Quality statement 2 – Time-critical therapy Indicator 2e: Time from onset of symptoms to thrombolysis Definitional attributes Name: Time from onset of symptoms to thrombolysis for patients with a final diagnosis of ischaemic stroke. Rationale: Meta-analysis of clinical trials has shown that thrombolysis improves outcomes and the outcomes are more pronounced with earlier intervention.1 Recombinant tissue plasminogen activator (rtPA) given up to 4.5 hours (i.e. up to 270 minutes) after ischaemic stroke onset is associated with an increased chance of favourable outcomes.1 Collection and usage attributes Computation: Time (in minutes) from symptom onset to administration of thrombolytic agent or intervention. Data for this indicator is analysed as median time and interquartile range (IQR) (in minutes) from symptom onset to administration of thrombolytic agent or intervention. IQR is calculated by subtracting the value at the 1st quartile (lower) from the 3rd quartile (upper): IQR = xu – xl Both median and IQR are calculated using the total number of patients with a final diagnosis of ischaemic stroke (I63.x, 164)a,b who are thrombolysed. Setting : Acute/Hospital. Comments: A denominator is not required for this indicator since median is calculated by locating the 50th percentile. The interquartile range (IQR) is the difference between the third and the first quartiles. It is a measure of dispersion. References 1. Wardlaw JM, Murray V, Berge E, del Zoppo GJ. Thrombolysis for acute ischaemic stroke. The Cochrane database of systematic reviews 2014;7. a ICD-10-AM (9th edition). b Note that although 164 is ‘Stroke, not specified as haemorrhage or infarction’, more than 80% of strokes coded to this category are ischaemic.
Quality statement 4 – Early rehabilitation A patient’s rehabilitation needs and goals are assessed by staff trained in rehabilitation within 24–48 hours of admission to the stroke unit. Rehabilitation is started as soon as possible, depending on the patient’s clinical condition and their preferences. Indicator 4a: Assessment for rehabilitation by a physiotherapist within 24–48 hours of hospital admission Definitional attributes Name: Proportion of patients with a final diagnosis of stroke with a documented physiotherapy assessment within 24–48 hours of presentation to hospital.1 Rationale: Early physiotherapy assessment is an important and clear starting point to the acute care assessment, management, rehabilitation, and discharge planning process. If applied systematically, early allied health assessment should improve the appropriateness of the ongoing inpatient and discharge care needs.1 Physiotherapy assessment is a good indicator of rehabilitation activity. Collection and usage attributes Computation: (Numerator ÷ denominator) x 100 Numerator: Total number of patients with a final diagnosis of stroke with a documented physiotherapy assessment within 24–48 hours of presentation to hospital. Numerator criteria: Inclusions Patients diagnosed with stroke (I61.x, I62.9, I63.x and 164).a Care type = ‘1’ (acute care).b Exclusions Nil. Denominator: Patients with a final diagnosis of stroke who were admitted to hospital. Denominator criteria: Inclusions Patients diagnosed with stroke (I61.x, I62.9, I63.x and 164).a Care type = ‘1’ (acute care).b Exclusions Patients who refuse the assessment/decline rehabilitation. Setting: Acute/Hospital. Comments: This indicator has been slightly modified from the Australian Council on Healthcare Standards indicator used as part of the previous Stroke Foundation Acute Services Audit which specifies an assessment within 48 hours of hospital admission. Rehabilitation assessment by a physiotherapist is associated with improved patient outcomes.2 a ICD-10-AM (9th edition). b METeOR identifier: 491557.
