallaght University Hospital 255 233 214

St Vincent’s University Hospital 363 302 275

Beaumont Hospital* 666 582 408*

Midland Regional Hospital Mullingar 174 116 107

Wexford General Hospital 175 135 122

Sligo University Hospital 195 153 144

Naas General Hospital 183 143 143

St James’s Hospital 309 218 218

Portiuncula Hospital 92 66 65

Cork University Hospital 450 378 374

Total 4784 3769 3481

77%

6%

2%4%

2% 1%

8%

Stroke Register Case HIPE Codes n4784

PDx Stroke i61, i63,

TIA

PDx i64

In-patient Stroke

2nd Dx Stroke

3rd Dx Stroke

Other

If the aggregate data from these 19 hospitals is used for any comparison by individual hospitals it is important that stroke teams:

Compare like with like by only analyzing cases with a principal diagnosis of Intracerebral Haemorrhage (ICD-10 I61) or Cerebral Infarction (ICD-10 I63)

Consider the implications of differences between national and local demographic profiles

9

Results

In this report the data are presented in table format along with a brief commentary. The analysis is

broken down into a number of sections:

Demographics

Admission/discharge data

Acute Stroke Interventions

Stroke Unit Care

Outcome

Demographics

As in all previous reports, over half, 56.5 % of all stroke cases coded as ICD-10 I61 or I63 in the 19

hospitals in 2017 were male (table 3). This is similar to the gender breakdown when compared to the

Irish Heart Foundation/HSE National Stroke Audit 2015 where males accounted for 57% of stroke cases

(McElwaine et al, 2015). This figure was 52% in the Irish National Audit of Stroke Care in 2008 (Horgan et

al, 2008).

Table 3: Gender (n=3,481)

There remains some differences in age profile by gender (table 3).

The mean age for males was 71.8 years and for females it was 73.1 years Irish National Audit of Stroke

Care 2008 found 72 years males, 78 years female (Horgan et al, 2008).

Table 4: Age Profile (%) (n=3,481)

N %

Male 1967 56.5

Female 1514 43.5

<65 Years 65 – 79 Years 80+ Years Mean (±SD)

Male 27.9 43.3 28.8 (70.6 ± 13.3)

Female 18.4 35.9 45.7 (75.5 ± 13.7)

10

Figure 2: Age Profile Figure 3: Mean age of stroke patients by gender 2012-2017

Using data from the 2012 to 2017 the trend in mean age by gender is shown in (Figure 3). While most

strokes occur in those aged 65 years and over, 28% of male strokes occur in working age an increase from

26% in 2016 (figure 4). With regard to females the proportion of strokes occurring in the under 65 age

group appears to be increasing 17.2% in 2013 to 18.4% in 2017 (figure 5).

Figure 4: Male strokes by age group 2012 to 2017

Figure 5: Female strokes by age group 2012 to 2017

27.9

43.3

28.8

18.4

35.9

45.7

0

10

20

30

40

50

<65yrs 65-79yrs 80+

Age Profile 2017

Male Female

6065707580

2006(INASC)

2012 2013 2014 2015 2016 2017

Male and Female Age Profile Trends

Male Female

0

20

40

60

2006(INASC)

2012 2013 2014 2015 2016 2017

Male Strokes by Age Trend

<65 65-79 80+

0

20

40

60

80

2006(INASC)

2012 2013 2014 2015 2016 2017

Female Stroke by Age Trend

<65 65-79 80+

11

Admission/Discharge Data

HIPE records data on a number of variables relating to the admission and discharge of each patient, such

as the type of admission (e.g. elective or emergency), admission source and discharge destination. The

patient’s length of stay is also collected, in addition to clinical codes recording what diagnoses were made

during the hospital stay.

Admission Type

As expected, the vast majority (98%) of stroke cases registered were classified as emergency admissions

(table 5).

Table 5: Admission Type of Stroke Register cases (n=3,481)

N %

Emergency 3413 98 Elective 30 0.86 Emergency readmission 17 0.48 Elective readmission 21 0.60

Admission Source and Discharge Destination

Analysing admission source without any other morbidity or stroke severity data does not inform to any

great extent. However, it does provide useful information when analysed in conjunction with discharge

destination to provide data on outcomes for stroke patients. The admission source data for cases entered

onto the National Stroke Register (table 6) shows that the majority of stroke patients (90.3%) are living at

home prior to their stroke.

Table 6: Admission Source (n=3,481)

N %

Home 3,144 90.3 Acute hospital Transfers 176 5.1 Nursing home 137 3.9 Non-acute Hospital Transfers

8 0.2

Temporary place of residence Other

13 3

0.4 0.1

12

Table 7 outlines the discharge destination of cases as coded by HIPE and also the discharge destination as

recorded within the NSR. HIPE data is complete while the NSR has 85% (2956/3481) coverage. In 2016, an

anomaly was identified in the coding of patients going to nursing homes and to external rehabilitation

facilities. The comparative data suggests that there is variance in how cases are coded particularly when

discharged to nursing home and/or rehabilitation facilities. The National Stroke Programme is working

with the Health Pricing Office to correct this anomaly. At present, the discharge to nursing home data

should be viewed with caution as it is more probable that it is a lower rate than the 15.8% recorded in

HIPE.

