Background: Implementation of stroke early supported discharge (ESD) services has been recommended in many countries' clinical guidelines, based on clinical trial evidence. This is the first observational study to investigate the effectiveness of ESD service models operating in real-world conditions, at scale. Methods and Results: Using historical prospective data from the United Kingdom Sentinel Stroke National Audit Programme (January 1, 2016-December 31, 2016), measures of ESD effectiveness were "days to ESD" (number of days from hospital discharge to first ESD contact; n=6222), "rehabilitation intensity" (total number of treatment days/total days with ESD; n=5891), and stroke survivor outcome (modified Rankin scale at ESD discharge; n=6222). ESD service models (derived from Sentinel Stroke National Audit Programme postacute organizational audit data) were categorized with a 17-item score, reflecting adoption of ESD consensus core components (evidence-based criteria). Multilevel modeling analysis was undertaken as patients were clustered within ESD teams across the Midlands, East, and North of England (n=31). A variety of ESD service models had been adopted, as reflected by variability in the ESD consensus score. Controlling for patient characteristics and Sentinel Stroke National Audit Programme hospital score, a 1-unit increase in ESD consensus score was significantly associated with a more responsive ESD service (reduced odds of patient being seen after >= 1 day of 29% [95% CI, 1%-49%] and increased treatment intensity by 2% [95% CI, 0.3%-4%]). There was no association with stroke survivor outcome measured by the modified Rankin Scale. Conclusions: This study has shown that adopting defined core components of ESD is associated with providing a more responsive and intensive ESD service. This shows that adherence to evidence-based criteria is likely to result in a more effective ESD service as defined by process measures.

Background Stroke Early Supported Discharge (ESD) is a service innovation that facilitates discharge from hospital and delivery of specialist rehabilitation in patients’ homes. There is currently widespread implementation of ESD services in many countries, driven by robust clinical trial evidence. In England, the type of ESD service patients receive on the ground is variable, and in some regions, ESD is still not offered at all. This protocol presents a study designed to investigate the mechanisms and outcomes of implementing ESD at scale in real-world conditions. This will help to establish which models of ESD are most effective and in what context. Methods A realist evaluation approach composed of two interlinking work packages will be adopted to investigate how and why ESD works, for whom and in what circumstances. Work package 1 (WP1) will begin with a rapid evidence synthesis to formulate preliminary realist hypotheses. Quantitative analyses of historical prospective Sentinel Stroke National Audit Programme (SSNAP) data will be performed to evaluate service outcomes based on the degree to which evidence-based ESD has been implemented. Work package 2 (WP2) will involve the qualitative investigation of purposively selected case study sites featuring in WP1 and covering different regions in England. The perspectives of clinicians, managers, commissioners, and service users will be explored qualitatively. Cost implications of ESD models will be examined using a cost-consequence analysis. Cross-case comparisons and triangulation of the data sources from both work packages will be performed to test, revise, and refine initial programme theories and address research aims. Discussion This study will investigate whether and how current large-scale implementation of ESD is achieving the outcomes suggested by the evidence base. The theory-driven evaluation approach will highlight key mechanisms and contextual conditions necessary to optimise outcomes and allow us to draw transferable lessons to inform the effective implementation and sustainability of ESD in clinical practice. In addition, the methodological framework will progress the theoretical understanding of implementation and evaluation of complex rehabilitation interventions in stroke care. Trial registration ISRCTN: 15568163, registration date: 26 October 2018.