Quality statement 4 – Early rehabilitation Indicator 4c: Treatment for a rehabilitation goal commencing during an acute hospital admission Definitional attributes Name: Proportion of patients with a final diagnosis of stroke who undergo treatment by a therapist for an identified and documented rehabilitation goal during their acute hospital admission. Rationale: Rehabilitation is effective in reducing stroke impairment and in preventing complications. Collection and usage attributes Computation: (Numerator ÷ denominator) x 100 Numerator: Proportion of patients with a final diagnosis of stroke who undergo treatment for an identified rehabilitation goal during their acute hospital admission. Numerator criteria: Inclusions Patients diagnosed with stroke (I61.x, I62.9, I63.x and 164).a Care type = ‘1’ (acute care).b Exclusions Nil. Denominator: Proportion of patients with a final diagnosis of stroke. Denominator criteria: Inclusions Patients diagnosed with stroke (I61.x, I62.9, I63.x and 164).a Care type = ‘1’ (acute care).b Exclusions Stroke patients who decline rehabilitation, return to pre-morbid function, are in a coma and/or unresponsive (not simply drowsy), or where there are limitations of therapy (i.e. advance care directive is enacted and/or the patient is on a palliative care pathway).1 Setting: Hospital. Comments: The rehabilitation goals should be determined jointly by the patient and their family, and undertaken by a qualified health professional with expertise in the particular impairment. The rehabilitation goals should be documented.1 Reference 1. Australian Stroke Coalition Rehabilitation Working Group. Assessment for Rehabilitation: Pathway and Tool 2012. Melbourne, Australia.c a ICD-10-AM (9th edition). b METeOR identifier: 491557. c Available at: .
Quality statement 5 – Minimising risk of another stroke Indicator 5b: Discharge on statin, antihypertensive and antithrombotic medications (ischaemic stroke) Definitional attributes Name: Proportion of patients with a final diagnosis of ischaemic stroke who are discharged on statin, antihypertensive and antithrombotic medications, where not contraindicated. Rationale: Ischaemic stroke patients should be discharged on statin, antihypertensive and antithrombotic medications to ensure optimal outcomes. Lowering lipid levels (using a statin) is an effective primary and secondary prevention treatment for vascular events, including stroke.1 The use of antiplatelet drugs has been shown to provide a 22% reduction in vascular events (myocardial infarction, stroke or vascular death) in patients with a previous stroke or transient ischaemic attack (TIA).2 Most antihypertensive drugs have been shown to reduce blood pressure, the recurrence of stroke and cardiovascular events.3 Collection and usage attributes Computation: (Numerator ÷ denominator) x 100 Numerators: Patients with a final diagnosis of ischaemic stroke discharged from hospital on statin, antihypertensive and antithrombotic medications, where not contraindicated. Numerator criteria: Inclusions Patients with a final diagnosis of ischaemic stroke (163.x, 164).a,b Care type = ‘1’ (acute care).c Exclusions Nil. Denominator: Patients with a final diagnosis of stroke who were discharged from hospital. Denominator criteria: Inclusions Patients diagnosed with ischaemic stroke (163.x, 164).a,b Care type = ‘1’ (acute care).c Exclusions Patients for whom statin, antihypertensive or antithrombotic medications are contraindicated, and for whom the contraindication(s) is documented. Setting: Acute/Hospital. a ICD-10-AM (9th edition). b Note that although 164 is ‘Stroke, not specified as haemorrhage or infarction’, more than 80% of strokes coded to this category are ischaemic. c METeOR identifier: 491557.
Quality statement 6 – Carer training and support A carer of a patient with stroke is given practical training and support to enable them to provide care, support and assistance to a patient with stroke. Indicator 6a: Carer support needs assessment Definitional attributes Name: Proportion of patients with a final diagnosis of stroke whose carer(s) have a documented formal needs assessment. Rationale: Assessment of carer support needs allows for referral to appropriate services. Collection and usage attributes Computation: (Numerator ÷ denominator) x 100 Numerator: Patients with a final diagnosis of stroke whose carer(s) have had a documented formal needs assessment. Numerator criteria: Inclusions Patients diagnosed with stroke (I61.x, I62.9, I63.x and 164).a Separation mode =‘9’ (discharge to usual residence or own accommodation).b Exclusions Stroke patients discharged from hospital who do not have a carer. Denominator: Patients with a final diagnosis of stroke who have a carer upon discharge from hospital. Denominator criteria: Inclusions Patients diagnosed with stroke (I61.x, I62.9, I63.x and 164).a Separation mode =‘9’ (discharge to usual residence or own accommodation).b Exclusions Stroke patients discharged from hospital who do not have a carer. Where patient or carer refuses a formal assessment. Setting: Hospital and/or home. Comments: N/A. Reference Supplementary source: National Stroke Foundation. National Stroke Audit: Acute Services Clinical Audit Report. Melbourne: NSF, 2013. a ICD-10-AM (9th edition). b METeOR identifier: 270094. Includes discharge to usual residence, own accommodation or welfare institution (includes prisons, hostels and group homes providing primarily welfare services).