Table 7: Discharge Destination

HIPE n=3481

Stroke Register n=2956 (525 missing)

N % N %

Home 1854 53.3 1697 57.4 Nursing home 550 15.8 221 7.5 Died 493 14.2 429 14.5 Transfer to acute hospital – Non-emergency 303 8.7 175 6.0 Emergency hospital transfer 105 3.0 Transfer to external rehab – non-HIPE facility 130 3.7 399 13.5 Transfer to non-acute hospital 15 0.4 Other 3 0.1 35 1.1 Hospice 4 0.1 Temporary Residence 5 0.1 Self-discharge 13 0.4 Absconded 2 0.1 Transfer to Psychiatric Hospital 4 0.1

Within the NSR cohort the in-hospital mortality rate was 14.2%. The Irish Heart Foundation/HSE National

Stroke Audit 2015 reported a mortality rate of 14% and the Sentinel Stroke National Audit Programme,

SSNAP (Royal College of Physicians 2017) report a 14.3% in-hospital mortality rate. When reported by

stroke type the NSR shows that the mortality for ischaemic stroke is 10.8% (326/3019) and 36.2%

(167/462) for haemorrhagic stroke.

13

Figure 6. National Mortality Rates NQAIS 2015-2017

Figure 6. indicates the mortality based on

stroke type using the National Quality

Assurance & Improvement System (NQAIS)

of all i61, i63 and i64 cases from 2015 to

2017. These results reflect the correlation

between NSR results and national HIPE data

results.

Caution is advised in comparing Irish

mortality rates with International and

National mortality rates in stroke, such as

the National Audit of Hospital Mortality

(NAHM) and the National Healthcare

Quality Reporting System (NHQRS) as data

is adjusted for casemix.

Stroke Onset and Admission

While HIPE records date of admission to hospital, time of admission is not recorded. Stroke teams are

asked to enter hospital arrival date and hospital arrival time. This can then be used to calculate delays to

hospital arrival from stroke onset in hours and minutes, which is more appropriate for stroke care when

“Time is Brain”.

However, both the date and time for stroke onset and hospital arrival must be known and recorded in

order to calculate accurately the delay between stroke onset and hospital arrival. This analysis excludes

in-patient stroke cases.

The date of stroke onset was recorded for 97% of cases (n=3078) but a stroke onset date and time was

only recorded in 54% of cases (n=1,723). It was recorded as unknown in 40% of cases (n=1,268).

The date of hospital arrival was recorded in 99% of cases (n=2,845) and the date and time of hospital

arrival was recorded in 94.8% of cases (n=3007). It was recorded as unknown in 1% of cases (n=37) with

no time recorded in 3% of cases (n=101). The number of cases analysable for time of onset to hospital

arrival is 1665, 52.5% increased from 46% in 2016.

Table 8 below outlines the median time from stroke symptom onset to hospital arrival but note the

reduced cohort available for this analysis, signifying a large portion of unknown, incorrect and/or missing

dates/times. For those cases that had times available, 61% arrived at hospital within four hours of

symptom onset, 53% within three hours and 47% within 2.5 hours (table 8). The Irish Heart

Foundation/HSE National Stroke Audit reported that 56% of patients arrived at hospital within 3 hours

(McElwaine et al, 2015).

10.9 9.9 9.9

30.5 30.8

36

0

5

10

15

20

25

30

35

40

2015 2016 2017

Per

cen

tage

National Stroke Mortality Rates 2015-2017

Ischaemic Stroke Haemorrhagic Stroke

14

Table 8: Time from stroke symptom onset to hospital arrival n=1665

*IQR = interquartile range, time by which 25% and 75% of patients arrived

The most recent clinical audit report from SSNAP states that the median time from onset to hospital arrival

in SSNAP was 2 hours and 50 minutes (IQR 1:28-8:46) (Royal College of Physicians 2017).

Table 9: Distribution of time from stroke symptom onset to hospital arrival (n=1,665)

Table 10 indicates a wide variation of onset to hospital arrival times. This information could be used

when reviewing time related emergency treatments such as thrombolysis.

Table 10. Time from stroke symptom onset to hospital arrival by hospital

Onset to Hospital Arrival Median IQR

Beaumont Hospital 01:31 00:49 02:04

Tallaght University Hospital 01:39 01:09 05:26

St Vincent’s University Hospital 01:53 01:13 03:40

Cavan General Hospital 02:16 01:32 05:17

Cork University Hospital 02:17 01:31 03:29

St Luke’s Hospital Kilkenny 02:20 01:24 05:14

Midland Regional Hospital Mullingar 02:21 01:30 09:42

Our Lady of Lourdes Drogheda 02:26 01:23 07:53

Naas General Hospital 02:30 01:34 05:07

St James’s Hospital 02:32 01:15 06:08

University Hospital Letterkenny 02:49 01:44 08:34

University Hospital Galway 03:03 01:41 13:58

Mayo University Hospital 03:12 02:00 06:00

University Hospital Waterford 03:12 01:48 09:10

Sligo University Hospital 03:14 01:40 06:40

Wexford General Hospital 04:01 02:00 06:10

Portiuncula Hospital 05:05 03:31 08:32

Mercy University Hospital 05:57 02:22 14:34

Bantry General Hospital 07:00 03:37 31:00

Median (IQR)*

Time (hh:mm) 1:53 (1:29-6:34)

< 2.5 hours < 3 hours < 4 hours

Time (%) 46.8 53.3 61.1

15

Hospital Length of Stay

Table 12 outlines the overall length of stay for stroke patients recorded on the stroke register. Hospital

length of stay can be related to the age of the patients and table 13 highlights the hospital length of stay

by age group. As expected, older patients have longer lengths of stay. The overall median length of stay

of stroke patients recorded on the stroke register remains at 9 days.

Table 12: Hospital Length of Stay (days, n=3,481)

Table 13: Hospital Length of Stay (days) by age group (n=3,281)

Stroke Care

Assessment by Stroke Team

Timely emergency department (ED) evaluation and stroke team assessment is paramount in review of all

stroke patients but in particular regarding the potential treatment of ischaemic stroke with thrombolysis.

