Improving the quality of medical and surgical care WELCOME.

Improving the quality of medical and surgical care

WELCOME


NCEPOD

Neil Smith

Improving the quality of medical and surgical care3

Remit

To review medical and surgical practice and to make

recommendations to improve the quality of the

delivery of care.


Remit

By undertaking confidential surveys covering many

different aspects of medical care and making

recommendations for clinicians and management

to implement.


History

• Report of a Confidential Enquiry into Perioperative Deaths -published Dec 1987

• Became the National Confidential Enquiry into Patient Outcome and Death in 2003

• Contract managed by NICE then the NPSA and now HQIP under the Clinical Outcome Review Programme


NCEPOD Supporting bodies

• Faculty of Public Health Medicine of RCP

• College of Emergency Medicine• Association of Anaesthetists• Association of Surgeons• Royal College of Anaesthetists• Royal College of Radiologists• Royal College of

Ophthalmologists• Royal College of Surgeons• Lay Representatives

• Faculty of Dental Surgery of RCS• Royal College of Pathologists• Royal College of Obstetricians &

Gynaecologists• Royal College of Physicians• Royal College of General

Practitioners• Royal College of Nursing• Royal College of Child Health and

Paediatrics


NCEPOD Observers

• Coroners’ Society• RCS Ed• RCP Ed• HQIP


Independent Advisory Group

• AoMRC• Funders• Lay• Nursing• Colleges


Structure

• 11 Non-clinical staff

• 7 Clinical Co-ordinators

• 550+ Local Reporters

• 100+ Ambassadors


The role of the Local Reporter

• History and evolution of the role

• What the role involves

• Handing on the baton


The role of the Ambassador

• History of the role

• What the role involves

• Support provided


Why it works

• Peer review

• Independence

• Put into a report what people already suspect…


Coverage

• England, Wales, Northern Ireland

• Offshore Islands

• Independent sector


Participation

• NHS trust participation is encouraged by – NHS Quality Accounts– Care Quality Commission– NCAPOP

• Doctors participation is encouraged by– GMC - Good Medical Practice/Good Surgical Practice– CPD


Reports

• Reports published cover a wide range of topics e.g.– Deaths within 30 days of surgery– Coronial autopsies– Trauma care– Coronary artery bypass grafts– Cancer care– Acute kidney injury– Parenteral nutrition– Surgery in the elderly


Trauma: Who cares?


Impact – early NCEPOD reports

• Improved provision of surgical, anaesthetic and critical

care facilities

• Emergency (CEPOD) theatres

• More involvement of senior staff

• Better supervision of trainees

• Reduction in inappropriate out of hours surgery

• More specialisation particularly for children


Who Operates When II (2003)

• Repeat of 1997 study Who Operates When

• To measure progress and show change

• Focus on staffing, practice and theatre facilities


WOW to WOW II

• 20% operations OOH by SHO

• 47% anaesthetics OOH by SHO

• 51% hospitals had “CEPOD” theatres

• 25% of non-elective cases performed in CEPOD theatre

• 6% operations OOH by SHO

• 25% anaesthetics OOH by SHO

• 63% hospitals had “CEPOD” theatres**

• 70% of non-elective cases performed in CEPOD theatre

WOW I 1997 WOW II 2003

** Further improvement to 87% identified in 2009 report (Caring to the end)


Emergency Admissions:

A journey in the right direction?A report of the National Confidential Enquiry into Patient Outcome and Death (2007)

Trauma: Who cares?

A report of the National Confidential Enquiry into Patient Outcome and Death (2007)

Impact – focussed studies


Acutely ill patients

• 1500 patients• Lack of consultant involvement• Lack of recognition of illness• Poor monitoring• Poor supervision• Lack of knowledge• Failure to seek help / working

outside competence


Impact – focussed studies


Trauma

• Trauma: Who cares?– 48% of patients received less than good

care in the view of the advisors– Consultant involvement low– Delays in treatment– Avoidable deaths– Patients received better care in centres that

reported a high volume of cases


Trauma

• Trauma: Who cares?– Widely accepted report by

the professions– Timely in view of Ara

Darzi’s reform of services

– Appointment of a new National Director for

Trauma care

This is a national health service and what we need is a national trauma system. ..our mortality rates are among the worst in the developed world.. This important study by NCEPOD restates the need for regional trauma systems.

