The temporal structuring of hyperacute stroke wards: what happens when and why?

What is known about this topic?

• Interest in 7-day working has hitherto taken two approaches: (1) a binary in-hours/out-of-hours approach or (2) a temporal variation approach, looking at blocks of time across the day and week.
• Measurement of temporal variation relies on routinely collected hospital and clinical audit data.
• There was a lack of clarity about how temporal variation arises.

What this analysis adds

• The SSNAP and London stroke service standards dominate the timing of clinical events in the ‘front-door’ part of the patient pathway, through setting of micro time limits that are evidence linked to clinical outcomes (1 hour, 4 hours, etc.).
• The SSNAP metrics later in the patient pathway have longer time limits (24 hours, 72 hours) that are not indicative of clinical benefit, but reflect cultural norms about rotas and activities, such as ward rounds, which have financial implications.
• Assessing temporal variation for events that are more than 1 hour after arrival in terms of in-hours and out-of-hours arrival periods was meaningless, as the punctuation of temporal structures, such as therapy rotas and ward rounds, was what determined clinical contacts.
• Repatriation from the HASU was temporally structured by the cultural norms and working patterns of other departments and organisations.
• Measuring temporal concepts, such as clustering, pressure and bottlenecks, is as important as consistency.

Introduction

A number of different approaches have been taken to try to understand temporal variation in stroke: the weekend in combination with night-time as a unitary out-of-hours block (e.g. Campbell et al.26); everything outside Monday–Friday, 08.00–18.00; 08.00–20.00 on Sunday and Wednesday as a comparison;31 and weekend admissions compared with weekday admissions.73

Latterly, debates about poorer outcomes for patients in secondary health-care systems outside the 5-day working week, or the ‘weekend effect’, have moved towards acknowledging patterns of temporal variation.22–25 Recently, this movement was characterised by the idea that certain times of the day, or days of the week, are associated with poorer outcomes for the patient, but that this is not limited to the weekend or night-time.22 As a result, the concept of out-of-hours working, which once dominated the discourse of the literature on temporal variation,22,26–28 has been re-evaluated.

Therefore, with a lack of compelling explanations for temporal variation, NHS England continues to implement its policy for a 7-day NHS by the year 2020.17 The NHS Long Term Plan18 states that all stroke units will, over the next 5 years, meet the NHS 7-day standards for stroke care and the national clinical guidelines for stroke over the next 5 years.

Our aim in this chapter is to develop the debate around 7-day working by describing the factors that influence the timing of clinical interventions in a particular acute setting, on a hyperacute stroke ward, and explaining how these factors influence studies of temporal variation. This will have a novel impact on (1) providing and organising construct for more accurate quantitative analysis of temporal variation in stroke and other acute diseases; and (2) using this to design health service provision, which takes temporal variation into account and returns health outcomes that are better linked to the care timeline.

Our starting position is that a binary conception of in hours and out of hours is inaccurate, and that there are many different characteristic time periods and patterns in activity on stroke wards, which we evidence in this chapter. Therefore, we use the term ‘temporal structuring’ to describe regular or changing temporal patterns that orient staff activities.90 Each ward creates its own temporal structures by its everyday practices and ideas about when to complete different tasks.90 Work in organisations such as hospitals is reliant on co-operation and connection between groups of people with different conceptions of temporality.91 This analysis was important in helping to untangle the conflicting and confusing evidence for temporal inconsistency, and clarifying controversy and providing a new direction for tackling this knotty problem. Ultimately, this contributes to the reduction of avoidable, systematic inequalities in stroke care and better outcomes for patients.

In Chapter 3, we reported the finding that certain aspects of evidence-based care are indeed provided with no discernible temporal variation, even when temporal variation was considered in very granular time periods. In Chapter 4, we reported that this was due to a number of factors, including adapting and extending roles, creating continuities between different times of day, building relationships and trust, prioritisation of ‘front-door’ interventions and unintended consequences of adaptations.

Research suggests that London is not unique in showing no significant ‘weekend effect’ in stroke patients in terms of such outcomes as LOS, mortality and functional outcome (both in hospital and at 90 days), both in similarly specialised comprehensive stroke centres62 and in unspecialised settings.14 Variation persists due to inconsistencies in medical, managerial and allied health professional staffing by time of day, delivery of therapist assessments and barriers to repatriation processes.

