Spreadsheet: 87706d1287581481-category-x-axis-labels-not-displaying-copy-network-20report-202010-2011-1-
Sheet: Data definitions

NETWORK DATA SET |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | data link to network
Indicator | ID | [NAME] | Metric | Data Definition | Rationale | Reporting frequency | Reporting to | Target | Vital signs | WM service spec | Sentinel | SITS-MOST | SINAP | Payment by results | Accelerated programme | CQC Quality Review | Data source | [NAME] | Walsall | Wolverhampton
Preventable Strokes | 1 | Acute | Proportion of patients presenting with stroke with AF anti-coagulated on discharge | This measure refers to secondary prevention.  Proportion of patients presenting with new stroke with atrial fibrillation who are discharged on anticoagulation.   Denominator- number of patients admitted with a stroke also with atrial fibrillation (newly diagnosed on this admission or previously diagnosed) Numerator- the number of these patients who were discharged on anticoagulation or who had a plan for anticoagulation  to start, when clinically appropriate, in the discharge letter or medical notes.   Record the number of patients admitted with confirmed stroke with atrial fibrillation. Record the number of patients who are discharged on anticoagulation and the number who have a plan for anticoagulation  to start in the next month in the discharge letter.  Tolerance- The metric has already taken into account the proportion likely to be excluded ie patients  in whom anticoagulation is contraindicated or who decline.   Anticoagulation refers to treatment with an anticoagulant such as Warfarin and not an antiplatelet such as [NAME] or Clopidogrel. | Atrial fibrillation is an important risk factor for stroke and is associated with about 15% of all strokes. • Optimal treatment of AF in the population could reduce overall stroke risk by 10% • Anticoagulation is highly effective in reducing stroke risk in patients with AF by approximately 70%   The RCP national Sentinel Audit 2008 demonstrated that only 24% of patients with atrial fibrillation (AF) were discharged on warfarin and only a further 9% of people were planned to receive it in the future. Thus only a third of people with AF were likely to be anticoagulated. There are some good reasons not to anticoagulate (high risk of falls, severe stroke, likely difficulties with compliance etc) but it would not be expected to account for more than about a third of the stroke population at most. Warfarin is twice as effective as aspirin  at preventing further stroke in people with AF. The rate of use has to be increased.  One of the nine key metrics for 'accelerating stroke improvement' | Monthly | Network | 60% by April 2011 |  |  |  |  |  |  | x |  | Trust | [NAME] - Deputy Head of Information | [NAME] & Older People | [NAME]
Pre hospital response | 2 |  | The proportion of patients achieving a call connect to door time of 60 minutes | Record the number of patients with stroke  ie with persisting neurological symptoms who screen postive using a validated tool and in whom hypoglycaemia has been excluded, who called an ambulance to bring them to hospital.  For these patients record the time in minutes from the call to the ambulance service to arrival at the hospital- this may be the Emergency Deprtment or radiology if the pathway is for patients to be scanned on arrival.  The average time and range of times from call to arrival can be calculated  '[NAME]' is the time at which the patient enters the hospital building as recorded by the ambulance crew  Exceptions- exclude patients who do not have a stroke diagnosis | The first steps to accessing emergency treatment is a rapid response  to a 999 call... National Stroke Strategy. All community medical services and ambulance services should be trained so they treat patients with symptoms suggestive of an acute stroke as an emergency requiring urgent transfer to a centre with specialised hyperacute stroke services. RCP National Clinical Guidelines for Stroke | Monthly | Network | All cases |  | x |  |  | x |  |  |  | WMAS (data on PRF) | [NAME] Head of Cardiac & Stroke Management | [NAME] Head of Cardiac & Stroke Management | [NAME] Head of Cardiac & Stroke Management
 | 3 | Acute | The proportion of cases achieving a door to needle time of 60 minutes | door to needle times and profile in time bands to be able to track improvements towards the 90 minute exemplar standard, specifically  the  door to needle component. |  | Monthly | Network | 0.8 |  | x |  |  | x |  |  |  | Trust | [NAME] - Deputy Head of Information | [NAME] & Older People | [NAME]
