Audit of inpatient acute stroke services in a university teaching hospital, 2020.

BACKGROUND: We aimed to assess stroke care at an Irish university teaching hospital and benchmark against national (Irish National Audit of Stroke 2019) and international (6th SSNAP Annual Report; American Heart Association, 2013) practice to inform a quality improvement strategy. METHODS: All patients with a HIPE discharge diagnosis of Cerebral Infarction or Cerebral Haemorrhage (1 January to 31 December 2019) were identified through both the HIPE database and the institutional Stroke Portal. RESULTS: A total of 419 patients were included (56.6% male, mean age 72). The following were comparable/better than findings from the Irish National Audit of Stroke: median duration of symptoms-3 h 6 min; 10% received thrombolysis; median door to needle time-60 min; 78.5% admitted to the stroke unit; 81.1% had a swallow assessment; in-patient mortality rate-10.5%; rates of institutionalisation-3.8%. The following areas were below the national average: overall door to imaging time-median 104 min; rate of thrombectomy-4%; 11.5% had mood screening; median length of stay- 12 days. DISCUSSION: Using national and international audit data as an institutional benchmark provides a standard with which a service can be compared to highlight areas for improvement. We identified mood screening, swallow screening, thrombectomy rates, length of stay and time to neuroimaging as key areas for development in our centre. We are currently completing a process map to determine cause, effect, and solutions, and we will implement change using PDSA methodology as per SQUIRE 2.0 guidelines. The results of the re-audit cycle for 2020 will be available in 2021 to inform our progress. Ongoing quality improvement is essential for stroke care, which is a leading cause of death and disability in Ireland.

Ten-year retrospective review (2003-2013) of 56 inpatient admissions to stabilize elevated phenylalanine levels.

Phenylketonuria (PKU) is an inherited metabolic disorder affecting phenylalanine metabolism. The Irish incidence is 1:4500. Currently, there are 500 patients under the care of the National Centre for Inherited Metabolic Disorders in Temple Street Children's University Hospital. Current practice is to admit PKU patients with phenylalanine (phe) levels that are consistently out of range despite an intensive multidisciplinary team input on an outpatient basis. The aim of this study was to evaluate changes in phe levels pre, during, and post admissions and to examine if there was a sustained impact post discharge. Fifty-six patients were admitted between January 2003 and December 2013. Patients were all <18 years of age. Greater than 70% (n = 39) of the reasons for admission were due to multiple issues. Average admission time was 5 days. There was a significant decrease in median phe levels from prior to the admission to during the admission. However, there was a significant increase in median phe levels from during the admission (505 µmol/L) to both the 1-6 months' and 7-12 months' time points (618 and 651 µmol/L, respectively). The results highlight that while inpatient admissions can stabilize levels within the acute setting, this is not sustained long term. The ward environment does not accurately replicate home circumstances. This study highlighted that the reasons for admission are most often multifactorial, which is less likely to be resolved during a brief admission period.

Finger Prick to Finger Tip: Use of Mobile Phone Technology to Send PKU Blood Results.

The Metabolic Dietetic Team in the National Centre for Inherited Metabolic Disorders (NCIMD) in Ireland deals with approximately 120 weekly phenylalanine (Phe) levels for both adults and children. A review of 500 Phe levels highlighted that 52% of the results were within the target range. Collaboration between information and communication technologies (ICT) departments, metabolic laboratory, and metabolic dietitians enabled the development of the PKU texting system. Following a successful pilot study, the system was then offered to all PKU patients aged over 2 years. The Phe is analysed and authorised on the laboratory system. The demographics are matched with the patient mobile phone number. Text messages are then validated and sent by the dietitian via a web portal using the Defero SMS texting service. Approximately 290 patients/families currently use the texting system. In order to assess the effectiveness of this quality improvement initiative, a patient survey was carried out in 2017. This showed 87% rated the system as either very good or excellent. 94% agreed it was time saving. 84% felt there was no influence on dietary compliance. Analysis of financial implications on dietetic time over 21 months revealed savings of €3,275 and 580 hours of dietetic time. There is no evidence, two years after implementation, that the system has had an effect on either the Phe levels in terms of recommended range or frequency of sampling.

Growth Patterns in the Irish Pyridoxine Nonresponsive Homocystinuria Population and the Influence of Metabolic Control and Protein Intake.

A low methionine diet is the mainstay of treatment for pyridoxine nonresponsive homocystinuria (HCU). There are various guidelines for recommended protein intakes for HCU and clinical practice varies. Poor growth has been associated with low cystine levels. This retrospective review of 48 Irish pyridoxine nonresponsive HCU patients assessed weight, height, body mass index (BMI), protein intake, and metabolic control up to 18 years at nine set time points. Patients diagnosed through newborn screening (NBS) were compared to late diagnosed (LD) patients. At 18 years the LD group (n = 12, mean age at diagnosis 5.09 years) were heavier (estimated effect +4.97 Kg, P = 0.0058) and taller (estimated effect +7.97 cm P = 0.0204) than the NBS group (n = 36). There was no difference in growth rate between the groups after 10 years of age. The HCU population were heavier and taller than the general population by one standard deviation with no difference in BMI. There was no association between intermittently low cystine levels and height. Three protein intake guidelines were compared; there was no difference in adult height between those who met the lowest of the guidelines (Genetic Metabolic Dietitians International) and those with a higher protein intake.