..The Government must now act on these recommendations and urgently implement a national trauma system.


AKI – key findings

• There was poor assessment of risk factors for AKI

• The advisors judged there to be an unacceptable delay in recognising post-admission AKI in 43% (42/98) of patients.

• A fifth (22/107) of post-admission AKI was both predictable and avoidable in the view of the advisors.

• Recognition of acute illness, hypovolaemia and sepsis was poor.

• Only 67/551 (12%) patients received RRT


AKI - Recommendations

• All patients admitted as an emergency, should have their electrolytes checked routinely on admission and appropriately thereafter. This will help prevent the insidious and unrecognised onset of AKI

• Predictable and avoidable AKI should never occur. For those in-patients who develop AKI there should be both a robust assessment of contributory risk factors and an awareness of the possible complications that may arise.


AKI - Recommendations

• NCEPOD recommends that the guidance for recognising the acutely ill patient (NICE CG 50) is disseminated and implemented.

• All acute admitting hospitals should have access to a renal ultrasound scanning service 24 hours a day including the weekends and the ability to provide emergency relief of renal obstruction.

• All acute admitting hospitals should have access to either onsite nephrologists or a dedicated nephrology service within reasonable distance of the admitting hospital.


AKI – NICE Guidance

Acute kidney injury

Prevention, detection and management of acute kidney injury up to the point of renalreplacement therapy

NICE Clinical Guideline 169 (issued August 2013)


AKI – NICE Guidance

Other deficiencies in the care of patients who died of acute kidney injury included failures in acute kidney injury prevention, recognition, therapy and timely access to specialist services. This report led to the Department of Health's request for NICE to develop its first guideline on acute kidney injury in adults and also, importantly, in children and young people.


Local impact

• Stake holder survey

• NCEPOD talks

• Poster competitions

• Checklists/audit tools


Running a study

Kathryn Kelly


Topic selection

• Call for topics made to all our stakeholders

• 1st review made by NCEPOD Co-ordinators

• 2nd review made by NCEPOD Steering Group

• Consensus exercise performed


Questionnaire development

• Expert group

– Identify study themes

– Determine what questions need to be asked

– Clinical q. or advisor assessment form

• Questionnaires developed

• Pilot*


Running the study

Eva Nwosu


Running the main study

• Main study

– Cases are identified to us*

– Clinical questionnaires sent to the LR or clinician*

– Extracts of the case notes requested*

– Organisational questionnaire by site*


Return of questionnaires and case notes

Dolores Jarman


Questionnaires /case-note return

• Qs sent with FREEPOST envelope– Recorded delivery: £1.10 using envelope

• Qs and case-notes logged on study database– NCEPOD number– Automated email to LR

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Questionnaire and case-note return

• Confidentiality– Case notes /Qs stored in locked cupboards– Electronic data protected– Anonymisation of patient data– Clinical coordinators, Advisors don’t have access

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Case Review Meetings, Analysis and Report Launch

Hannah Shotton


Who are NCEPOD Case Reviewers?

• Active working clinicians

• Review other clinicians work

• Assess cases

• Common themes

• Recommendations


Case Reviewers

• Multidisciplinary Group

• Specialties

• Hospitals

• Recruitment *


Case Reviewer meetings

• 8-10 advisors

• 5 cases – CNs & Q

• Assessment Form


Case Reviewer meetings

• Overall quality of care assessed on a 5 point scale

• Cause for Concern – Group discussion – Chief Executive & Lead Co-ordinator – Letter to Medical Director