 |  | Acute | The proportion of cases achieving a door to needle time of 30 minutes | door to needle times and profile in time bands to be able to track improvements towards the 90 minute exemplar standard, specifically  the  door to needle component. |  | Monthly | Network |  |  | x |  |  | x |  |  |  | Trust | [NAME] - Deputy Head of Information | [NAME] & Older People | [NAME]
 | 4 | Acute | To map using first 4 digits of postcode linkages between calls to WMAS (suspected stroke)  and “hard to reach”/areas of high stroke risk – to underpin targeting social marketing campaigns | refer to WMAS for definitions -  linkages between calls to WMAS (suspected stroke)  and “hard to reach”/areas of high stroke risk – to underpin targeting social marketing campaigns | refer to WMAS for rationale | Quarterly | Network | All calls |  | x |  |  |  |  |  |  | WMAS | [NAME] Head of Cardiac & Stroke Management | [NAME] Head of Cardiac & Stroke Management | [NAME] Head of Cardiac & Stroke Management
Pre-hospital assessment | 5 | Acute | Proportion of patients with neurological symptoms screened by ambulance personnel using a validated tool to determine a diagnosis of stroke or transient ischaemic attack. | Denominator - number of patients with sudden onset of neurological symptoms brought to hospital by ambulance.  Numerator - number of these patients  screened by ambulance personnel using a validated tool to determine a diagnosis of stroke/TIA | In people with sudden onset of neurological symptoms, a validated tool such as the FAST test should be used outside hospital to screen for a diagnosis of stroke and TIA. RCP National Clinical Guidelines for Stroke. ….health and care staff are able to reco | Quarterly | Network | All cases |  | x |  |  |  |  |  |  | WMAS (data on PRF) | [NAME] Head of Cardiac & Stroke Management | [NAME] Head of Cardiac & Stroke Management | [NAME] Head of Cardiac & Stroke Management
Access to stroke thrombolysis | 6 | Acute | Total number of stroke admissions | TACI, PACI, LACI, POCI, intracerebral bleed, does not include admitted TIA or SAH patients |  | Monthly | Network |  |  | x |  |  | x |  |  |  | Trust | [NAME] - Deputy Head of Information | [NAME] & Older People | [NAME]
 | 7 | Acute | Total number of ischaemic strokes | TACI, PACI, POCI, LACI only |  | Monthly | Network |  |  | x |  |  | x |  |  |  | Trust | [NAME] - Deputy Head of Information | [NAME] & Older People | [NAME]
 | 8 | Acute | Proportion of patients with confirmed ischaemic  stroke who are thrombolysed | Denominator -Total number of ischaemic strokes (ie: TACI, PACI, POCI, LACI only) Numerator - number of patients thrombolysed  For each patient with confirmed stroke record  Was the patient given thrombolysis?  Yes / No     If no, what were the reasons for | Onset of symptom to lysis  - Aim statement  - 3 hours. This information should be reported in 30 minute time bands | Monthly | Network | 0.1 |  | x |  | x | x |  |  |  | Trust | [NAME] - Deputy Head of Information | [NAME] & Older People | [NAME]
 | 9 |  | Proportion of patients whose call to needle time is less than 90 minutes | Denominator -  number patients receiving thrombolysis Numerator number of these patients whose call connect to needle time was less than 90 minutes |  | Quarterly | RCP/Network |  |  |  |  |  |  |  |  |  | WMAS | [NAME] Head of Cardiac & Stroke Management | [NAME] Head of Cardiac & Stroke Management | [NAME] Head of Cardiac & Stroke Management
 | 10 |  | Proportion of patients whose onset of symptoms to needle time less than 180 minutes | Denominator -  number patients receiving thrombolysis Numerator number of these patients whose onset of symptoms to needle  time was less than 180 minutes | Onset of symptom to lysis  - Aim statement  - 3 hours. This information should be reported in 30 minute time bands | Quarterly | Network |  |  |  |  |  |  |  |  |  | WMAS | [NAME] Head of Cardiac & Stroke Management | [NAME] Head of Cardiac & Stroke Management | [NAME] Head of Cardiac & Stroke Management