Figure 16 summarises our findings about temporal consistency in the HASUs, reported in our previous three chapters (see Chapters 3–5).

FIGURE 16 Summary of findings from Chapters 3–4 about HASU temporal consistency. 24/7, 24 hours a day, 7 days a week. (Figure not reproduced here; see the original article.)

Methods

Full methods are outlined in Chapter 2. The basis of these findings depends on thematic analysis and mixed-methods synthesis of:

• staff interviews
• observations
• quantitative data analysis of the SSNAP database 1 January to 31 December 2014
• documentary analysis of the SSNAP guidelines and London stroke service standards guidance.

Analysis

An inductive coding process initiated the analysis, for which authors GB, AIGR, ABL and JE derived a group of codes relating to definitions of ‘in hours’ and ‘out of hours’. We developed this with a set of working ideas about how these different definitions had arisen. This was incorporated into iterative processes of discussion with the whole authorship team, in which we developed different ideas about how best to use our quantitative data to truly measure temporal variation. Many of these discussions involved ‘dialogues’ between the qualitative (particularly observational) and the quantitative data. For example, when we felt that we had witnessed temporal variation, we then tried to find a measure that might reflect the dynamic we had identified. This exposed difficulties with the SSNAP data set and provoked new measures (such as looking at patients who had not been eligible for thrombolysis) to expose procedural elements that might be prone to greater temporal variation. The resultant analysis was the result of these processes, presented partly in a thematic form around the concept of temporal structuring, with graphically illustrated examples.

Results

Our results reconsider temporal variation measurement and meaning, by exploring the patients’ pathways through the HASU. We contrast this with the temporal structures of the HASU, of which the patients may have limited awareness, and how these have an impact on the timing of patient care. We finally present a critique of the current methods of measuring temporal variation based on routinely collected data, highlighting the relationship between patient need, quality of care and how these are measured..

Understanding the patient pathway

The first part of this analysis was a schematic or generalised account of the patient’s pathway through the HASU and how patients’ clinical outcomes are influenced by the temporal structures of the HASU. The second part describes in more detail what the temporal structures operating in the HASUs are and how they came to exist. The final section describes how the patient pathway interacts with temporal structures to create measured temporal variation.

Consistent with patient-focused studies,92 our observations and interviews characterised the HASU patient pathway in three main temporal intervals: (1) acute care, (2) assessment and stabilisation, and (3) repatriation (Figure 17).

FIGURE 17 Patient-centred model of stroke patient HASU pathway and temporal structures. a, Quality assurance metrics refer to SSNAP,54 Royal College of Physicians guidelines93 and the London stroke service standards.36 (Figure not reproduced here; see the original article.)

‘Front-door’ activities

Front-door activities begin when a patient arrives via ambulance or other transport to the ED of a hospital. Ambulances are instructed to take patients suspected of stroke to a hospital with a HASU. Patients arrive at hospitals with a suspected stroke at all hours of the day, although the numbers of admissions are higher during the day than at night, and during the week than at the weekend. From there, patients receive a number of neurological and medical tests and a brain scan, before immediate treatment decisions are made, such as tPA. Those who are still suspected to have had a stroke are admitted to the ward when a bed becomes available.

Clinical assessment, investigation and provision of time-critical treatments

During their stay on the ward, patients are given a range of clinical input, including medical, nursing and allied health professionals (e.g. occupational therapy, speech and language therapy, physiotherapy). Therapists assess the patient for independence, nutrition, continence, mood, etc., and repatriation is contingent on these findings. Patient-centred temporal structures are created by patients’ needs and biorhythms, such as needing to eat, move around and connect with their families. Clinical input was therefore broadly temporally structured around these needs, with therapeutic input, such as assessments and curative therapy, and non-emergency nursing care, such as washing, feeding and liaising with family members, given during the day. Similarly, medical assessments, scans and reviews take place during the day, although emergency medical attention can be provided at any time.