Guidance from the American Heart Association/American Stroke Association advises that ED patients with

suspected acute stroke should be triaged with the same priority as acute myocardial infarction or serious

trauma, regardless of the severity of neurological deficits (Jauch et al, 2013). Figure 7 shows that where

data was available, 69% of stroke patients were seen by the stroke team within 3hrs of admission. This is

up from 54% in 2016.

Within the National Stroke Register, stroke teams are asked

to document the date and time of hospital arrival and also the

date and time that the patient was seen by the stroke team.

This enables calculation of the delay to review by the stroke

team. However, the reduced cohort available for this analysis

(2101) must be noted, signifying a large portion of missing

dates/times.

Median (IQR) Mean (±SD)

Length of stay 9 (5 – 19) 18.2 (±28.4)

< 65 Years 65 – 79 Years 80+ Years

Median (IQR) 7 (4 – 14) 9 (4 – 19) 11 (9-24)

Mean (±SD) 15.1 (±26.3) 18.3 (± 31.1) 20.3 (±25.9)

45%

11%13%

21%

10%

30mins 60mins 3hrs

24hrs >24hrs

16

Figure 7. Time seen by Stroke Team n=2101

The median time to assessment by the stroke

team after admission was 43 minutes; figure 8

reflects a significant improvement in timeliness

of assessment by the medical team.

Figure 8. Number of minutes to be seen by medical team 2013 - 2017.

Brain Scanning (CT or MRI)

Data in relation to CT or MRI brain scanning was available for 3323 patients and this includes the patients

who had a stroke as an inpatient. In total, 97% of patients had a CT or MRI scan after their stroke in their

hospital of admission with a further 2.8% of patients having a CT or MRI scan performed pre-admission or

in a previous hospital in cases of hospital transfer as per Table 14.

Table 14: Brain CT or MRI Performed n=3323, (Missing data = 158)

Data in relation to the timeliness of imaging has always been important in order to ensure prompt decision

to treat, however given recent advances in the acute phase of stroke it is even more important to become

aware of access to imaging and treatment within each hospital.

In 2018, a national quality improvement programme commenced in conjunction with the RCPI which aims

to reduce ‘door to decision to treat’ times. Baseline data from 2016 and 2017 will be valuable in its

evaluation. Table 15 indicates the ‘Door to Imaging’ times for each hospital.

N %

Yes 3214 97

No 10 0.3

Performed pre admission/hospital transfer 94 2.8

Unknown 5 0.2

0

200

400

600

800

2013 2014 2015 2016 2017

Min

ute

s

17

Table 15: Door to imaging median and interquartile range by hospital.

Thrombolysis

Administration of recombinant tissue

plasminogen activator (tPA/thrombolysis)

is a proven effective treatment for

ischaemic stroke and should be

administered as soon as possible after

onset of symptoms within a 4.5 hour

window in the absence of

contraindications. In this analysis the

denominator for the thrombolysis data is

different from the rest of this report at

3,133 as it interrogates both i63 and i64

codes to align with the National Stroke

KPIs. Table 16. Thrombolysis rates n=3133.

Table 16 shows that for patients with a principal diagnosis of i63 or i64, the IV thrombolysis rate was

11.9% when unknown and missing/not recorded cases were removed. SSNAP reported a thrombolysis

rate of 11.6% in their most recent report (Royal College of Physicians, 2017). Table 17 indicates the IV

thrombolysis rates by hospital.

Door to Imaging

Number of cases with DTI times recorded

Number of cases within 45mins N (%) Median IQR

Bantry General Hospital 54 7 (13) 01:13 00:56 - 01:59

Beaumont Hospital 219 96 (44) 00:52 00:23 - 03:21

Cavan General Hospital 17 5 (29) 01:10 00:29 - 03:51

Our Lady of Lourdes Drogheda 157 37 (24) 01:38 00:43 - 04:57

University Hospital Galway 277 112 (40) 01:11 00:20 - 05:38

St James's Hospital 193 73 (38) 01:14 00:28 - 03:23

St Luke’s Hospital Kilkenny 108 16 (15) 02:09 01:01 - 14:54

University Hospital Letterkenny 176 24 (14) 03:27 01:14 - 16:55

University Hospital Mayo 158 21 (13) 02:31 01:04 - 13:24

Mercy University Hospital 84 9 (11) 02:58 01:29 - 07:47

Midland Regional Hospital Mullingar 99 27 (27) 01:26 00:42 - 05:08

Naas General Hospital 123 56 (46) 00:48 00:16 - 03:42

Portiuncula Hospital 29 0 10:47 02:14 - 22:39

Sligo University Hospital 118 15 (13) 02:43 01:10 - 12:08

St Vincents University Hospital 233 74 (32) 01:05 00:36 - 03:34

Tallaght University Hospital 188 26 (14) 01:59 01:10 - 04:55

University Hospital Waterford 114 19 (17) 02:37 01:13 - 05:31

Wexford General Hospital 102 5 (5) 05:53 01:48 - 20:38

N %

Yes 363 11.6

No 1,397 44.6

Contraindicated 1306 41.7

Combined IV and intra-arterial

thrombolysis 5 0.2

Blank 62 1.9

18

Table 17: Principal Diagnosis of i63 or i64 n=3133 and thrombolysis rates.

The ‘Door to Needle’ time was

available in 76% (278) cases.

The median time from door to

needle nationally was 71

minutes with an interquartile

range of 50-101 minutes.

SSNAP UK reports a median

door to needle time of 52mins

(IQR 36 – 75).

