What does it take to provide clinical interventions with temporal consistency? A qualitative study of London hyperacute stroke units

Abstract

ObjectivesSeven-day working in hospitals is a current priority of international health research and policy. Previous research has shown variability in delivering evidence-based clinical interventions across different times of day and week. We aimed to identify factors influencing such variations in London hyperacute stroke units (HASUs).DesignInterview and observation study to explain patterns of variation in delivery and outcomes of care described in a quantitative partner paper (Melnychuk et al).SettingEight HASUs in London.ParticipantsWe interviewed HASU staff (n=76), including doctors, nurses, therapists and administrators. We also conducted non-participant observations of delivery of care at different times of the day and week (n=45; ~102 hours). We analysed the data for thematic content relating to the ability of staff to provide evidence-based interventions consistently at different times of the day and week.ResultsStaff were able to deliver ‘front door’ interventions consistently by taking on additional responsibilities out of hours (eg, deciding eligibility for thrombolysis); creating continuities between day and night (through, eg, governance processes and staggering rotas); building trusting relationships with, eg, Radiology and Emergency Departments and staff prioritisation of ‘front door’ interventions. Variations by time of day resulted from reduced staffing in HASUs and elsewhere in hospitals in the evenings and at the weekend. Variations by day of week (eg, weekend effect) resulted from lack of therapy input and difficulties repatriating patients at weekends, and associated increases in pressure on Fridays and Mondays.ConclusionsEvidence-based service standards can facilitate 7-day working in acute stroke services. Standards should ensure that the capacity and capabilities required for ‘front door’ interventions are available 24/7, while other services, for example, therapies are available every day of the week. The impact of standards is influenced by interdependencies between HASUs, other hospital services and social services.

Variation in quality of acute stroke care by day and time of admission: prospective cohort study of weekday and weekend centralised hyperacute stroke unit care and non-centralised services

“…However, for other less time-critical measures, such as senior stroke physician assessment within 24 hours and therapist assessments within 72 hours, we found significant variation by day and time of admission across the week in London HASUs. This suggests that some performance standards like ‘front door’ interventions may be emphasised more than others and analysis of qualitative data collected in Black et al 39 complemented our findings 39. The second implication is that there are differences in acute stroke care between London HASUs and the rest of England across the week, with less variation in quality of care and outcomes in London HASUs.…”

“…What our study adds is analyses of variation in quality of care and outcomes in London HASUs separately following the centralisation of acute stroke services in London in 2010, which has been shown to increase the quality of care and outcomes on average across the week 29 30. Our findings were further expanded in Black et al 39 that aimed to identify factors influencing this variation 39…”

Factors associated with delays in revascularization in patients with chronic limb-threatening ischaemia: population-based cohort study

“…There may be lessons to learn from the centralization of acute stroke services in London, which alleviated the effect of the day and time of admission on brain imaging and thrombolysis 40 . A strong relationship with the radiology department has been considered as one of the reasons for the success of this initiative 41 . Increased access to imaging resources would also facilitate the quick progress of the patient with CLTI through the diagnostic pathway, whereas redistribution of imaging as well as cardiorespiratory test slots to correlate with the variation in demand may alleviate this disparity in waiting times.…”

Temporal structures that determine consistency and quality of care: a case study in hyperacute stroke services

“…We have previously published findings about how stroke services produce consistent outcomes despite variation in staffing and resources and the unintended consequences 12 13. This revealed that services must deploy their efforts disproportionately on those aspects that have the greatest impact on clinical outcomes, employing strategies such as stretching junior staff roles at night to achieve consistency 12.…”