A regionwide analysis of breach causes and the correlation between processes, policies and service achievement

ABSTRACT

Introduction: The SSNAP stroke unit domain audit results have declined during the covid-19 pandemic. As recovery plans are implemented regionally, this study aims to understand the barriers to rapid admission to stroke speciality beds. Findings will inform quality improvement opportunities and change. Method(s) A mixed method approach was applied. Details pertaining to all patients that breached the four hour standard were collected across fourteen acute services for two months. This included all patients that were following the stroke pathway irrespective of final diagnosis. Additionally, details of all protocols pertinent to this KPI were established to identify effectiveness of local policy. The bed management was investigated for efficacy (stroke teams verses other) and differences in and out of hours explored. Covid as a direct cause was examined. Result(s) Analysis continues, however preliminary regional and team centred reports are collated. Eleven policies were examined. A negative association was identified between policies in place and admissions within four hours. A positive correlation existed between stroke team management of speciality beds and timely admissions, however, 67% of SU's were managed by other teams. 20% of breaches were multifactorial. Four covid related causes were detected. More breaches occurred in hours. The day of the week had no direct association with admission delay. Robust management of medical outliers is fundamental. Conclusion(s) Initial findings do not support assumptions. SU beds are not well managed well despite policies in place to support this. Breaches to stroke unit admissions is multifactorial but the failure to safeguard stroke speciality beds is key.