Table 18. Door to Needle times to patients who received thrombolysis n=278.

i63 i64 cases TPA cases %TPA i63 cases

Mercy University Hospital 90 10 11.1%

Mayo University Hospital 171 13 7.6%

University Hospital Galway 270 26 9.6%

Naas General Hospital 126 32 25.4%

St Luke’s Hospital Kilkenny 91 17 18.7%

Bantry General Hospital 55 3 5.5%

Beaumont Hospital 369 51 13.8%

St James’s Hospital 186 38 20.4%

Sligo University Hospital 132 6 4.5%

Letterkenny University Hospital 176 16 9.3%

Midland Regional Hospital Mullingar 103 14 13.6%

Our Lady of Lourdes Drogheda 161 15 9.3%

Wexford General Hospital 120 4 3.3%

St Vincent’s University Hospital 240 17 7.1%

Tallaght University Hospital 204 29 14.2%

Cavan General Hospital 146 16 11.0%

University Hospital Waterford 98 9 9.2%

Cork University Hospital 337 52 15.4%

Portiuncula Hospital 58 0 N/A

TPA with DTN data

Median Time

Interquartile Range

Mercy 6 00:45 00:42 01:02

Mayo 8 00:51 00:27 01:06

Galway 25 00:51 00:30 01:26

Naas 24 00:51 00:27 01:06

Kilkenny 17 00:57 00:39 01:12

Bantry 2 00:57 00:51 01:04

Beaumont 51 00:58 00:28 01:28

James 35 01:06 00:49 01:28

Sligo 6 01:10 00:51 01:14

Letterkenny 12 01:12 01:07 01:28

Mullingar 10 01:37 01:03 02:03

Drogheda 12 01:25 00:57 02:17

Wexford 4 01:31 01:22 01:41

SVUH 15 01:33 01:07 02:14

Tallaght 29 01:34 01:02 02:15

Cavan 13 01:43 01:05 01:55

Waterford 9 01:45 01:11 02:02

19

Thrombectomy

Thrombectomy in stroke is the mechanical removal of a blood clot within the large vessels of the

cerebral circulation. Thrombectomy for acute stroke is provided by Beaumont Hospital on a 24 hour

basis, 7 days a week. Additionally, Cork University Hospital provides an 8-8 hour service, 5 days a week

for their surrounding network. Outside these hours, suitable patients may be transferred to Beaumont

Hospital for treatment. Data on thrombectomy is collected in Beaumont Hospital and Cork University

Hospital and recorded on the National Stroke Register. The National Thrombectomy Service produced

an annual report in 2017 and provides further detailed analysis of the thrombectomy service.

In 2017, 271 cases were recorded as having had a thrombectomy on the National Stroke Register. These

cases were referred from hospitals throughout the country including those not analysed in this report

therefore thrombectomy rate is not reportable in this report. The rate of thrombectomy reported in the

National Thrombectomy Service Annual Report is 5.6%.

Antithrombotic therapy

91.8% (3196/3481) had data recorded on antithrombotic therapy. Figure 9 indicates the number of

patients who were treated with antithrombotics. In 2017, 72.2% (2513/3481) were reported as treated

with antithrombotics. Figure10 shows that 76% (1923/2513) of cases were commenced on

antithrombotics within 24hrs.

Figure 9. Antithrombotic therapy n=3185 Figure 10. Start times for antithrombotics n=2513

79%

8%

13%

0%

Yes No Contraindicated Unknown

56%20%

8%

2% 14%

Day 1 Day 2 Within 7 Days

> 7Days Unknown

20

Atrial Fibrillation

93% (3236/3481) had data recorded on atrial

fibrillation (AF). 33% (1073/3236) of cases were

reported to have AF and 61.5% (660/1073) of those

cases were known to have AF prior to stroke. This was

reported as 57.2% in 2015.

Figure 11. No. of cases with Atrial Fibrillation n=3236 (245 missing data).

Of the cases that were known to have AF pre stroke 53%

(350/660) were prescribed anticoagulation pre stroke,

two thirds of which were prescribed NOACs. 61%

(74/121) of cases on warfarin pre stroke were not within

the 2-3INR range on admission. Table 19 indicates the

breakdown of Afib data by stroke type.

Figure 12 Afib diagnosis pre stroke.

Table 19 Breakdown of Ischaemic and Haemorrhagic Afib data

Secondary prevention data for patients with AF was available in 85.9% (922/1074) cases.

73.8% (680/922) of cases were prescribed

antiplatelet and/or anticoagulation on

discharge and in 84.4% (574/680) of those

cases the treatment was identified.

On discharge, 91% of cases with AF are on anticoagulation with the preference for NOAC prescribing.

Table 20. Secondary prevention for AF cases n=574 (106 missing data).

Stroke Type Afib known prior to stroke % (n)

On anticoagulation prior to stroke % (n)

Prescribed NOACs % (n)

Prescribed Warfarin % (n)

If on Warfarin was INR 2-3 on admission % (n)

Ischaemic n3020

18.8% (568/3020)

51.7 (294/568) 63.2 (186/294) 36.7 (108/294) 29.6 (32/108)

Haemorrhagic n461

19.9 (92/461) 58.7 (54/92) 68.5 (37/54) 31.5(17/54) 29.4 (5/17)

Secondary Prevention for AF % (n)

NOAC 85% (491/574)

Warfarin 5% (30/574)

Antiplatelet Therapy 6% (36/574)

Antiplatelet and Anticoagulant 3% (17/574)

33%

59%

5% 3%

Yes No Results pending Unknown

660

374

24

0

200

400

600

800

AF Dx PreStroke

No AF PreStroke

Unknown

21

Admission to Stroke Unit

The admission of patients to stroke units, staffed by appropriate specialists, has been shown in numerous

studies to reduce the rates of mortality and morbidity after stroke (European Stroke Organisation, 2008,

Jauch et al, 2013,). Table 21 shows that 70.6% of stroke patients were admitted to a stroke unit after

excluding not recorded data. This was 65.9% in 2016, 63.4% in 2015. Reasons for non-admission to the

stroke unit are documented in table 22 for the 1004 patients who were not admitted.