Objective: To identify why the National Clinical Guideline recommendation of 45 minutes of each appropriate therapy daily is not met in many English stroke units. Design: Mixed-methods case-study evaluation, including modified process mapping, non-participant observations of service organisation and therapy delivery, documentary analysis and semi-structured interviews. Setting: Eight stroke units in four English regions. Subjects: Seventy-seven patients with stroke, 53 carers and 197 stroke unit staff were observed; 49 patients, 50 carers and 131 staff participants were interviewed. Results: Over 1000 hours of non-participant observations and 433 patient-specific therapy observations were undertaken. The most significant factor influencing amount and frequency of therapy provided was the time therapists routinely spent, individually and collectively, in information exchange. Patient factors, including fatigue and tolerance influenced therapists’ decisions about frequency and intensity, typically resulting in adaptation of therapy rather than no provision. Limited use of individual patient therapy timetables was evident. Therapist staffing levels were associated with differences in therapy provision but were not the main determinant of intensity and frequency. Few therapists demonstrated understanding of the evidence underpinning recommendations for increased therapy frequency and intensity. Units delivering more therapy had undertaken patient-focused reorganisation of therapists’ working practices, enabling them to provide therapy consistent with guideline recommendations. Conclusion: Time spent in information exchange impacted on therapy provision in stroke units. Reorganisation of therapists’ work improved alignment with guidelines.

During the shutdown of the CERN Large Hadron Collider in 2013-2014, an additional pixel layer was installed between the existing Pixel detector of the ATLAS experiment and a new, smaller radius beam pipe. The motivation for this new pixel layer, the Insertable B-Layer (IBL), was to maintain or improve the robustness and performance of the ATLAS tracking system, given the higher instantaneous and integrated luminosities realised following the shutdown. Because of the extreme radiation and collision rate environment, several new radiation-tolerant sensor and electronic technologies were utilised for this layer. This paper reports on the IBL construction and integration prior to its operation in the ATLAS detector.

Over the last 20years, England, Wales and Northern Ireland have developed an audit programme that now encompasses nearly all patients admitted to hospital with a stroke. This article records and reviews some questions that have been answered using data from the audit: Is the rate of institutional care after rehabilitation a possible measure of outcome? Does stroke unit care in routine practice give the benefits shown in randomized controlled trials? How is the quality of stroke care affected by a patient's age and the time of their stroke? Do patient-reported measures match those obtained from the professionals recording of processes of care? How do the processes of care after stroke affect mortality? Is thrombolysis safe to use in patients over the age of 80? Do staffing levels matter? Does assessing the safety of swallowing really make a difference? Do clinicians make rational decisions about end-of-life care in patients with haemorrhage? Does socioeconomic status influence the risk of stroke, outcome after stroke and the quality of stroke care? How much does stroke really cost in England, Wales and Northern Ireland? The article concludes that this national audit has improved stroke care across the United Kingdom, has given answers to important questions that could not be answered in any other way and has shown that benefits found in research do generalize into real clinical benefits in day-to-day practice.

Introduction The purpose of this study is to investigate which factors are associated with physiotherapy provision to hospitalised stroke patients. Methods Data were analysed for stroke patients admitted to hospital in England and Wales between April 2013 and March 2017 recorded on the Sentinel Stroke National Audit Programme (SSNAP) national stroke register. Associations between different patient factors, and applicability for and intensity of physiotherapy were measured using multi-level logistic and regression models. Findings: Data from 306,078 patients were included on the SSNAP register. Median age was 77 years (IQR 67–85) and 84.7% of patients with completed stroke severity data had a mild-moderate stroke. In all, 85.2% of patients recorded on SSNAP were deemed applicable for physiotherapy. Applicability for physiotherapy was 47% higher among thrombolysed patients (aOR 1.47, 95% CI 1.40–1.54), 36% lower in those with severe pre-morbid disability (aOR 0.64, 95% CI 0.58–0.71) and more than 2.5-fold higher among patients admitted to hospitals with greater availability of early supported discharge (aOR 2.62, 95% CI 1.28–5.37). Patients who were younger, male, had less pre-morbid disability, lower stroke severity, sustained an infarction, received thrombolysis, and had fewer medical complications were more likely to receive more intensive physiotherapy post-stroke. Conclusion Several patient and service organisational factors are associated with physiotherapy provision to stroke patients, some of which may not be justifiable. Physiotherapists should be aware of these factors when planning and delivering physiotherapy as well as any possible biases associated with physiotherapy provision to patients post-stroke.