Repatriation

Hyperacute stroke units are designed to provide hyperacute intervention, with an expected LOS for the patient of around 3 days. The price was calculated on a bed-day basis. There was a different price for day 1 compared with days 2–4, which have the same price, and post day 4, which will be priced at the standard excess bed-day rate.36 This means that repatriation from the HASU to a stroke unit (ASU), a patient’s home or a care home is an important part of HASU staff work. Preparing a patient for discharge involves co-ordinated assessments and paperwork from a variety of staff, including nursing, allied health professionals and the repatriation co-ordinator:

So we, we certainly don’t rush patients home, um, but there is a continuous pressure to rush patients out to create beds, [. . .], so, some patients, we can get into the hospital much quicker than other patients, just by knowing what access they have to necessary services in the community. In terms of repatriation, there are ongoing huge delays, there are patients unnecessarily in the HASU who have been ready for 7 days, up to 2 weeks sometimes, waiting for transfers, and they’ve suffered, because they’re not always prioritised by the therapists, has been a SU [stroke unit] patient, by the fact that they’re geographically still on the HASU patient, even though they should have moved into SU mode.

The temporal expectation of the HASU to repatriate patients within a short time frame was frustrated by how the pathway can be inhibited by the availability of beds at the destination of the patient:

As long as they’re not um needing an investigation for the Monday then they will go home, um, we will make referrals but obviously we can’t follow them up um until the Monday, because obviously with the community teams aren’t working, if anyone needs a package of care restart or anything, then they’ll have to stay until Monday as well.

Temporal structures acting on the patient pathway

Temporal imperatives: quality assurance metrics

London HASUs are subject to two sets of quality assurance metrics: (1) the SSNAP, which applies to all stroke services in England, Wales and Northern Ireland; and (2) the London stroke service standards. The SSNAP pro forma demands detailed information about patients and their care, including temporal information about the timing of certain procedures. The London stroke service standards (which influence funding for the HASUs) demand temporal indicators measured from ‘clock start’ (entrance to the hospital for patients outside hospital or the time stroke symptoms are spotted for inpatients), including:

• a ‘door to needle’ (thrombolysis) time of 45 minutes for eligible patients
• dysphagia screening within 4 hours
• patients scanned within 12 hours (although given the standard for thrombolysis, most patients will be scanned within 30 minutes to ascertain eligibility)
• assessment by a stroke specialist physician within 24 hours
• therapist assessment within 72 hours.

Therefore, the items with the shortest timelines in these standards are focused around prolonging life and improving assessments and interventions in the diagnostic assessment phase of the patient pathway. The London stroke service standards additionally prescribe the level of staffing for each HASU according to the size of the unit, expectations with regard to delays, the proportion of time spent on the HASU (as opposed to other wards), etc., with financial implications for compliance.

London stroke service standards relating to contact with stroke staff (e.g. consultant and therapists) are much broader, with expected timelines of up to 72 hours post admission and 45 minutes of therapeutic daily contact. Considering quality of care and the real impact of these interventions on patient outcomes, the difference between seeing a therapist 10 hours after admission and 20 hours after admission is unknown. The 72-hour limit imposed by the SSNAP quality assessment was deliberately judged in the context that stroke therapists do not routinely work at weekends and, at the time the standards were set, were unlikely to transfer to a 7-day working pattern in the foreseeable future.

Temporal peaks: staff rotas

Nursing, medical and therapy rotas followed very different patterns and varied in each HASU. Our interviews suggested that there was awareness that bedside nursing was temporally structured to be a constant, with overlapping shifts covering the whole 24-hour period. For example, there was one HASU that had an early shift (07.30–15.30), a late shift (12.30–20.30) and a night shift (20.00–08.00) (Table 17).

The aim of this structure was to have the maximum staffing from 12.30 to 15.30, which was deemed to be an especially busy period. Other HASUs had a day shift (e.g. 07.00–19.30) and a night shift (19.00–07.30). The structure of nurse rotas was partly defined by the London stroke service standards, which in themselves concretise beliefs about the value of certain professional roles. For example, in some hospitals, nurses take on organisational roles, such as patient repatriation and bed management, in the evenings and at weekends. They may also have to occupy two daytime roles, such as nurse in charge and responding to patients arriving in the ED (see Chapter 4, Adapting and extending roles, and Chapter 5, Impact of separating the nurse in charge and thrombolysis nurse roles on clinical processes).