Table 21: Admission to Stroke Unit (n=3135, missing data = 146 (4.5%)

N %

Yes 2416 70.6%

No 1004 29.4%

A free text box was added in 2014 to provide further explanation for non-admission if required. The three

main reasons for selecting ‘other’ were: patients transferring to or from another hospital; end of life care;

and intensive care unit admission.

Table 22: Reasons for non-admission to stroke unit n=1004

N %

No stroke unit 191 19.0

Other 360 35.9

Bed not available 369 36.8

Infection control risk 13 1.2

Unknown 71 7.1

Table 23 indicates the percentage of cases admitted to a stroke unit by hospital. This is a National Stroke

KPI and the 2017 KPI result is 69.2%, consistent with the outcome of this report. The national target is

90%.

22

Hospital Registered Cases i61, i63

Admitted to Stroke Unit

% Admitted to Stroke Unit

Bantry General Hospital 56 51 91%

Beaumont Hospital 408 282 69%

Cavan General Hospital 153 96 63%

Our Lady of Lourdes Drogheda 185 159 86%

University Hospital Galway 312 234 75%

St James’s Hospital 218 177 81%

St Luke’s Hospital Kilkenny 114 96 84%

Letterkenny University Hospital* 191 N/A N/A

Mayo University Hospital 183 174 95%

Mercy University Hospital 96 62 65%

Midland Regional Hospital Mullingar 107 40 37%

Naas General Hospital 143 105 73%

Portiuncula Hospital 65 36 55%

Sligo University Hospital 144 140 97%

St Vincent’s University Hospital 275 186 68%

Tallaght University Hospital 214 183 86%

University Hospital Waterford 121 91 75%

Wexford General Hospital 122 42 34%

Cork University Hospital 374 263 70%

Grand Total 3481 2417 69% Table 23. Admission to a stroke unit

*No Stroke Unit

Swallow Screening in Stroke Units

Swallow screening is considered a good

indicator of organized stroke care. In 2017,

65.9% (1905) of cases had a swallow screen

completed, of those 32.3% (617) had the

swallow screen completed within four hours.

Figure 13. Swallow Screening n=3481

1905897

89 590

Yes No Unknown Blanks

23

Table 24 indicates that admission to a

stroke unit triples the rate of having a

swallow screen completed.

Table 24: Swallow screening rates in Stroke Units

Mood Screening

The reporting of mood screening was added into the dataset in 2017 and there was a 75.4% (2624)

response rate to this data point. The completion of a mood screen is low at 34.5% (620), excluding blank

cases, and work is on-going within the National Stroke Programme to complete a mood guidance

document. At present a depression pathway is available on the National Stroke Programme website

https://www.hse.ie/eng/services/publications/clinical-strategy-and-programmes/management-of-post-

stroke-depression-care-pathway.pdf

As with the swallow screening admission

to a stroke unit increases the rate of

receiving assessment of mood as part of

comprehensive stroke care.

Table 25: Mood screening rates in Stroke Units

Stroke Unit Length of Stay (LOS)

The National Stroke Register captures the dates of admission and discharge from the stroke unit, which

allows calculation of length of stay for each patient in the stroke unit and also the proportion of the

patient’s overall stay in the hospital that was in the stroke unit.

There were 2416 patients admitted to the stroke unit and the length of stay was available for 2316 (96%)

patients.

Median (IQR) Mean (±SD)

Stoke unit LOS 9(4 – 15) 14 (±18.4)

Table 26: Length of Stay in Stroke Unit days, n=2316 (missing data = 100)

Admitted to a Stroke Unit n=2416

Not admitted to a Stroke Unit n=1004

Swallow Screen completed

67% (1619/2416) 28% (282/1004)

Admitted to a Stroke Unit n=2416

Not admitted to a Stroke Unit n=1004

Mood Screen completed

32.9% (570/2416) 11.1% (111/1004)

24

Outcomes

In 2017, the addition of pre-stroke and discharge Modified Rankin Score (MRS) was introduced. In 2017,

72% (2512) of cases had a pre-stroke MRS and 73% (2551) had a discharge MRS. 71% (2472) had a pre-

stroke MRS and discharge MRS recorded. Mortality results within this domain need to take into account

the sample size for analysis (71%). Online training was offered to all data inputters to support accurate

recording of the tool. It was agreed that results would be grouped as: no disability (0), Mild disability (1

or 2) and Moderate/Severe (3, 4 or 5), figure 14.

Figure 14. Pre-Stroke and Discharge Modified Rankin Score n=2472

MRS and Stroke Type

In 2017, the National Stroke Register recorded 87% (3019) ischaemic strokes (i63) and 13% (462)

haemorrhagic strokes (i61). Figures 15 and 16 indicates the outcomes by stroke type. An increased level

of disability and mortality is shown for haemorrhagic stroke. The mortality in this cohort is remarkably

similar to the national mortality by stroke type in NQAIS.

Figure 15. Ischaemic MRS Outcomes. Figure 16. Haemorrhagic MRS Outcomes.

27%

68%

34%

18%

26%

14%

13%

0

D I S C H A R G E M R S

P R E - S T R O K E M R S

M O D I F I ED R A N K I N S C O R E O U T C O M ES N = 2 4 7 2

0 1,2 3,4,5 6

29%

68%

35%

18%

25%

14%

11%

0%

D I S C H A R G E

P R E - S T R O K E

M O D I F I ED R A N K I N S C O R E O U T C O M ES - I S C H A EM I C N = 2 1 7 2

0 1,2 3,4,5 6

12%

66%

18%

16%

35%

18%

35%

0%

D I S C H A R G E

P R E - S T R O K E

M O D I F I ED R A N K I N S C O R E O U T C O M ES - H A EM O R R H A G E

N = 3 0 1

0 1,2 3,4,5 6

25

Multidisciplinary Team Assessment

The variables within the National Stroke Register relating to assessments by the multidisciplinary team,

including Clinical Nurse Specialist and Health and Social Care Professionals (HSCP), only ask if the

assessment was conducted.