Background and Purpose— Well-organized stroke care is associated with better patient outcomes, but the most important organizational factors are unknown. Methods— Data were extracted from the Sentinel Stroke National Audit Programme of adults with acute stroke treated in stroke hospitals in England and Wales between April 2013 and March 2015. Multilevel models with random intercepts for hospitals were used to estimate the association of each variable with 30-day mortality to estimate the impact of admission to differently organized hospitals. Results— Of the 143 578 patients with acute stroke admitted to 154 hospitals, 14.4% died within 30 days of admission. In adjusted analyses, admission to hospitals with higher ratios of nurses trained in swallow screening was associated with reduced odds of death ( P =0.004), and admission to hospitals with daily physician ward rounds was associated with 10% lower odds of mortality compared with less-frequent ward rounds (95% CI, 0.82–0.98; P =0.013). Number of stroke admissions and overall ratio of registered nurses on duty at weekends were not found to be independently associated with mortality after adjustment for other factors. Conclusions— If these associations are causal, an extra 1332 deaths annually in England and Wales could be saved by hospitals providing care associated with a ratio of nurses trained in swallow screening of at least 3 per 10 beds and daily stroke physician ward rounds.

INTRODUCTION:Stroke registries are used in many settings to measure stroke treatment and outcomes, but rarely include data on health economic outcomes. We aimed to extend the Sentinel Stroke National Audit Programme registry of England, Wales and Northern Ireland to derive and report patient-level estimates of the cost of stroke care.METHODS:An individual patient simulation model was built to estimate health and social care costs at one and five years after stroke, and the cost-benefits of thrombolysis and early supported discharge. Costs were stratified according to age, sex, stroke type (ischaemic or primary intracerebral haemorrhage) and stroke severity. The results were illustrated using data on all patients with stroke included in Sentinel Stroke National Audit Programme from April 2015 to March 2016 (n = 84,184).RESULTS:The total cost of health and social care for patients with acute stroke each year in England, Wales and Northern Ireland was £3.60 billion in the first five years after admission (mean per patient cost: £46,039). There was fivefold variation in the magnitude of costs between patients, ranging from £19,101 to £107,336. Costs increased with older age, increasing stroke severity and intracerebral hemorrhage stroke. Increasing the proportion of eligible patients receiving thrombolysis or early supported discharge was estimated to save health and social care costs by five years after stroke.DISCUSSION:The cost of stroke care is large and varies widely between patients. Increasing the proportion of eligible patients receiving thrombolysis or early supported discharge could contribute to reducing the financial burden of stroke.CONCLUSION:Extending stroke registers to report individualised data on costs may enhance their potential to support quality improvement and research.

Introduction: National clinical guidelines in England and Wales recommend that intravenous thrombolysis is provided regardless of pre-stroke disability, but thrombolysis trials have included very few patients with a modified Rankin scale (mRS) score of more than 2. We therefore analysed data from the national stroke register of England and Wales of over 100,000 records to determine the safety and outcomes of thrombolysis in patients with varying levels of pre-stroke disability. Methods: Data were extracted from the national stroke register (Sentinel Stroke National Audit Programme (SSNAP)) of adults with acute ischemic stroke treated in all hospitals in England and Wales from April 2013-March 2015. Results: Of 128826 adults with acute ischemic stroke admitted to 202 hospitals, 23850 (18.5%) were dependent in some activities of daily living before stroke (mRS of more than 2). Of these, 1926 (8.1%) were treated with intravenous alteplase (iv-tPA). Of the patients with an mRS greater than 2 who were treated with iv-tPA, 1239 (64.3%) were female, 120 (6.2%) had an onset whilst already an inpatient, and 1395 (72.4%) were fully conscious upon arrival at hospital. The median age was 84 years (IQR 78-89); the median NIHSS score 15 (IQR 9-21). Of the 1320 patients (68.5%) with a fully completed NIHSS at arrival and at 24h after thrombolysis, the median change in NIHSS was a 3 point improvement (IQR 0-7). A total of 214 patients (11.1%) had complications from thrombolysis; 104 (5.4%) had symptomatic intracranial hemorrhage, 10 (0.5%) had angioedema, 21 (1.1%) had extracranial bleeds and 82 (4.3%) had some other type of thrombolysis complication. Inpatient case fatality rate was 29.2%, and 10.2% were newly institutionalised in a care home (14.4% of those discharged alive). Conclusions: Patients treated with iv-tPA who were not independent before stroke have similar rates of complications as reported for independent patients in national registries and clinical trials. However stroke for patients with pre-stroke disability carries a high risk of mortality and a high proportion of survivors are discharged to long term care for the first time.