Therapists were mostly employed in standard 09.00–17.00 shifts on weekdays, but some HASUs experimented with extended shifts to 18.00 and short shifts at weekends. This was in recognition of the backlog that would be created without any therapy presence (see Chapter 4, Variations in delivering therapist assessments). However, this was seen as a ‘skeleton service’ rather than full cover.

Patients confirmed that physiotherapeutic activity was restricted to assessments on the weekend, leading to a feeling of disappointment due to lack of progress:

I was a bit disappointed actually because the Thursday was the first day I actually went to physio [physiotherapy]. And I just thought they were so [. . .] they’d got me on the parallel bars, you know see if we can [. . .] you can walk and put [. . .] and I thought this is brilliant, you know, this is what I want, you know, a step forward. And then, of course, it I didn’t have it for 4 days [due to a Bank Holiday]. So that was disappointing.

Medical rotas were characterised by the presence and leadership of consultants during normative working hours (e.g. 09.00–18.00), and junior doctors on day and night shifts. Consultants were present at the weekend and available by telephone at night. However, the correspondence between shifts and the times that medical staff would actually be on the HASU ward was less clear. Patients and carers reported that consultants were hard to access in the late afternoon on a Friday, a time when carers might particularly want advice and discussion:

Our interviews showed broad acceptance of the lowered staffing and testing provision at night. Doctors, in particular, felt that they were not restricted in their management of a patient, ‘There is nothing I would want to have done that would be restricted based on time’ (SHO, H6), despite the limited availability of tests (such as MRI scans and Doppler ultrasound studies) at night (see Table 11 for individual scan availability for each HASU at different times). In particular, it was felt that therapists did not need to be on the ward at night:

There’s always going to be a different need in the day and the nights, I think. You know, the therapists aren’t going to be doing physiotherapy and occupational therapy assessments at 3 o’clock in the morning.

Despite this certainty, participants expressed uncertainty about when peak activity ended, with some rotas ending too early in the day and potential value in extending therapy hours into the early evening:

I’m not sure that doctor numbers at night need to be the same as during the day because it is normally less busy especially, you know after midnight, things usually quieten down not every night obviously, maybe what a compromise would be would be to have a 7-day service but also the daytime hours to be extended either with consultants or junior doctors later into the evening because actually you know staff start leaving at 5 or 6 and actually that’s when it tends to get very busy. It’s the early part of the evening that is the time that maybe and even for therapists, they often don’t have time to finish seeing all their patients by 4 o’clock which is I believe when they normally leave or 5 o’clock so maybe a slightly longer therapy day.

This quotation highlights that patients need therapy to continue beyond a traditional 17.00 or 18.00 shift end. We observed that this was often related to the presence of family members on the ward and patients waiting to be discharged. This may account for the diurnal pattern observed by Bray et al.:22 that delivery of clinical processes can become slower as the day progresses. Participants also debated whether or not medical testing was available, with some seeing availability in relation to necessity:

We can get everything at any time. We don’t always get everything at any time, because there is, of course, out of hours, there is a restriction to saying, is it really necessary, or we would rather do it tomorrow [. . .] So you have to be a little bit more selective in terms of indication for a certain procedure, such as CT angiography or so on. It just has to do with someone has to read those scans, and there are not that many people there at night. However, in general, we can get an MRI, we can get a CTA advanced imaging, for example, any time, and the same with neurosurgical procedures.

Other participants saw the differences in availability in relation to the ease with which scans would be approved:

I would say no much different unless, let’s say in anyone has an MRI scan during the daytime it might happen, we can very quickly but at night mostly it will not happen [. . .] because I mean for [. . .] there’s no CD [carotid Dopplers] we can request out of hours if we have a problem. [It’s] a big problem because we need to get radiological approval so we have to go through all the processes.

In reality, only one HASU was able to carry out MRI at night, and that was through consultant–consultant referral rather than open access (see Table 11). At the weekend, five of the eight HASUs could access MRI, but some were restricted to a limited number of slots per day. Weekends were also characterised by the use of CT angiography rather than carotid Doppler ultrasound studies to examine for carotid disease, driven by the unavailability of ultrasound technicians at weekends to perform the Doppler studies. This quote does reveal, however, that part of the decision-making about what was natural for night-time was also based on whether or not something was ‘necessary’. Necessity was in itself temporally mediated, as the naturalness of daytime work creates an expectation that night-times are for selective actions only.