In 2017, a HSCP specific dataset was designed, looking at the time frames within which the assessment

are carried out and other relevant variables. From 2018 data will be collected by HSCPs (physiotherapy,

occupational therapy and speech and language therapy) which will increase the level of data on in-patient

rehabilitation. We anticipate that this will take some time to embed into practice as it did for the main

register and will support HSCPs in this initiative.

Table 27 indicates that 81% of cases are assessed by a multidisciplinary team and 79% are assessed by a

Clinical Nurse Specialist in Stroke (table 28).

Table 27: Assessment by Multidisciplinary Team

Table 28: Assessment by Clinical Nurse Specialist/Advanced Nurse Practitioner

Clinical Nurse Specialist/Advanced Nurse

Practitioner n3481

N %

Yes 2755 79.1

No 593 17

Not Indicated 1 .03

Unknown 3 0.1

Missing/Not recorded 129 3.7

Multidisciplinary Team

N %

Yes 2,818 80.9

No 442 12.8

Unknown 221 6.3

26

Data regarding assessment by the various Health and Social Care Professionals is shown in tables 29 and

30. Removing the data for patients for whom an assessment was not indicated and also removing the

missing and unknown data shows that 98% of applicable patients received a Physiotherapy assessment,

96% received an Occupational Therapy assessment and 94% received a Speech and Language Therapy

assessment, 76% were seen by a Dietitian, 56% were seen by a Medical Social Worker and 11% saw a

psychologist. 73% were seen by a Clinical Nurse Specialist/Advanced Nurse Practitioner. However, the

proportion of missing data range between 20 and 30% and this needs to be taken into account and

addressed to ensure more accurate reporting of assessment by the Health and Social Care Professionals.

Table 29: Assessment by Physiotherapist, Occupational Therapist and Speech and Language Therapist (n=3,481)

Physiotherapist Occupational

Therapist

Speech &

Language

Therapist

N % N % N %

Yes 2635 75.7 2476 71 2055 59

No 49 1.4 87 3.2 138 3.9

Not Indicated 84 2.4 166 4.8 425 12.2

Unknown 2 0.1 1 .03 11 0.3

Missing/Not recorded 711 20.4 751 21 852 24.5

Table 30: Assessment by Dietitian, Medical Social Worker and Psychologist (n=3,481)

*Low referral rate may reflect low representation of psychologist on MDT as found in IHF/HSE National Stroke Audit

2015

Dietitian Medical Social Work Psychology*

N % N % N %

Yes 945 27.1 707 20.3 133 3.8

No 302 8.6 548 15.7 1080 31

Not Indicated 1103 31.6 990 28.4 890 25.5

Unknown 16 0.5 7 0.2 10 0.3

Missing/Not recorded 1115 32 1229 35.3 1368 39.3

27

Appendices

Appendix 1. National Stroke Register Steering Group Members

Prof. Joe Harbison, Consultant Stroke Physician, St. James’s Hospital- Chairperson

Dr Ronan Collin, Clinical Lead National Stroke Programme

Ms Ciara Breen, Occupational Therapist, University Hospital Galway

Deirdre Cunningham, Coding Manager, Beaumont Hospital

Ms Nora Cunningham, Clinical Nurse Specialist, University Hospital Limerick

Ms Trish Daly, Advanced Nurse Practitioner, Naas General Hospital

Dr Teresa Donnelly, Clinical Lead, MRH Tullamore

Dr Rachael Doyle, Consultant Geriatrician, Chairperson, IHF Council on Stroke

Mr Philip Dunne, I.T. Systems Support, Healthcare Pricing Office

Ms Emma Hickey, Clinical Nurse Specialist, Beaumont Hospital

Dr Frances Horgan, IHF Council on Stroke

Prof. Peter Kelly, Consultant Neurologist, Mater Hospital (Chair May2011–June 2013)

Ms Deirdre Lynch, Coding Manager, St Vincent’s University Hospital

Ms Joan McCormack, National Stroke Programme, Programme Manager, RCPI

Ms Hannah Murugan, St Luke’s Hospital, Kilkenny

Jackie Naughton, Coding Manager, Mercy University Hospital

Ms Imelda Noone, Advanced Nurse Practitioner, St Vincent’s University Hospital

Prof. Martin O’Donnell, Consultant Geriatrician, University Hospital Galway

Dr John Thornton, Consultant Radiologist, Clinical Stroke Lead, Beaumont Hospital

Ms Triona Dooley, Coding Manager, University Hospital Limerick

28

Appendix 2. National Stroke Register Dataset HIPE Portal Data Entry / Stroke (V3.0.2) 06 Dec 2016