Background Prognosis after intracerebral hemorrhage (ICH) is poor and care-limiting decisions may worsen outcomes.Aims To determine whether in current UK stroke practice, key acute care decisions are associated with stroke subtype (ICH/ischemic) and whether these decisions are independently associated with survival.Methods We extracted data describing all stroke patients included in a UK quality register between 1 April 2013 and 31 March 2014. Key care decisions in our analyses were transfer to higher level care on admission and palliation in the first 72h. We used multivariable regression models to test for associations between stroke subtype (ICH/ischemic), key care decisions, and survival.Results A total of 65,818 patients were included in the final analysis. After ICH (n=7020/65,818, 10.7%), 10.5% were palliated on the day of admission and 19.3% by 72h (vs. 0.7% and 3.3% for ischemic stroke). Although a greater proportion were admitted directly to higher level care after ICH (3.7% vs. 1.5% for ischemic stroke), ICH was not independently associated with the decision to admit to higher level care (adjusted odds ratio (OR): 1.12, 95% confidence interval (95%CI): 0.95-1.31, p=0.183). However, ICH was strongly associated with the decision to commence palliative care on the day of admission (OR: 7.27, 95%CI: 6.31-8.37, p<0.001). Palliative care was independently associated with risk of death by 30 days regardless of stroke subtype.Conclusions When compared to ischemic stroke, patients with ICH are much more likely to commence palliative care during the first 72h of their care, independent of level of consciousness, age, and premorbid health.

Background and Purpose— In 2010, Greater Manchester and London centralized acute stroke care into hyperacute units (Greater Manchester=3, London=8), with additional units providing ongoing specialist stroke care nearer patients’ homes. Greater Manchester patients presenting within 4 hours of symptom onset were eligible for hyperacute unit admission; all London patients were eligible. Research indicates that postcentralization, only London’s stroke mortality fell significantly more than elsewhere in England. This article attempts to explain this difference by analyzing how centralization affects provision of evidence-based clinical interventions. Methods— Controlled before and after analysis was conducted, using national audit data covering Greater Manchester, London, and a noncentralized urban comparator (38 623 adult stroke patients, April 2008 to December 2012). Likelihood of receiving all interventions measured reliably in pre- and postcentralization audits (brain scan; stroke unit admission; receiving antiplatelet; physiotherapist, nutrition, and swallow assessments) was calculated, adjusting for age, sex, stroke-type, consciousness, and whether stroke occurred in-hospital. Results— Postcentralization, likelihood of receiving interventions increased in all areas. London patients were overall significantly more likely to receive interventions, for example, brain scan within 3 hours: Greater Manchester=65.2% (95% confidence interval=64.3–66.2); London=72.1% (71.4–72.8); comparator=55.5% (54.8–56.3). Hyperacute units were significantly more likely to provide interventions, but fewer Greater Manchester patients were admitted to these (Greater Manchester=39%; London=93%). Differences resulted from contrasting hyperacute unit referral criteria and how reliably they were followed. Conclusions— Centralized systems admitting all stroke patients to hyperacute units, as in London, are significantly more likely to provide evidence-based clinical interventions. This may help explain previous research showing better outcomes associated with fully centralized models.