Temporal rhythms: board rounds, handovers and ward rounds

Clinical meetings and visits, such as staff handovers, the ward round and visiting hours, pattern the day and constitute the framework on which clinical interventions are organised. For a patient to receive evidence-based care, these moments of communication between all the staff members, the patients and their families are pivotal. Almost every HASU we observed had both a board round (sometimes called a MDT meeting) and a ward round every weekday, and a variety of arrangements at the weekend (Table 18). For example, we observed that site H2 had no board round at the weekend, but therapists liaised directly with the nurse in charge about which patients to prioritise. The consultant also made decisions about which patients were ready to be repatriated and communicated this directly to therapists (out-of-hours observation, H2). Although site H3 did have a board round at the weekend, a consultant reported that it was a much smaller group, comprising only one physiotherapist, one occupational therapist and no SLT. A nurse in site H8 reported that a lack of weekend board round made it easier to do other tasks, such as teaching and administration (see Table 18).

Individual disciplines often had handovers between ending and starting shifts (nurses, junior doctors) or a team meeting to collate information in advance of the ward round (therapists). These events had to occur before the whole ward board round to contribute to decision-making:

It’s brilliant, on a daily basis, the day staff come in, 7.30, and the shift starts immediately, maybe it takes 30 to 45 minutes, we hand over and we do it thoroughly, we go through every piece of the patients notes, do it thoroughly, from medication, to mobility, whether they’re eating and drinking, their breathing score, their speak and everything, we go through everything by the bedside, their skin and everything that’s going on with them, so we do that for each and every patient, and when you talk to us, come in, I do the ward round, with the therapists and the doctors, so we go through all the patient with the doctors and the therapists before we start the ward round.

The ward round was a single daily event in most HASUs, starting in the morning and lasting 1–2 hours. Some HASUs had a second ward round in the afternoon. Given the short intended duration of patient stay at the HASU, much of the conversation in the board round revolved around new admissions and potential for discharge:

[. . .] so the multidisciplinary team meetings, we have Monday to Friday, twice a day, so at 10 o’clock in the morning, so that we can talk about with the therapists, patients that have come in overnight, and prioritise patients who might be able to be discharged, and let the therapist know, who’s stroke and who’s not a stroke.

In HASUs without a weekend board round (sites H2, H5 and H8), our interviews revealed that patients were disadvantaged by needing to wait until Monday morning to see the MDT:

On the weekend, there’s one therapist on a Saturday for 4 hours, and one therapist on a Sunday for 4 hours. Um and so we don’t then have the sort of formal MDT meeting, and those therapists come in, I think, I think it’s, 1 day it’s an occupational therapist, 1 day it’s a physiotherapist, and they come in to try and prioritise, patients that might be able to be discharged over the weekend. Um, so, so we don’t have the MDT meetings on a Saturday or a Sunday. And sometimes patients do build up over the weekend, because they need to be assessed by, by therapists.

In our interviews, junior doctors, therapists and nurses described how the ward round acted as a stimulus for new work activities, which filled the rest of the afternoon. Every ward also had restricted visiting hours for families, normally starting in the mid-afternoon. The arrival of families and friends while staff were trying to carry out these activities created an intense working phase, with conflicting priorities between the needs of both parties. Families want information and updates on their relatives from doctors and nurses, yet this was a crucial time of day for carrying out diagnostic tests, therapeutic treatments and making discharge arrangements:

I think during the day we do [. . .] I’d say the busiest time of the day really is just [. . .] is maybe [. . .] comes about just after lunch time, really. The patients have been reviewed on the ward round by the medical staff, so some new plans are written up [. . .] so I’d say that’s the most [. . .] that’s probably the busiest part of the day erm, and it’s really the part of the day where we are open, really starting to open to visiting as well, just after lunch, so at that stage we’re going to be having a chat with some of the families and things as well, and trying to update them [. . .]