Question Options Short Name

1. Which hospital was patient transferred from (if any) 0000 Not Applicable

0941 Children’s Crumlin

0101 St Columcille’s

0102 Naas General

0908 Mater Hospital

0910 SVUH

0925 Peamount Hospital

0955 Cappagh Orthopaedic

0940 Temple Street

0947 St Luke’s Rathgar

0904 SJH Dublin

0108 Connolly Blanchardstown

0912 Michaels Dun Laoghaire

0950 RVEEH

0960 National Rehabilitation

0930 Coombe Hospital

0932 Rotunda Dublin

0931 National Maternity Hosp

1270 Tallaght Hospital

1762 Josephs Raheny

0954 Clontarf Orthopaedic

1001 Blackrock Hospice

0600 Waterford

0601 St Luke’s KK

0605 Wexford

0602 Kilcreene

0607 Clonmel

0705 Finbar’s Cork

0704 Bantry

0913 Mercy Cork

0915 South Infirmary

0703 Mallow

0724 CUH

0726 Kerry

0301 Limerick Maternity

0300 Limerick

0302 Croom Limerick

0918 St Johns Limerick

0305 Ennis

0304 Nenagh

0803 Roscommon

0919 Portiuncula

0800 Galway

0802 Mayo

0801 Merlin Park

0203 Tullamore

0202 Mullingar

0201 Portlaoise

0500 Letterkenny

0501 Sligo

0922 Drogheda

0402 Cavan

0400 Louth County

0404 Monaghan

0403 Navan

8888 Other

Trans Hosp

1A. Why was the patient transferred 1 Thrombolysis

2 Thrombectomy

3 Neuro Surgery

8 Other

Trans Reason

1B. If other transfer reason, please specify Trans Reason Other

1C. If other transfer hospital, please specify Trans Hosp Other

2. Symptom onset date Onset Date

29

3. Symptom onset time (enter 9999 if unknown) Onset Time

3A. If symptom onset time is unknown, what date was the patient last known to be well

Last Well Date

3B. If symptom onset time is unknown, what time was the patient last known to be well

Last Well Time

4. Did the stroke occur while the patient was in hospital for treatment of another condition

1 Yes, 2 No

9 Unknown

Hosp Str

4A. If no, date of presentation to hospital Arr Date

4B. If no, time of presentation to hospital Arr Time

4C. If presentation time is unknown, was presentation to hospital within 4.5 hrs of symptom onset

1 Yes, 2 No

9 Unknown

Arr 4.5hrs

5. Medical team / Stroke team assessment date Assess Date

5A. Medical team / Stroke team assessment time Assess Time

6. Brain CT or MRI performed 1 Yes, 2 No

3 Performed pre adm / hosp transfer

9 Unknown

Imaging

6A. If yes, First Brain Imaging date Img Date

6B. If yes, First Brain Imaging time Img Time

7. Did the patient receive I.V. Thrombolysis (Key Performance Indicator) 1 Yes, 2 No

5 Contraindicated

Thrombolysis

7A. If yes, enter date Thromb Date

7B. If yes, enter time Thromb Time

7C. If yes, was intracerebral bleed seen on scan within 36 hrs 1 Yes, 2 No

9 Unknown

Intracereb Bleed

7D. If intracerebral bleed, was neuro deterioration associated with it 1 Yes, 2 No

9 Unknown

Neuro Deter Assoc

*8. Did the patient have thrombectomy in this hospital (Beaumont / CUH only) 1 Yes, 2 No Thrombectomy

8A. NIHSS pre-thrombectomy NIHSS Pre

8B1. Date of performance of non contrast CT Non Con CT Date

8B2. Time of performance of non contrast CT Non Con CT Time

8C1. Date of performance of non contrast CTA Non Con CTA Date

8C2. Time of performance of non contrast CTA Non Con CTA Time

8D1. Date of contact with the endovascular stroke centre Contact Endo Date

8D2. Time of contact with the endovascular stroke centre Contact Endo Time

8E1. Date of decision to transfer patient Trans Dec Date

8E2. Time of decision to transfer patient Trans Dec Time

8F1. Date of arrival at the endovascular stroke centre Date Arr Endo

8F2. Time of arrival at the endovascular stroke centre Time Arr Endo

8G1. Did the patient have repeat non invasive imaging in the endovascular stroke centre

1 Yes, 2 No

9 Unknown

Img Repeat

8G2. If yes, please specify 1 Non contrast CT

2 CTA

3 Perfusion CT

4 MRI

Img Type

8H. Site of most proximal occlusion 1 MCA 1

2 MCA 2

3 Basilar

4 ICA carotid T/L

5 ICA cervical segment

6 PCA

7 Vertebro basilar

Most Prox Occ

8J. Second occlusion site 2nd Occ Site

8K. Associated carotid stenosis greater than 50% 1 Yes, 2 No

9 Unknown

Assoc Carotid

30

8L1. TICI pre thrombectomy TICI Pre

8L2. TICI post thrombectomy TICI Post

8M1. Date of groin puncture Groin Punc Date

8M2. Time of groin puncture Groin Punc Time

8N1. Date of first pass 1st Pass Date

8N2. Time of first pass 1st Pass Time

8P1. Date of first reperfusion 1st Reperf Date

8P2. Time of first reperfusion 1st Reperf Time

8Q1. Date of final angio Final Angio Date

8Q2. Time of final angio Final Angio Time

8R. Immediate complications 0 Not Applicable

1 Haemorrhage

2 Embolus into separate vascular territory

3 Dissection

8 Other

9 Unknown

Imed Comp

8S. NIHSS 24 hour post-thrombectomy NIHSS Post

8T1. Following procedure was patient transferred immediately back to primary receiving hospital

1 Yes, 2 No

9 Unknown

Trans Prim Rec

8T2. If no, when was patient admitted to the endovascular stroke centre 1 0-3 hrs

2 3-12 hrs

3 12-24 hrs

4 24+ hrs

Trans Endo Centre

9. Was a swallow screen completed 1 Yes, 2 No

9 Unknown

Swallow

9A. If yes, was swallow screen completed within 4 hours of presentation 1 Yes, 2 No