Introduction: The Sentinel Stroke National Audit Programme (SSNAP) is the new national stroke register of England and Wales. It has been designed to harness the power of “Big Data” to produce near real-time data collection, analysis and reporting. Sophisticated data visualization is used to provide customized analytics for clinical teams, administrators, healthcare funders and stroke survivors and carers. Methods: A portfolio of cutting edge data visualisation outputs, including team level slidedecks, performance charts, dashboards , and interactive maps, was produced. Visualisations for patients and the public were co-designed with stroke survivors. Stakeholder feedback regarding accessibility and usefulness of the resources was sought via online polls. Results: Key SSNAP results are made accessible electronically every three months in a range of bespoke graphical formats. Individualised slidedecks and data summaries are produced for every hospital, funding group, and region to enable provider level performance and quality reporting and regional and national benchmarking. Dynamic maps enhance dissemination and use of results. Real time root cause analysis tools help teams identify areas of improvement. Feedback reports unprecedented utility of these resources for clinical teams, funders, regional and national health bodies, patients and the public in identifying areas of good practice and requiring improvements, highlighting variations, and driving change. Conclusion: SSNAP is a potential new model of healthcare quality measurement that uses recent developments in big data analytics and visualization to provide information on stroke care quality that is more useful to stakeholders. Similar approaches could be used in other healthcare settings and populations.

Background: The safety and outcomes of thrombolysis with intravenous tPA in patients with mild stroke or very severe stroke are still debated. We describe the use and outcomes from thrombolysis across the full range of stroke severity in England and Wales. Methods: The Sentinel Stroke National Audit Programme (SSNAP) is the prospective stroke register for England and Wales, with 100% population coverage. Data are entered by clinical teams using a secure online web portal. Symptomatic intracranial haemorrhage (SIH) was defined pragmatically (evidence on imaging plus clinical deterioration). Results: 58,769 ischaemic stroke patients were admitted from April 2013-March 2014, and 7598 (12.9%) received tPA; median NIHSS was 4 (IQR 2-9). Of the 6578 (86.9%) patients treated with tPA with documented NIHSS, 816 (12.4%) were mild (NIHSS 0-4) and 650 (10.0%) were very severe (NIHSS ≥ 22). The overall incidence of SIH was 4.0% (95% CI 3.5-4.5). Risk of SIH increased with stroke severity: 1.4% with NIHSS 0-4, 3.1% with NIHSS 5-14, 5.7% with NIHSS 15-21 and 8.8% with NIHSS ≥22. The association between NIHSS and SIH was similar across stroke onset-tPA times of 0-3 hrs, 3-4.5 hrs and >4.5 hrs. Compared to patients with NIHSS 5-14, patients with NIHSS 0-4 or NIHSS ≥22 had an adjusted odds ratio for SIH of 0.47 (0.3-0.9) and 2.6 (1.9-3.7) respectively. Outcomes in patients with NIHSS ≥22 treated with tPA were poor: 30 day mortality was 36% and 71% of survivors had a poor outcome (modified Rankin Scale score 3-5). Most patients (77%) with mild stroke treated with tPA had a good outcome (mRS 0-2) and 30day mortality was 2.4%. Conclusions: Thrombolysis in mild or very severe stroke is common practice in England and Wales. Risk of SIH following IV tPA is strongly related to stroke severity; the risk is significantly higher among severe strokes, for whom outcomes with tPA remain poor.