In some HASUs, the nurse rotas were adjusted to account for this, with overlapping shifts in the early afternoon, to tackle the workload, and shifts extending longer into the afternoon. Consultants do not have this arrangement, and must still engage in assessing new potential stroke patients in the ED or in other wards of the hospital. Patients’ families often wish to speak only to a consultant, which creates a conflict:

We’ve had feedback from the patients and families about access to the consultant. One of our problems is that you know, it’s very busy our HASU, so the consultant will do ward round in the morning, it takes them ’til 11 or 12 every day to finish the ward round. They’ve then got [ED] all through the afternoon. So they may just [. . .] and then they’ve got to do a follow-up ward round late afternoon to deal with all the new things that have happened during the day. So there’s a lot of pressure on them that takes them away from sitting down with the families and talking with them. So I think, and visiting hours is from 3 o’clock onwards. And we used to have open visiting, and it was chaos. I mean, incredibly noisy environment, very, very difficult for rehab, very unrestful. And so on. So we’ve, personally I think that, we’ll try and do this, is that everybody gets a meeting with the consultant to discuss things, but the feedback is it’s not happening all the time.

The natural progression of patient pathways also has an impact on the peaks of daily activity on the ward. For example, discharges that are planned early in the day often extend into the evening. This may be caused by waiting for sign-off from a range of professionals (e.g. consultant, therapist), for hospital transport or for a family member to finish work. There are also late admissions to the ward, which are prioritised, delaying consultant approval for discharge.

In one early evening observation, hospital transport to take a patient home was booked early in the morning and was meant to arrive within a 90-minute window around 16.00. The nurses tried to co-ordinate transport with the patient’s care package and, as the transport ran later and later, the nurses became increasingly anxious about the possibility of the patient going home. Many telephone calls were made to the transport provider and to the patient’s social worker. Despite the early-morning booking, the patient could not be guaranteed a transport time because he was low priority compared with patients with higher needs (such as dialysis). The transport eventually arrived at 19.00, but without the wheelchair that was ordered by the nurse. The social worker was still not contactable by telephone and the discharging nurse was concerned about the patient’s medication. They decided to give him the medication on the ward and confirmed that his wife and son were at home to receive him. In another evening observation, we saw a patient being transferred to a local stroke unit by ambulance as late as 21.00. There were concerns that the receiving stroke unit would not have enough staff to accept the patient if the ambulance could not get there on time. This example demonstrates the complexity of intersecting temporal work needed to discharge a patient and how this intense activity can continue into the evening.

At night, all therapeutic activity is suspended and decisions to discharge cease. Some patients will still be admitted and the lack of consultant presence in the hospital was often raised by interview participants as something that affects their workload. The decision to admit a patient at night was made usually by a junior stroke doctor, or sometimes an ED doctor, in most HASUs with the help of a band 5 or 6 stroke nurse.

This creates an extra workload early in the morning for HASU staff, who must assess and try to transfer the non-stroke patients out of the ward. One participant suggested that a registrar could be competent to make the admission decisions at night, but it should be someone with a substantial experience of stroke patients. Many registrars on the ward at night are either covering neurology doctors (with less experience of acute medicine and the stroke care pathways and protocols than the regular day team) or acute medicine- or geriatric medicine-trained doctors (with less experience of neurological conditions that mimic stroke):

Some of the registrars are excellent and have done lots of strokes and you may get a very junior registrar who I think, I think they’ll always going to be safe [. . .] and provide safe care but in terms of efficiency [. . .] and there is something about experience that a consultant would add something in that respect.

It is likely that a ward with extra demand from non-stroke patients will have less workforce capacity to conduct timely tests and treatment protocols in line with national guidance. It is important to note that the use at night of doctors who are less familiar with stroke patterns or the stroke service routines than the day team is based on an assumption about the temporal workload during this time. Nevertheless, this has an impact on the processes of care around ward capacity and pathway management the next day, exemplifying the contingent and deterministic nature of the concept of ‘out of hours’: working activities at night affect activities during the day and vice versa.

Temporal norms: acceptance of differences in night and weekend activity

Despite the organisation of the HASU to provide certain aspects of the service on a 24/7 basis, the cultural expectation of some HASU staff and more widely in the hospital was that provision of certain types of care at night and at weekends is just for emergencies. For example, although it was deemed routine to gain additional information about the diagnosis using a MRI in addition to a CT head scan during the week, this was often not considered a priority at weekends, despite the presence of radiology teams:

So I think there’s a bit of a culture change about, well, you know, it may not be a life-saving investigation but, you know, this allows the patient to be processed much more efficiently and quickly if it’s done now, rather than Monday, so it does seem a culture that you know, that can wait ‘til Monday because it’s not urgent or emergency. [. . .] sometimes to get an opinion, a radiology [. . .] a consultant opinion, is quite difficult out of hours. [. . .] It’s difficult enough in the week, actually, for us, but doing Saturday and Sunday, that just doesn’t happen.