9 Unknown

Swallow 4hrs

10. Modified Rankin Scale pre stroke 0 Zero

1 One

2 Two

3 Three

4 Four

5 Five

6 Six

9 Unknown

Pre Strk Rankin

11. Admitted to Stroke Unit (Key Performance Indicator) 1 Yes, 2 No Stroke Unit

11A. If yes, date admitted to Stroke Unit (Key Performance Indicator) SU Adm

11B. If yes, date discharged from Stroke Unit (Key Performance Indicator) SU Dis

11C. If no, reason why 1 No Stroke Unit

2 Bed Not Available

5 Infection Control Risk 8

Other

SU No

11C2. If other reason, please specify SU No Other

12. Allied Health Professional (AHP) Assessment 1 Yes, 2 No AHP

12A. If yes, Physiotherapy 1 Yes, 2 No

3 Not Indicated

9 Unknown

Physio

12B. If yes, Occupational Therapy 1 Yes, 2 No

3 Not Indicated

9 Unknown

Occup

12C. If yes, Speech and Language 1 Yes, 2 No

3 Not Indicated

9 Unknown

SLT

12D. If yes, Dietetics 1 Yes, 2 No

3 Not Indicated

9 Unknown

Dietet

31

12E. If yes, Medical Social Work 1 Yes, 2 No

3 Not Indicated

9 Unknown

MSW

12F. If Yes, Psychology 1 Yes, 2 No

3 Not Indicated

9 Unknown

Psyc

13. Was the patient assessed by Stroke Nurse Specialist 1 Yes, 2 No

9 Unknown

Assess SNP

13A. If no, reason why Assess SNP No

14. Multidisciplinary Meeting Case assessment 1 Yes, 2 No

3 Not Indicated

9 Unknown

Multidisc

14A. Was an assessment of mood completed and documented by a

member of the multi- disciplinary team

1 Yes, 2 No

3 Not Indicated

9 Unknown

Mood Assess

15. Does the patient have Symptomatic Carotid Stenosis 1 Yes, 2 No

9 Unknown

Stenosis

15A. If Symptomatic Carotid Stenosis, was the patient referred for Carotid Endarterectomy

1 Yes, 2 No

9 Unknown

Refer

Endarterectomy

15B. If Symptomatic Carotid Stenosis, was the patient referred for Carotid Stenting 1 Yes, 2 No

9 Unknown

Refer Stenting

16. New or Altered Antithrombotic Therapy prescribed for acute treatment 1 Yes, 2 No

3 Contraindicated

9 Unknown

Antithromb Acute

16A. If yes, Antiplatelet Or Anticoagulant (for acute treatment) start date Antiplatelet

17. Does the patient have Atrial Fibrillation 1 Yes, 2 No

4 Results Pending

9 Unknown

Atrial Fib

17A. If Atrial Fibrillation, was atrial fibrillation known prior to stroke onset 1 Yes, 2 No

9 Unknown

AFib Prior

17B1. If yes, please specify Antiplatelet / Anticoagulant - prior to stroke 0 NOAC

1 Warfarin

5 Aspirin

6 Clopidogrel

7 Other Antiplatelet

8 Dual Antiplatelet Therapy

9 Antiplatelet & Anticoagulant

Anticoag Prior

17C. If atrial fibrillation known prior to stroke onset, and Warfarin, was INR 2-3 at Stroke onset

1 Yes, 2 No

9 Unknown

INR 2-3

17D. If Atrial Fibrillation, Anticoagulation prescribed for secondary prevention 1 Yes, 2 No

9 Unknown

Anticoag 2nd

17D1. If yes, please specify Antiplatelet / Anticoagulant - on discharge 0 NOAC

1 Warfarin

5 Aspirin

6 Clopidogrel

7 Other Antiplatelet

8 Dual Antiplatelet Therapy

9 Antiplatelet & Anticoagulant

Anticoag Discharge

17D2. If no, please enter reason documented 1 No reason documented

2 Major bleeding (prior history)

3 Severe illness (e.g. cancer, dementia)

04 Poor compliance (known or

suspected)

5 Patient refused anticoagulation

6 Alcohol excess

7 Falls

8 Extreme frailty

9 Liver disease

Anticoag Doc

32

18. Modified Rankin Scale on discharge 0 Zero

1 One

2 Two

3 Three

4 Four

5 Five

6 Six

9 Unknown

On Dis Rankin

19. Discharge destination 1 Home

2 Patient died

3 Discharge to long term care

4 Discharge to off-site rehab 5

Transfer to referring hosp

6 Transfer to other hosp for on-going

stroke care

7 Home with ESD

8 Other

9 Unknown

Dis Dest

*Q8 is answered in Beaumont Hospital and Cork University Hospital only.

33

References

European Stroke Organisation (2008) Executive Committee and the ESO Writing Committee. Guidelines

for the management of ischaemic stroke and transient ischaemic attack. Cerebrovasc Dis 2008;25:457-

507.

Horgan F, Hickey A, McGee H, O’Neill D, on behalf of INASC Team (2008). Irish National Audit of Stroke

Care: Main Report. Dublin. Irish Heart Foundation.

Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, McMullan PW Jr,

Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H; on behalf of the

American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Peripheral

Vascular Disease and Council on Clinical Cardiology (2013) . Guidelines for the early management of

patients with acute ischaemic stroke: a guideline for healthcare professionals from the American Heart

Association/American Stroke Association. Stroke 2013;44:870-947.

McElwaine P, McCormack J, Harbison J on behalf of the National Stroke Programme Audit Steering Group

(2015). Irish Heart Foundation /HSE National Stroke Audit 2015.

National Office of Clinical Audit (2016) National Audit of Hospital Mortality. RCSI.

National Patient Safety Office (2017) National Healthcare Quality Reporting System. Department of

Health. Dublin

National Quality Assurance and Improvement System (2018) https://www.healthatlasireland.ie/

Accessed on 17/7/18

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Accessed on 17/7/18 https://www.strokeaudit.org/results/Clinical-audit/National-Results.aspx