Direct admission to a stroke ward | 11 | Acute | Proportion of patients admitted directly to an acute stroke unit within 4 hours of hospital arrival | Denominator- number of patients with confirmed stroke   Numerator- number of patients with confirmed stroke in an acute stroke unit bed at 4 hours after arrival at hospital. For each patient with confirmed stroke record date and time  patient arrived in h | Timely access to acute stroke units prevents death and increases independence. National Stroke Stategy. One of the nine key metrics for 'accelerating stroke improvement' NICE Quality Standard | Monthly | Network | 90% by 2011 |  | x |  |  | x |  | x |  | Trust | [NAME] - Deputy Head of Information | [NAME] & Older People | [NAME]
Access to brain imaging | 12 | Acute | Proportion of stroke patients scanned within one hour of  hospital arrival | Needs to be collected as two metrics; one for patients who require immediate imaging (i) and one for patients who do not (ii). i) Proportion of patients scanned within one hour of hospital arrival Denominator - Number of patients admitted with acute strok | Brain imaging should be performed immediately for  defined groups of people with acute stroke. For people without indications for immediate imaging scanning should be performed as soon as possible.(within a maximum of 24 hours after onset of symptoms) RCP | Monthly | Network | 50% by April 2011 |  | x |  |  | x | x | x |  | Trust | [NAME] - Deputy Head of Information | [NAME] & Older People | [NAME]
 | 13 |  | Proportion of stroke patients  scanned within 24 hours of hospital arrival |  |  | Monthly | Network | 100% by April 2011 |  | x | x |  | x | x | x |  | Trust | [NAME] - Deputy Head of Information | [NAME] & Older People | [NAME]
Access to neurological services | 14 | Acute | Number of patients requiring urgent referral for neuro-surgery assessment/treatment |  |  | Annually | Network |  |  | x |  |  |  |  |  |  | Trust
 | 15 | Acute | Length of time between referral and assessment/transfer for neuro-surgical opinion | Denominator is number of patients requiring urgent referral for neuro-surgery assessment/treatment [NAME] is referal time recorded for each patient and mean average calculated | mean average time for those referred to metric id 14 | Annually | Network |  |  | x |  |  |  |  |  |  | Trust
Acute stroke care | 16 | Acute | Proportion of patients that spend 90% of their hospital stay on a stroke unit | see VSMR v1.14 guidance | Reported as a DH Vital sign | Monthly | Network | 80% by 2011 | x | x | x |  | x | x | x |  | Trust | [NAME] - Deputy Head of Information | [NAME] & Older People | [NAME]
 | 17 | Acute | Screened for swallowing disorders within 24 hours of admission | Denominator - number of patients diagnosed with stroke on admission  Numerator - number of these patients who were screened for swallowing disorders within 24 hours of admission | …survival is strongly associated with the processes of care that are carried out more frequently on a stroke units…there are significant differences in MDT working and medical management. National Stroke Strategy. Key standards bundle is consistent with t | Annually | RCP/Network | 0.8 |  | x | x |  | x |  |  |  | Trust | Collective review (e.g. Sentinel, CQC) | Collective review (e.g. Sentinel, CQC) | Collective review (e.g. Sentinel, CQC)
 | 18 | Acute | Proportion of eligible patients receiving the first dose of aspirin, (or an alternative anti-platelet agent, such as clopidogrel)  within 24 hours | The denominator is the total number of ischaemic strokes (ie: TACI, PACI, POCI, LACI only)  The numerator is the number of these patients who were prescribed aspirin or an antiplatelet within 24 hours of admission | All patients should have an initial dose of 300mg of aspirin either orally, or rectally as tolerated, and continued into the acute phase (unless contra-indicated or unless haemorrhage is shown on CT or is clinically likely)   An alternative anti-platelet | Annually | RCP/Network | 1 |  | x | x |  | x |  |  |  | Trust | Collective review (e.g. Sentinel, CQC) | Collective review (e.g. Sentinel, CQC) | Collective review (e.g. Sentinel, CQC)
 | 19 | Acute | Received a physiotherapy assessment within 24 hours of admission | The denominator is number of patients diagnosed with stroke on admission   The numerator is the number of these patients provided with physiotherapy within 72 hours | Reasons for non assessment could be recorded in patient records | Annually | RCP/Network | 24hrs Network (72 hours Sentinel auduit) |  |  | x |  | x |  |  |  | Trust | Collective review (e.g. Sentinel, CQC) | Collective review (e.g. Sentinel, CQC) | Collective review (e.g. Sentinel, CQC)