It is important to note that that during the day the HASU consultant usually determines the treatment plan and the investigation pathway, and will control resources to prioritise some patients over others for tests, such as MRI, when there is finite capacity. In contrast, at night, the decision-making about treatment and investigations is, to a large extent, the responsibility of the onsite team without involvement of the consultant. The contrast at night and at the weekend contributes to a sense of having to work hard to ‘get things done’, leading to avoidance or deferral, or laborious referral procedures, such as arranging tests by direct communication from consultant to consultant:

There’s probably one extra step on the phone call trying to organise the CT scan because you call the radiology registrar and explain that you want a scan rather than calling CT directly whereas during the day you tend to just order CT and they will get a radiologist to report your scan or they automatically get done during 9–5, you want a quicker result then you call them. But it’s more like a permission in a way because you know CT won’t do it without a radiology registrar calling them and saying you can do a scan.

This deferral could have knock-on effects for patients who were waiting for specific tests to be discharged, leading to frustration:

I was up on there for 5 days just for an echocardiograph. Er [. . .] my wife came in on the, er, Monday or, Monday, yeah, because I’d already been up, taking up a bed for 2 days where I couldn’t do anything. [. . .] why I wasn’t the first one down there on the Monday to get me out of the place. I was just surprised. And then when they say, ‘Are you still here?’ I’m going, ‘Can you found out?’.

How temporal structures have an impact on measurement of temporal variation

The third section of this chapter describes how the temporal structures outlined above result in measured temporal variation. Temporal variation in stroke has mainly been assessed using the SSNAP data set. This has the advantage that it was a stroke-specific database relating to nationally agreed standards of care, but carries the risk that the metrics imposed as a measure of quality in this database could become concretised as definitive of care quality more widely.

Temporal imperatives relate to outcomes and not quality

The consensus measures in the SSNAP are taken from national guidelines for stroke93 and mostly concern the timing, rather than the nature, of interaction. For example, therapists who did work at the weekend described being more likely to do assessment work to meet SSNAP targets than to deliver therapy:

At the weekend you have either an OT [occupational therapist] or a physio[therapist] and it’s reduced hours. So hardly, not much at all. Em, so it becomes a totally different role, so you’re just, er, doing a quick assessment of people and making sure that basic therapy needs are met. But it’s a different role at the weekend anyway because again those, the office people aren’t working, ESDs [early supported discharges] aren’t there and discharge planning can’t really be done.

This was echoed by patients, who reported being stationary in bed over the weekend while there was limited therapist presence:

But after that day, I got quite distressed about being in bed for so long. [. . .] by the evening, I said, ‘I just need to get up, please, put me in a chair anywhere’. You know, ‘My back has been on this mattress now for so long, I just can’t take it, I need to move’. [. . .] Yes, [the nurse], she said I had a red mark on my back. I said, ‘Have I?’ I said, ‘Yes’ [laughs] it was a red mark on your back. You’re getting on the mattress so that was alright.

We suggest, therefore, that many quality indicators are not included in the temporal structures of quality metrics. These could include more information on the actual therapeutic processes and activities taking place, and how these were experienced by the patient and their family. It could also include ‘softer’ outcomes, such as bed sores, muscle strength, mood, etc.

Rotas and temporal rhythms are more deterministic than time of admission on longer time-related indicators

Looking further at the limitation of the longer binary temporal variables (e.g. whether or not a patient was seen by a consultant within 24 hours, whether or not the patient saw a therapist within 72 hours), the time of admission is no longer fully relevant. Figure 18 illustrates this problem: the lines shown are based on the median time intervals for patients arriving in the time slots indicated from our SSNAP data set. Patients A and B both arrive on a weekday in hours. However, patient A sees a therapist after 24 hours and patient B sees a therapist after 60 hours because there are no therapists on the HASU over the weekend. Patient C arrives on a Sunday (out of hours), but sees a therapist relatively quickly when they return to work on Monday.