Analysis

• Not statistical (scientific) research

• Qualitative analysis of Case Reviewer opinion of quality of care- AF

• Supplemented by data from OQ & CQ


Analysis

• Data scanned into preset database and validated/cleaned

• Strategy of analysis

• Data analysed using descriptive statistics in MS Excel

• Results reviewed by Case Reviewers, Steering Group and Study Advisory Group


Report writing

• Report written by Clinical coordinators and NCEPOD staff

• 2 Drafts: Reviewed by Steering group, Study Advisory group & Case Reviewers

• Ensure recommendations are up-to-date

• Final draft of report sent to designers


Report Launch/dissemination

• PDF of the full report and a summary document are produced

• Disseminated to stake-holders*

• Report Launched at day event with representative speakers from relevant associations


Data Security

Robert Alleway


Confidentiality

• It applies to the patient data

• It applies to the doctor and the hospital

• Section 251

• DPA 1998

• Ethics


What we would like to avoid at NCEPOD


What we do…• Information Security policy document (ISO/IEC 27001:2005)

• Information Security Procedures

• Assign Information Asset Owners

• Information Security Forum

• Improved data security by encryption, passwords, and confidential disposal of paper

• NHS mailbox for receiving data and emails from Local Reporters

• Polythene envelopes and considered using DX boxes


Current Studies


Gastrointestinal Bleeds



• Gastrointestinal Haemorrhage (GIH) is a common cause of hospital admission and death.

- incidence 100/100,000 adults annually- overall in-hospital mortality is 10%

• GIH is managed by both medical and surgical teams and requires a multidisciplinary approach.

- management differs between upper and lower GIH

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Gastrointestinal Bleeds• To identify the remediable factors in the quality of care

provided to patients who are diagnosed with an upper or lower GIH

– Initial assessment and treatment plan

– Availability and timeliness of interventions (e.g. endoscopy, IR

and surgery)

– Use of guidelines, protocols and policies

– Organisational aspects of care including network arrangements



• Method: Population/Inclusions

• All patients aged 16 or over who were admitted between the 1st January 2013 and the 30th April inclusive

• Diagnosed as having a gastrointestinal haemorrhage (GIH) at any time during their inpatient stay.

• The diagnosis does not have to be the patients primary diagnosis

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• The spreadsheet collected data on a number of fields many of

which are key to the study

• Retrospective via ICD10 coding (e.g. K92.2)

• Focus on severe bleeders

– Cross reference with blood transfusion data

– Patients receiving 4 or more units of blood included in peer review

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• Sample of ~ 900 patients (with a maximum of 5 patients per hospital)

• Clinician questionnaire

• Photocopied case note extracts requested for each patient included in the study sample

• Organisational questionnaire – Information regarding facilities, equipment, policies and guidelines relevant to the management of patients with a GI Bleed

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• Exclusions

• Coded incorrectly for GI Bleed

• Did not have a transfusion of over 4 units

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Current Status

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• Data collection for clinician questionnaires and case notes is closed

• Still accepting organisational questionnaires

• Initial findings have been presented to SAG, Reviewers and SG

• Report currently being drafted, launch in June 2015


Sepsis

Hannah Shotton


Sepsis: Introduction

• Sepsis is an overwhelming systemic response to infection

• Untreated can lead to severe sepsis (+dysfunction of one or more organs) and septic shock

• Can arise in patients in the community or in deteriorating patients in hospital

• It is associated with a high mortality and morbidity

• Variety of care bundles but not used universally and always well implemented


SEPSIS: Aim

“To identify and explore avoidable and remediable factors in the process of care for

patients with sepsis”


SEPSIS: Objectives

• To examine organisational structures, processes, protocols and care pathways for sepsis recognition and management in hospitals from admission through to discharge or death

• To identify avoidable and remediable factors in the management of the care for a sample of adult patients with sepsis, throughout the patient pathway from presentation to primary care (if applicable) throughout secondary care to discharge or death

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Sepsis: Key areas

• Recognition of sepsis• Evaluation of systems in place to facilitate

recognition/ escalation/ treatment• Management of infection• MDT approach• Communication• End of life care

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Sepsis: Study population

• Adult patients (≥16 years old) diagnosed with sepsis that are seen by the critical care outreach team (or equivalent) or that are admitted directly to critical care during the study period:

6th - 20th May 2014

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Sepsis: Exclusions

• Immunosuppressed neutropaenic patients on chemotherapy or immunosuppressant drugs for transplant programmes.