 | 20 | Acute | Received an assessment by an Occupational Therapist within 4 working days of admission | The denominator is number of patients diagnosed with stroke on admission   The numerator is the number of these patients provided with an assessment by an Occupational therapist within 96 hours | Reasons for non assessment could be recorded in patient records | Annually | RCP/Network |  |  |  | x |  | x |  |  |  | Trust | Collective review (e.g. Sentinel, CQC) | Collective review (e.g. Sentinel, CQC) | Collective review (e.g. Sentinel, CQC)
 | 21 | Acute | Weighed at least once during admission | The denominator is total number of patients diagnosed with a stroke  on admission  The numerator is the number of these patients weight at least once during admission | Reasons for non assessment could be recorded in patient records | Annually | RCP/Network |  |  |  | x |  | x |  |  |  | Trust | Collective review (e.g. Sentinel, CQC) | Collective review (e.g. Sentinel, CQC) | Collective review (e.g. Sentinel, CQC)
 | 22 | Acute | Had their mood assessed by discharge | The denominator is total number of patients diagnosed with a stroke   The numerator is the number of these patients who had mood assessed by discharge | Reasons for non assessment could be recorded in patient records | Annually | RCP/Network |  |  |  | x |  | x |  |  |  | Trust | Collective review (e.g. Sentinel, CQC) | Collective review (e.g. Sentinel, CQC) | Collective review (e.g. Sentinel, CQC)
 | 23 | Acute | With clear rehabilitation goals agreed by the multi-disciplinary team | The denominator is total number of stroke patients  The numerator is the number of these patients whose rehabilitation goals were agreed by a multi-disciplinary team | Reasons for non assessment could be recorded in patient records | Annually | RCP/Network |  |  |  | x |  | x |  |  |  | Trust | Collective review (e.g. Sentinel, CQC) | Collective review (e.g. Sentinel, CQC) | Collective review (e.g. Sentinel, CQC)
Management of high risk TIA patients - Clinic Appointment | 24 | TIA | Proportion of high risk TIA patients investigated and treated within 24 hours of first contact with a health professional | see VSMR v1.14 guidance | DH TIA Vital sign | Monthly | Network/SHA | 60% by April 2011 | x | x |  |  | x |  | x |  | Trust | [NAME] - Deputy Head of Information | [NAME] & Older People | [NAME]
TIA intervention | 25 | TIA | Time from specialist assessment of TIA to carotid intervention for those patients with TIA requiring carotid surgery | Record the number of patients who underwent carotid surgery. Record the date of TIA assessment at stroke specialist TIA clinic, and the date of carotid surgery.   Calculate the average time in days and the range of days between the  assessment and the sur | Carotid intervention for recently symptomatic severe carotid stenosis should be regarded as an emergency procedure in patients who are neurologiclly stable and should ideally be performed within 48 hours of TIA/ minor stroke National Stroke Strategy. Pati | Annually | Network |  |  |  |  |  |  |  |  |  | Trust | review involving network/informatics/acute | review involving network/informatics/acute | review involving network/informatics/acute
Involving patients and carers | 26 | Whole pathway | methods were used in month to involve people with stroke and their carers in strategic planning and commissioning of stroke and TIA services | There should be evidence of use of user/ carer views to inform services in any setting where stroke services are provided?  E.g. Evidence of discovery interviews for stroke patients,  patient satisfaction surveys, board reports for stroke patients, focus | People who have had a stroke, and their relatives and carers, have access to practical advice, emotional support, advocacy and information throughout the care pathway and lifelong. National Stroke Strategy | Annually | Network |  |  |  |  |  |  |  |  |  |  | All | All | All
Patient and carer information and advice | 27 | Whole pathway | proportion of patients received stroke specific information (written or documented explanation) in an appropriate format by an appropriately trained health professional about  a)Diagnosis and prognosis b) A single point of contact for future support after | Appropriate format- is information offered which meets communication access guidelines ie suitable for people with aphasia, visually impaired (large print/audio), non-native English speaking. Appropriately trained health professional- an individual who is | People who have had a stroke, and their relatives and carers, have access to practical advice, emotional support, advocacy and information throughout the care pathway and lifelong. National Stroke Strategy | Annually | Network |  |  |  |  |  |  |  |  | x | Whole pathway | All | All | All
