NHS GRAMPIAN

Mortality

Aim

This paper is submitted to the Board for information on the plan of work to review existing systems around the early identification and treatment of hospitalised patients at risk of deterioration.

Strategic Context

The national Hospital Standardised Mortality Ratio (HSMR) has shown a 5% reduction during the period of October 2006-June 2010. In order to continue to further improve on this reduction, the Chief Executives have been tasked with reviewing the current systems within their Boards in terms of identifying and taking action for those patients in hospital who are at risk of deterioration.

Discussion

  1. Background

It is recognised that reviewing existing systems that emphasise planning, communication, teamwork and the implementation of evidence-based practice is the first step to identifying any gaps that may exist and facilitate action for further improvement. Examples from two Scottish Boards have shown such an approach can lead to a reduction in the number of patients deteriorating and subsequently a reduction in HSMR.

Carrying out this review in one Board they found concerns with:

  • Terminal Care Patients who did not need to be in an acute care hospital
  • Compliance with Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) policy
  • Inaccuracies with coding of the cause of death
  • Variation in record keeping
  • Variable care (Out of Hours, weekends)
  • Reliable use of an Early Warning Score (EWS)
  • Problems with communication and escalation of clinical issues.
  • Failed rescue within 30 minutes
  • Harm (e.g. Infection, falls, adverse drug events)

Their Clinical Improvement Board focussed on this work by:

  • Setting an ambitious aim to reduce HSMR by 30% by 2012.
  • Developing a Driver Diagram to direct their work.
  • Communicating their aim to all staff and the public.
  • Integrating this work into every day clinical practice.
  • Focused the Professional Development and Clinical Governance/Risk Management teams on this work with Clinical Improvement facilitators linked to wards.

To date they have shown a 12% reduction in their HSMR with:

  • The Board now expecting to see data
  • Frontline staff having an increased understanding of data.
  • Teams understanding how data links to overall aims (i.e. reduce mortality)
  • An increased understanding of the importance of human factors (e.g. effective handover)
  • More transparency on describing harm with increased involvement of families with Significant Adverse Events.

In a second Board the focus was on examining the reliably of getting a Doctor to a patient within 30 minutes of identification ofdeterioration. In investigating their existing systems, identifying areas for improvement and taking action they have:

  • Reduced arrest calls by 85%
  • Increased DNACPR decision compliance and documentation
  • Reduced Out of Hours transfer to Intensive Care (ITU)
  • Reduced invasive ventilation
  • Reduced renal haemofiltration
  • 90% patients with sepsis are managed in general wards – not ITU
  • Reduced organ support – 2.4 down to 1.3 organs
  • Reduced ITU length of stay
  • ITU beds released
  • Reduced ITU drug budget.

2. Assessment

NHS Grampian has multiple systems in place that support the early identification, action and rescue of patients. Some key points to note are:

Early Warning Scoring Systems (EWS)

  • Implemented in Aberdeen Royal Infirmary (ARI), DrGraysHospital, Royal Aberdeen Children’s Hospital, AberdeenMaternityHospital and WoodendHospital. The majority of ward areas are monitoring their compliance. Aberdeenshire Community Hospitals have implemented this in Aboyne and are spreading to other areas. Their work has been shortlisted for a UK Nationwide Patient Safety award. Mental Health are currently exploring this system to determine its relevance for their client group.
  • Clinical Lead for EWS, along with Professional Development and Patient Safety, has been carrying out Walkrounds in ARI to facilitate education and support for the use of the form, as well as ascertaining feedback to continue to modify and improve the system.

Clinical Groups

  • There is an agreement for a corporate Clinical Management Forum
  • Acute Sector Clinical and Nurse Lead forum – units are looking at morality data/cases
  • Moray Consultant and GP forum – looked at morality and agreed to link audit work to this theme.It will be carrying out monthly case note reviews on this.

Harm and incidents

  • Extensive work is being done to ensure senior managers and clinicians receive timely alerts and information from system
  • All high and catastrophic incidents are reviewed by Director of Nursing and Quality and Chief Operating Officer
  • Grampian Falls Group formed – agreed NHS Grampian is lacking a corporate direction to this work and lacks accountability and monitoring.

Quality Dashboard

  • A high level dashboard has been developed and is now being implemented. This includes data and narrative to support the work around mortality, adverse events, infection and patient experience
  • Currently working on an agreed process for dissemination of the dashboard and subsequent feedback of explorations of the data and any improvements undertaken within services.

Data

  • Multiple data being requested from frontline teams for various local and national requirements. Moray Senior Charge Nurses have implemented a quality scorecard with an IT system to support this. An agreement has been made to roll out this approach across NHSGrampian and this is now being taken forward
  • Discussions have commenced between Clinical Governance and Risk Management (CGRM), Health Intelligence and eHealth regarding data systems and the idea of a data “virtual post box” linked to reporting is being progressed.

Links

  • A virtual improvement group which integrated all the improvement programmes so that there was commonality to improvement approaches is being resurrected under the Quality Strategy Steering Group.

Patient Safety Work Programme

A considerable amount of work is ongoing within NHS Grampian to improve the safety and quality of hospital care using evidence-based tools and techniques to increase the reliability of everyday systems and processes. Real time data is being gathered unit-by-unit as this spreads and the staff caring directly for patients are leading the changes. Work in this area has focussed in Acute Care settings as part of national programmes such as the Scottish Patient Safety Programme (SPSP), Leading Better Care, Releasing Time to Care, Clinical Quality Indicators and Better Together. This has linked with existing work for example on prevention and control of infection. This has spread to Community Hospitals and Moray have been successful in securing support to carry out pilot work linking patient safety work between primary and secondary care.

Key Risks

Without a focussed effort of work around this, it is unlikely that NHS Grampian will be able to demonstrate a reduction in HSMR.

Conclusion

The key points shown above are only a snapshot of activity involved in reducing HSMR. For example the Resuscitation team, Hospital @ Night Team, Nurse Practitioners, local and national clinical audits all have crucial roles. What is perhaps not clear at present is how all groups and activity fit together. It is therefore proposed that a small sub-group with key clinical representatives is formed to determine how reliable NHS Grampian’s systems are. To support this work an NHS Grampian specific Driver Diagram highlighting actions and interventions has been developed and is included in this paper at page 5.

Recommendations

The Board is asked to:

  • Agree and support the work outlined in the NHS Grampian Mortality Driver Diagram
  • Provide particular support to the actions relating to the Key Driver to “Promote the position of safety within the organisation”, recognising some involve a role for the Board
  • Support the setting up ofa system so thatdata is easily accessible for frontline teams, patients and the public;this involves setting up a data board in the Conference Room
  • Support the use of the “Is your care safe, effective and person centred?” tool within Walkrounds.

Executive Leads

Richard Carey, Chief Executive Officer – for mortality work

Elinor Smith, Director of Nursing and Quality - for patient safety in general

Helen Robbins

Head of Clinical Governance and Risk Management

Jenny Ingram

Team leader and Programme Manager for SPSP

18 January 2011

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