• Pregnant women up to 6 weeks post-partum (covered by MBRRACE-UK sepsis study)

• Patients on end of life care pathway at time of diagnosis or consultant-led decision made not to escalate (prior to entry into the study)

• Patients that develop sepsis after 48 hours on ICU/HDU• Children <16 years

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Sepsis: Case ID/ data collection

• Study contacts identify patients with sepsis admitted to ICU/HDU and seen by CCOT during study period– Spreadsheet: details of consultant, date identified for the

study• Cases selected- 5/hospital


Sepsis: Data collection

• Clinician questionnaire – completed by named consultant- Collect data on acute care from admission (or 2 weeks before

ID) up to 30 days after identified by the study ~60% so far• Case note extracts

– Admission to discharge/30 days after entry into the study. ~60% so far

• Organisational questionnaire– Collect data on organisation of care– To be sent to all hospitals that deal with adult patients with

sepsis ~55% so far


Advisor case review

• Multidisciplinary group of Advisors review case notes and questionnaires and rate the quality of care– 130 cases seen

• GP details identified for patients that saw GP in relation to the hospital episode– Request for GP notes– GP Advisors review cases February 2015

• Questionnaire to Ambulance Trusts

• Publication Autumn 2015


Study timeline


Acute Pancreatitis


Background

The incidence of acute pancreatitis ranges from 150 to 420 cases per million population in the UK

Gallstones and alcohol account for the majority (50% and 25 % respectively)

In order to determine the aetiology and monitor progress, further investigations and imaging are necessary – there is often disagreement between clinicians about whether /when these should occur


Background

Severe pancreatitis should be managed in a HDU/ITU setting, but their condition and co-morbidities will determine access

Mortality rate is 14-25% increasing to 47% with complications, half the deaths occurring within 2 weeks of onset

Patients with AP 2o to gallstones should have definitive treatment within 2 weeks to prevent acute recurrences and increased risk of mortality, but this does not always happen due to availability of resources


Background

Supporting evidence

BSG guidelines (2003) provide recommendations for diagnosis and management of pancreatitis, however adherence is not always possible and they are often challenged

− Scoring systems for severity stratification to determine level of care

− Recommended time frames for radiological/surgical interventions

− Use of antibiotics


Aim

Aim/ Objectives

To explore remediable factors in the process of providing care to patients admitted with acute pancreatitis.

- Criteria used to determine severity of acute pancreatitis- The appropriateness of investigation request pattern and ITU

support requests- The compliance with existing guidelines- Use of radiological imaging and its timing- Timeliness of transfers


Acute Pancreatitis

Method/patient sample

Retrospective case note review of a sample of patients during a defined time period

Identify patients through ICD10 codes for acute pancreatitis: K85.0, K85.1, K85.2, K85.3, K85.8, K85.9(HES (2012): 24373 admissions for acute pancreatitis, 22400 of which were emergency admissions)

Identify markers of ‘severity’ HDU/ITU admissions Previous inpatient episodes


Study Advisory Group

• Ms Joanne Bishop Hepato-Pancreatico-Biliary Nurse Specialist, Leicester

• Mr Tim Brown Pancreatico-biliary Surgeon, Swansea• Dr Mark Callaway Radiologist, Bristol• Dr David Cressey Intensivist, Newcastle• Mr Chris Halloran Surgeon, Liverpool• Ms Jill Henderson Pancreatitis Nurse Specialist, Newcastle• Dr Mike Mitchell Gastroenterologist, Belfast• Mr Murali Partha Surgeon (joint proposer of study), Ipswich• Dr Stephen Pereira Gastroenterologist, London• Ms Mary Phillips Hepato-Pancreatico-Biliary Specialist Dietitian,