FIGURE 18 Exemplars of patient trajectories and temporal variation in relation to the time and day of admission based on median SSNAP data for the time periods indicated. (Figure not reproduced here; see the original article.)

Therefore, looking at outcomes such as therapist contact as a binary variable in relation to the time or day of admission was meaningless, for two reasons: (1) the SSNAP and London stroke standards accept that therapists do not work over the weekend, showing a cultural expectation that this state of affairs was normative and did not affect patient outcomes; and (2) the trajectory of the patient pathway in relation to therapist ward rotas dictates the length of time taken to see a therapist, not the time of admission. Similarly, the time taken to see the consultant was directly related to the patient pathway in relation to the morning ward round, not whether their time of admission was in hours or out of hours.

Temporal consistency at the patient level does not capture bottlenecks or other ‘knock-on’ effects

Patient-level data cannot capture the important peaks and troughs in activity at a ward level, or the relationship between ward activity and individual patient-level care. In Chapter 4 we discussed how temporally inconsistent care created delays in repatriation (see Chapter 4, Factors influencing length of stay). Backlogs and bottlenecks were created by inconsistent staffing, such as the junior doctors’ risk-averse admission behaviours at night (when more stroke mimics are admitted) (see Chapter 4, Unintended consequences of adaptations) or the reduced therapy presence on the weekend.

This phenomenon reveals the limitation of patient-level data: it is not the patient being admitted at the weekend who is affected, but the one who arrives on Monday to a HASU with highly pressured therapists who are struggling to resolve the backlog of unseen patients. Separately, temporal variation in the admission of stroke mimics may also cause periods of high staff pressure and workload. This is due to stroke patient displacement into wards away from the HASU and the transfer of resources from patients on the stroke pathway to those without stroke but occupying stroke beds, which in turn could lead to adverse outcomes for stroke patients.

Inconsistencies in staff pressure could affect risk levels and lead to staff ill health and suboptimal patient care. This was exemplified in one Wednesday observation (site H3), when we witnessed ‘knock-on’ effects late in the day due to discharge delays. We arrived at 16.30 to find that the ward was already over capacity and there were patients in the ED waiting to be admitted. The atmosphere was hectic, as the consultant and junior doctors worked into overtime to try and empty the beds. Owing to the pressures on the ward, they had not had their second board round of the day. In this case, the consistency with which the staff were able to deliver interventions was directly affected by the delays incurred by fact that care needed to be delivered to patients who were about to be discharged. Conversely, the patients being discharged may have been at higher risk of poor care, given the pressure to move them out of the ward quickly.

Discussion

The SSNAP and London stroke service standards dominate the timing of clinical events in the ‘front-door’ part of the patient pathway through setting of micro time limits that are evidence linked to clinical outcomes (1 hour, 4 hours, etc.). The SSNAP metrics later in the patient pathway have longer time limits (24 hours, 72 hours) that are not indicative of clinical benefit but reflect cultural norms about rotas and activities, such as ward rounds, which have financial implications. Temporal variation in events that occur > 1 hour after arrival in terms of ‘in-hours’ and ‘out-of-hours’ arrival periods is not necessarily a good measure of consistency, as the punctuation of temporal structures, such as therapy rotas and ward rounds, is what determines clinical contacts. Repatriation from the HASU was temporally structured by the working patterns of other departments and organisations. Measuring temporal concepts, such as clustering, pressure and bottlenecks, is as important as consistency.

Summary

• Assessment of temporal variation requires a new paradigm, in which markers of quality reflect the whole pathway and incorporate better information about risk, safety, temporal delay and patient-centred outcomes (e.g. management of fluid balance and impaired swallow function).
• This could include routinely collected markers of ward complications, such as chest infections, thrombolysis haemorrhages, falls (i.e. safety in general).
• Temporal structures should be considered with respect to variation (e.g. different patterns of ward rounds or rotas and how these can have an impact on pressure, safety and patient experience).
• Outcomes that are measured only in immediate proximity to time of arrival should be measured in relation to this point in time (e.g. within 4 hours). Other outcomes could be measured relative to agreed standards, such as daily physiotherapy, aspirational rates of infection or falls and psychological well-being.