Manju Krishnan

PurposeSecondary prevention of stroke requires effective cardiovascular risk factor (RF) management, including blood pressure control, lipid lowering treatment and antithrombotic therapy to reduce the risk of recurrent stroke. Optimal management of risk factors is challenging in older, frailer people, who also have worse outcomes after a stroke. There is limited evidence evaluating secondary prevention quality and outcomes in frail populations. To understand the trends (and factors associated with inequity) in the provision of RF management we developed the `Evaluation of Population Secondary Prevention Quality and Outcomes Post-Stroke (ESP-QOPS) in Wales' e-cohort. The aims of this project include describing (i) the provision of post-stroke evidence-based risk factor management (ii) trends in frailty and outcomes, and (iii) evaluating the impact of suboptimal risk factor provision on adverse outcomes stratified by frailty status. ParticipantsWe identified 71,696 patients with a first recorded stroke diagnosis in primary or secondary care between 2010-2023 in Wales. Findings to DateThe incidence of stroke gradually increased from 4,968 to 5,391 patients per year between 2010-2023, with 70% of diagnoses made in the secondary care setting. Of diagnoses made in primary care, less than 20% were subsequently admitted to secondary care.

Background/aims: Nasogastric tube (NGT) feeding is required for artificial nutrition and hydration in those with impaired swallow due to a stroke. A baseline analysis of new NGT insertions on our acute stroke unit revealed considerable delays in the process and poor documentation of the risk–benefit discussions. We undertook a quality improvement project aimed at improving safety and reducing the delay in NGT insertion from an average of 5.2 hours (baseline) to under 3 hours in 6 months with a secondary aim of improving the documentation of risk–benefit discussions from 0% (baseline) to 50% during the same period. Methods: Multiple Plan-Do-Study-Act cycles of change ideas were implemented, including regular staff awareness sessions, introduction of new labels for the multidisciplinary team meetings and an NGT decision tool. The change ideas we used were directly linked to the secondary and primary drivers of the improvement journey with the help of a driver diagram. Process mapping helped to tighten our pathways. Consecutive data of timings were collected on an excel sheet and charted on a statistical process control chart. The compliance with documentation on the NGT decision tool was charted on a run chart. Results: The project achieved a consistent improvement in time taken from decision making to NGT insertion from a baseline average of 5.2 hours to 1.7 hours within 6 months and the new process was stable with an upper control limit reduction from 14.1 hours to 6.7 hours. The usage of the NGT decision tool increased from 0% to 80% during the same time period. Conclusions: The project achieved its aims and was able to improve patient care by changing the behaviour and culture within the team. The improvement has been sustained on an 8-month review, and the change has become ‘business as usual’ for the team.