Timely access to psychological support | 28 | Rehabilitation and life after stroke | Proportion of patients who  are referred to a service providing psychological support for mood, behaviour or cognitive disturbance  by six months after stroke. | Denominator - number of patients  with stroke, alive at 6 months post stroke. Numerator- number of patients who have been seen (assessed and /or treated) by a service providing psychological support capable of managing mood, behaviour or cognitive disturbance | People who have strokes access high quality rehabilitation. Targeted interventions can help specific problems. National Stroke Strategy.  Patients receive the …emotional support they need.  Carers should be able to access the help and support they need.RC | Monthly | Network/SHA | 40% by April 2011 |  |  |  |  |  |  | x |  | CSRT |  | [NAME] | [NAME]
Improving the quality of end of life care | 30 | End of life | Proportion of patients at end of life on an appropriate pathway | For the purposes of this metric end of life refers to patients who are deemed to be terminally unwell and need to receive palliative care as defined  by the multidisciplinary or medical team  Appropriate pathway for example the Liverpool Care Pathway, is a management plan which takes into account the individuals wishes for end of life care and  withdraws unnessessary interventions.  The denominator is the number of patients defined in the medical notes as being at the end of life. The numerator is the number of patients at the end of life who are placed on an appropriate pathway for end of life care. | DH End of Life Care Strategy : first annual report promotes high quality care for all adults at the end of life | Annually | Network |  |  |  |  |  |  |  |  |  |  | Pam Cansdale | TBC | TBC
Assessment and review | 31 | Rehabilitation | Proportion of stroke patients that are reviewed six months after leaving hospital | Number of stroke patients reviewed at 6 months post hospital discharge   Denominator-number of people with stroke discharged alive who are still alive at 6 months Numerator- number of stroke patients reviewed at 6 months post hospital discharge   [NAME] | People who have had strokes either living at home or in care homes, are offered a review from primary care services of their health and social care status and secondary prevention needs, typically at 6 weeks and 6 months after leaving hospital. This is fo | Monthly | Network | 95% by 2011 |  |  |  |  |  |  | x |  | Trust | [NAME] - Deputy Head of Information | [NAME] & Older People | [NAME]
Access to ESD services | 32 | Rehabilitation and transfer of care | Proportion of patients supported by a stroke skilled Early Supported Discharge team | This needs to be collected as two components i) the availability or otherwise of an early Supported Discharge Team and ii)proportion of  patients supported by and Early Supported Discharge Team i) is there an Early Supported Discharge Team according to th | Early Supported Discharge to a comprehensive stroke specialist and multidisciplinary team (which includes social care) in the community but with a similar level of intensity to stroke unit care, can reduce mortality and institution rates. National Stroke | Monthly | Network | 40% by September 2011 |  |  |  |  |  |  | x |  | CSRT | [NAME] | Alison Stone/Liz Brown | [NAME]/[NAME]
 | 33 |  | Presence of an Early Supported discharge team | Is there an Early Supported Discharge Service according to the guidance given below.   This is reported as Yes/No.  To answer Yes the service must have seen at least one patient for early supported discharge If No select from the following Intention to im |  | Monthly | Network | see rationale |  |  |  |  |  |  | x |  | CSRT | [NAME] | Alison Stone/Liz Brown | [NAME]/[NAME]
Transfer of care - discharge from hospital | 34 | Rehabilitation and transfer of care | Number of days from hospital discharge to first face to face contact with stroke skilled  community rehabilitation team | Record the number of patients eligible for  community stroke rehabilitation ie where a clinical need for ongoing rehabilitation by a stroke skilled service is defined and documented by the hospital MDT. Record the number of days from the date the patient | Transfers between different teams and between different organisations should occur at the apropriate time and without delay. RCP National Clinical Guidelines for Stroke | Annually | Network |  |  |  |  |  |  |  |  |  | CSRT | [NAME] | Alison Stone/Liz Brown | [NAME]/[NAME]