Guildford• Dr Pat Twomey Chemical Pathologist, Bury St Edmunds• Ms Marion Thompson Lay rep

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Current Status

• Met with the Study Advisory Group

• Developing initial drafts of questionnaires

• Finalising protocol

• LR starter packs to be sent out next week

• Recruiting Cases reviewers

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Study timeline


Provision for Mental Health in Acute Care

Hannah Shotton


Mental Health in Acute Care: Introduction•Poor mental health is the largest cause of disability in the UK and closely connected with poor physical health

•Patients with a mental health disorder have more medical illness, longer hospital stays, poorer outcome and shorter life expectancy

•Concern that healthcare professionals may have stigmatising attitudes/prejudice towards patients with mental health disorders and they may receive a poorer quality of care

•Series of recent reports highlighting issues and outlining standards of care and recommendations of how to achieve them


Mental Health in Acute Care: Aim

• Study Advisory Group meeting 12th February 2015

• Pilot study April/May 2015• Data collection will begin May 2015• Publication November 2016


Mental Health in Acute Care:


NCEPOD Checklists


Purpose

To allow Trusts/hospitals to benchmark

themselves against NCEPOD report

recommendations


Format

• Simple table format (example in packs)

• Recommendation• Is it met? Y/N/Partially/ Planned• Comments (Examples of good practice or deficiencies

identified)• Action required• Time scale• Person responsible


Audit Tool


Purpose

• To provide health care professionals with a tool to carry out local audits based on the findings of each of the NCEPOD reports

• Aimed to be as simple to use as possible

• Examples of use– Junior doctors who needed to do an audit– Reporting back to Trust boards– Evidence of CPD activity– Compliance with NHSLA CNST standard 2.9


Format

• Audit pack• Introduction and method• Overall quality of care• Key findings and recommendations

• Data collection tool

• Data comparison tool


Data collection tool


Data comparison tool Hospital Number _____________________

Recommendations

Data collection tool

Response

Action

required All emergency admissions, regardless of specialty, should have their electrolytes checked routinely on admission and appropriately thereafter.

Q7c – Were U + Es measured as part of the initial assessment? Q11 – Which risk factors were not adequately assessed/documented (biochemistry)? Q19a/b – Was investigation of the patient’s AKI adequate (biochemistry)

Yes Yes Yes

No No No

Initial clerking of all emergency patients should include a risk assessment for AKI. Risk factors for AKI should be clearly documented in the patients’ notes.

Q10b – Adequate risk assessment of AKI? Q11 – Which risk factors were not adequately assessed/documented?

Yes

No

All acute admissions should receive adequate senior reviews with a consultant review within 12 hours of admission.

Q28a - Did the patient receive adequate senior reviews Q28b – Time to first consultant review

Yes ≤12 hrs

No >12 hrs

Appropriate modalities should be employed to fully assess the patient’s AKI.

Q19a Was investigation of the patient's AKI adequate?

Yes

No

All patients with AKI should have a suitable management plan established and documented.

Q21a Was the documented management plan adequate for this patient?

Yes

No

NCEPOD AKI data comparison tool


Audit tools


Audit tool

• On website

• Rolled out for each new study and being back dated for previous studies

• Feedback appreciated


The Surgical Outcome Risk Tool (SORT)



• NCEPOD “Knowing the Risk” study (2011)

• Identification of high risk patients

• Risk prediction tool developed and validated to calculate death within 30 days of inpatient surgery

• British Journal of Surgery: 12 November 2014



• Rapid and simple data entry of 6 variables, including patient characteristics (age and cancer) to calculate % mortality risk

• Solely preoperative variables

• In the analyses, SORT also found to have greater accuracy than 2 other preop tools



At the time of publication, this work represents the largest analysis of risk prediction tools in a UK cohort of patients undergoing inpatient surgery in multiple surgical specialties

App available in 2015

www.bjs.co.ukwww.sortsurgery.com


Thank you

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Improving the quality of medical and surgical care WELCOME.

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