Introduction: Patients and their carers find it difficult to access information following a stroke or transient ischaemic attack (TIA). To improve the provision of this information, the Royal College of Physicians' National Clinical Guideline for Stroke (4th edition, 2012) was accompanied by a booklet designed for patients and their carers. Dissemination of the information was enhanced with the development of smartphone applications that are freely available on both iOS and Android devices. Here we present a report into the use of these applications. Methods: The applications were designed to reflect the content of the booklet with the information primarily accessed via a scrollable index, with separate sections to provide information on support services available in the UK. Data on usage were anonymously collected during the first eight months following global release. The hypothesis that users would preferentially access information on particular topics was tested. Results: The smartphone applications were downloaded a total of 2,046 times (1,503 iOS and 543 Android), of which 61.3% was by individuals in the UK. Topics covering rehabilitation were most commonly accessed, accounting for 33.2% of all application usage. Within this category, ‘Care after a stroke or TIA (principles)’ represented 14.5% of use and ‘Sex after stroke’ represented 13.1%. The next most commonly accessed category was ‘Specialist early care’ with 25.0% of total application usage, of which the topic ‘Brain scan’ accounted for 24.5%. Overall, the most commonly accessed index item was titled ‘Stroke, what is it?’, and this represented 8.27% of total application usage. Within the category of support services, 45.6% of usage was directed towards accessing information on ‘Local health services and stroke clubs’. Conclusions: Smartphone applications are useful adjuncts for the dissemination of information to patients and their carers following a stroke or TIA. Users exhibit a preference for information on rehabilitation and specialist early care. Future publications should target these topics for more in-depth discussion.

BackgroundObservational studies have reported higher mortality for patients admitted on weekends. It is not known whether this "weekend effect" is modified by clinical staffing levels on weekends. We aimed to test the hypotheses that rounds by stroke specialist physicians 7 d per week and the ratio of registered nurses to beds on weekends are associated with mortality after stroke.Methods and findingsWe conducted a prospective cohort study of 103 stroke units (SUs) in England. Data of 56,666 patients with stroke admitted between 1 June 2011 and 1 December 2012 were extracted from a national register of stroke care in England. SU characteristics and staffing levels were derived from cross-sectional survey. Cox proportional hazards models were used to estimate hazard ratios (HRs) of 30-d post-admission mortality, adjusting for case mix, organisational, staffing, and care quality variables. After adjusting for confounders, there was no significant difference in mortality risk for patients admitted to a stroke service with stroke specialist physician rounds fewer than 7 d per week (adjusted HR [aHR] 1.04, 95% CI 0.91-1.18) compared to patients admitted to a service with rounds 7 d per week. There was a dose-response relationship between weekend nurse/bed ratios and mortality risk, with the highest risk of death observed in stroke services with the lowest nurse/bed ratios. In multivariable analysis, patients admitted on a weekend to a SU with 1.5 nurses/ten beds had an estimated adjusted 30-d mortality risk of 15.2% (aHR 1.18, 95% CI 1.07-1.29) compared to 11.2% for patients admitted to a unit with 3.0 nurses/ten beds (aHR 0.85, 95% CI 0.77-0.93), equivalent to one excess death per 25 admissions. The main limitation is the risk of confounding from unmeasured characteristics of stroke services.ConclusionsMortality outcomes after stroke are associated with the intensity of weekend staffing by registered nurses but not 7-d/wk ward rounds by stroke specialist physicians. The findings have implications for quality improvement and resource allocation in stroke care. Please see later in the article for the Editors' Summary.

Background: There is inconsistent evidence that patients with stroke admitted to hospital out of regular working hours (such as weekends) experience worse outcomes. We aimed to identify if inequalities in the quality of care and mortality exist in contemporary stroke care in England.Methods: SINAP is a prospective database of acute stroke patients, documenting details of processes of care over the first 72 hours. We compared quality of care indicators and mortality at 72 hours, 7 days and 30 days, for patients who arrived within normal hours (Monday-Friday 8am to 6pm) and for those who arrived out of hours, using multivariable logistic and Cox proportional hazard models. Quality of care was defined according to time from arrival at hospital to interventions (e.g., brain scan), and whether the patient received therapeutic interventions (such as thrombolysis).Results: 45,726 stroke patients were admitted to 130 hospitals in England between 1 April 2010 and 31 January 2012. Patients admitted out of hours (n = 23779) had more features indicative of worse prognosis (haemorrhagic stroke, reduced consciousness, pre stroke dependency). Out of hours admission was significantly associated with longer delays in receiving a CT scan or being admitted to a stroke unit, and reduced odds of receiving thrombolysis. After adjusting for casemix, there was no consistent evidence of higher mortality for patients admitted out of hours, but patients admitted at the weekends had a higher risk of 30 day mortality (OR 1.14, 95% CI 1.06-1.21)Conclusion: Inequalities in the provision of stroke care for people admitted out of regular hours persist in contemporary stroke in England. The association with mortality is small and largely attributable to higher illness severity in patients admitted out of hours.