Discharge destination | 35 | Rehabilitation and transfer of care | Percentage of patients transferred from the final inpatient setting to their usual place of residence | Denominator, number of stroke patients discharged alive from the final hospital inpatient setting ie acute combined or rehabilitation unit.  Numerator - number of patients discharged to usual place of residence ie home or carehome.  Record final discharge | Measuring success- a greater proportion of individuals affected by stroke to live independently. National Stroke Strategy | Annually | Network |  |  |  |  |  |  |  |  |  | CSRT/Trust | [NAME] | Alison Stone/Liz Brown | [NAME]/[NAME]
Living independently with a stroke | 36 | Life after stroke | Percentage of patients living at home at 6 weeks post discharge form hospital | The denominator is the number of stroke patients discharged alive. The numerator is the number of of patients living independently at 6 weeks |  | Quarterly | Network |  |  |  |  |  |  |  |  |  | Trust | [NAME] - Deputy Head of Information | [NAME] & Older People | [NAME]
 | 37 |  | Percentage of patients living at home at 6 months post discharge from hospital | The denominator  is the number of stroke patients disharged alive. The numerator is the number of of patients living independently at 6 months . |  | Quarterly | Network |  |  |  |  |  |  |  |  |  | CSRT | [NAME] | Alison Stone/Liz Brown | [NAME]/[NAME]
 | 38 |  | Percentage of patients living at home one year post discharge from hospital | The denominator  is the number of stroke patients disharged alive. The numerator is the number of of patients living independently at one year. | High quality in-hospital rehabilitation and community stroke rehab/enabling services and social care services can enhance independence.  National Stroke Strategy NSF Long Term Conditions Living at home is defined  as a residence which the individal permanently inhabits alone or with family of friends. This can include private or rented accomodation, supported housing; sheltered or warden controlled, but not institutional accomodation ie residential or nursing home or intermediate care placement. The individual may be in receipt of formal or informal care no matter how intensive. | Quarterly | Network |  |  |  |  |  |  |  |  |  |  | [NAME] | Alison Stone/Liz Brown | [NAME]/[NAME]
 | 39 | Whole pathway | Providers will have systems in place to enable the collection of patient/relative satisfaction of service | Statement of baseline position of how patient/relative satisfaction systems operate | No re | Annually | Network |  |  | x
Governance | 40 | Whole pathway | Trusts to ensure neuro-vascular and neuro-imaging reviews are in place, are multi disciplinary, and occur at least annually |  |  | Annually | Network |  |  | x |  |  |  |  |  |  | Trust
Research | 41 | Whole pathway | Patients should be offered the opportunity to participate in research and trials | Statement of baseline position |  | Annually | Network |  |  | x |  |  |  |  |  |  | Whole pathway
Joint health and social care management | 42 | Life after stroke | Proportion of patients and carers with joint care plans on discharge from hospital | Denominator- number of stroke patients discharged alive Numerator - number of these patient who have a copy of their  joint care plan on discharge from hopsital to final place of residence.  Joint care plan- documented evidence of an assessment and management plan which takes into account the patients health and social care needs.  Exceptions: Exclude patients who have no documented health or social care needs, patients not resident in the UK and patients who refuse a health/social care assessment or intervention. | Everyone with a long term condition should be offered a care plan by 2010  (Our health ,Our Say) and all primary care trusts and  local authorities will need to have established joint health -social care managed networks/teams to support this. National Stroke Strategy | Monthly | Network | 85% by April 2011 |  |  |  |  |  |  | x |  | CSRT/Trust/Social care | [NAME] | Alison Stone/Liz Brown/Anne Lewis Stroke ward | [NAME]/[NAME]