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Stroke is one of the first focuses for The Health Roundtable. Hilary Boyd, a consultant for the Australasian organisation which all our district health boards are signed up to, outlines the stroke initiatives and the Roundtable’s role.

 

A more active role for nursing, decision support software and discharge packs for patients are some stroke initiatives under way by The Health Roundtable.

All district health boards are currently members of the New Zealand chapter of the Australasian organisation which helps members on both sides of the Tasman gather patient care data, benchmark services and brings people together to share good ideas.

Mary Gordon, director of nursing at Canterbury DHB, says the impetus for the New Zealand chapter came from nursing leaders. She says leaders wanted a group where all New Zealand boards could join together and do benchmarking specifically aimed at service improvement. The benefits, Gordon says, include being integrated into all Roundtable activities, access to nursing metrics and nursing-sensitive indicators, nursing workshops and Australasian-wide information.

“The key initiatives for New Zealand have been improving the ED length of stay, stroke improvement and operating theatre,” Gordon says. “There have been a number of other initiatives that DHBs have participated in, including patient safety, ‘stranded patient’ and maternity benchmarking.”

Collection and distribution of key performance indicator (KPI) data is a core activity of The Health Roundtable. Sue Wood, director of nursing at MidCentral DHB says an extensive suite of reports is available on diagnosis-related groups of all types. “The clinical nurse specialists at MidCentral are looking at the reports that relate to their client groups for use in their MDT service evaluations and quality improvement activities,” Wood says.

Within the stroke area, data includes the percentage of stroke patients arriving at hospital in an ambulance (recognising that this is a medical emergency), rates of CT/MRI investigations, pressure ulcers and the percentage of patients discharged to the usual place of residence.

Bernie Mullin, public health physician at The Health Roundtable, says such data can be useful to determine whether patients are receiving the right investigations, any complications associated with care, and patient outcomes. This data also allows multidisciplinary teams to establish baseline data, set goals, develop practice priorities, compare their services with other boards and monitor trends within their service over time.

Mary Griffiths, clinical nurse specialist at Canterbury DHB, says the data can be useful for identifying the areas where staff need to put more effort in. One area she identified as needing improvement was the educational material available for stroke patients. As a result they have developed a discharge pack and a sticker. They put the sticker in the medical notes to record that people have received all of the material, Griffiths says.

In the last two years, the Stroke Pathways Initiative at Canterbury DHB has seen the implementation of other improvements, ranging from practice innovations to guideline development. In Christchurch, nurses have taken on a more active role supporting thrombolysis and doing dysphagia-screening on the ward. Nurses have to be highly skilled, so part of Griffiths’ role is auditing the ongoing competencies of nurses.

A more active nursing role in stroke reduces the workload for consultants. “I write the referrals for patients – under-65-year-olds – to go for rehab at our younger persons’ facility, which means that the consultant doesn’t have to come over and see them,” Griffiths says. She has recently extended this for over-65-year-olds.
Griffiths is also developing continence protocols, which is a first for acute stroke. “In the area of acute stroke, 60 per cent are incontinent for the first few days. You don’t want to be putting catheters in and that sort of thing because then people get UTIs and delirium.” Griffith says when the protocols are finished she will be taking them to other boards in New Zealand who are interested in stroke.

Another stroke initiative gaining interest amongst boards is MidCentral’s TIA/Stroke decision support software. This electronic-based tool allows GPs to triage patients with transient ischæmic attack/minor stroke, so they get the best medical care available. Anna Ranta, stroke lead physician, says the tool means that GPs can manage patients in the community, access urgent CT and ultrasound imaging, refer patients to the TIA clinic or, depending on the risk profile, send patients straight to the emergency department for admission and assessment by the stroke team within 24 hours of presentation.

One of the benefits of the local chapter is seen to be ready access to a network of clinical and operation staff throughout New Zealand to discuss problems with and share ideas. Griffiths has used the email stroke network of clinical nurse specialists to share thrombolysis self-learning packages, information on dysphagia-screening and educational material. Griffiths says their colouring booklet for children called Grandpa’s had a stroke, is popular. “It’s a great little story at child level to explain what stroke’s about,” she says.
Ranta has also utilised networking in her quest to roll out her decision-based tool nationwide. And, as a result of presenting at a Roundtable meeting in May, several other boards are now committed to developing local TIA pathways so that Ranta can adapt the tool to their district.

Gordon believes nurses should be involved in all the workstreams of the Roundtable. So whenever Canterbury DHB sends a team to any of the workshops they always include a nurse, as part of an interdisciplinary approach. “It’s all about service improvement,” she says. “We are part and parcel of the fundamentals of delivery of care.”