Background and Purpose— Case mix adjustment is required to allow valid comparison of outcomes across care providers. However, there is a lack of externally validated models suitable for use in unselected stroke admissions. We therefore aimed to develop and externally validate prediction models to enable comparison of 30-day post-stroke mortality outcomes using routine clinical data. Methods— Models were derived (n=9000 patients) and internally validated (n=18 169 patients) using data from the Sentinel Stroke National Audit Program, the national register of acute stroke in England and Wales. External validation (n=1470 patients) was performed in the South London Stroke Register, a population-based longitudinal study. Models were fitted using general estimating equations. Discrimination and calibration were assessed using receiver operating characteristic curve analysis and correlation plots. Results— Two final models were derived. Model A included age (<60, 60–69, 70–79, 80–89, and ≥90 years), National Institutes of Health Stroke Severity Score (NIHSS) on admission, presence of atrial fibrillation on admission, and stroke type (ischemic versus primary intracerebral hemorrhage). Model B was similar but included only the consciousness component of the NIHSS in place of the full NIHSS. Both models showed excellent discrimination and calibration in internal and external validation. The c-statistics in external validation were 0.87 (95% confidence interval, 0.84–0.89) and 0.86 (95% confidence interval, 0.83–0.89) for models A and B, respectively. Conclusions— We have derived and externally validated 2 models to predict mortality in unselected patients with acute stroke using commonly collected clinical variables. In settings where the ability to record the full NIHSS on admission is limited, the level of consciousness component of the NIHSS provides a good approximation of the full NIHSS for mortality prediction.

OBJECTIVE:To estimate the relations between the organisation of stroke services, process measures of care quality, and 30 day mortality in patients admitted with acute ischaemic stroke.DESIGN:Prospective cohort study.SETTING:Hospitals (n=106) admitting patients with acute stroke in England and participating in the Stroke Improvement National Audit Programme and 2010 Sentinel Stroke Audit.PARTICIPANTS:36,197 adults admitted with acute ischaemic stroke to a participating hospital from 1 April 2010 to 30 November 2011.MAIN OUTCOME MEASURE:Associations between process of care (the assessments, interventions, and treatments that patients receive) and 30 day all cause mortality, adjusting for patient level characteristics. Process of care was measured using six individual measures of stroke care and summarised into an overall quality score.RESULTS:Of 36,197 patients admitted with acute ischaemic stroke, 25,904 (71.6%) were eligible to receive all six care processes. Patients admitted to stroke services with high organisational scores were more likely to receive most (5 or 6) of the six care processes. Three of the individual processes were associated with reduced mortality, including two care bundles: review by a stroke consultant within 24 hours of admission (adjusted odds ratio 0.86, 95%confidence interval 0.78 to 0.96), nutrition screening and formal swallow assessment within 72 hours (0.83, 0.72 to 0.96), and antiplatelet therapy and adequate fluid and nutrition for first the 72 hours (0.55, 0.49 to 0.61). Receipt of five or six care processes was associated with lower mortality compared with receipt of 0-4 in both multilevel (0.74, 0.66 to 0.83) and instrumental variable analyses (0.62, 0.46 to 0.83).CONCLUSIONS:Patients admitted to stroke services with higher levels of organisation are more likely to receive high quality care as measured by audited process measures of acute stroke care. Those patients receiving high quality care have a reduced risk of death in the 30 days after stroke, adjusting for patient characteristics and controlling for selection bias.