Services Provided Introduction
3.2 Participation in Clinical Audit
During 2013/14, 29 national clinical audits and 3 national confidential enquiries covered NHS services that Wye Valley NHS Trust provides.
During that period Wye Valley NHS Trust participated in 27 (93%) national clinical audits and 3 (100%) national confidential enquiries of the national clinical audits and national
confidential enquiries which it was eligible to participate in. Decisions were made not to participate in the remaining two national audits, as follows:
The decision not to participate in the National Cardiac Arrest Audit was taken after review by Resuscitation Committee showed that the national audit would not provide anything over and above that already provided by the Trust’s well established audit of all cardiac arrests.
The Trust did not participate in the current round of the Paediatric Asthma Audit as results from previous rounds showed that the Trust performed well. The clinical team involved wished to focus their 2013/14 audit activity on areas where
improvements may be required.
The table below lists the national clinical audits and national confidential enquiries that Wye Valley NHS Trust was eligible to participate in during 2013/14 and indicates whether or not participation took place. The table also shows the number of cases submitted to each audit or enquiry as a percentage of registered cases required by the terms of that audit or enquiry for those where data collection was completed during the period April 2013-March 2014.
Eligible National Audits WVT participated Percentage of required cases submitted Comments
Acute coronary syndrome or Acute
myocardial infarction
Data submission ongoing Adult critical care (Case Mix
Programme)
Data submission ongoing
National Bowel Cancer Audit Data submission
ongoing
Cardiac Rhythm Management National
Audit
Data submission ongoing
Data for calendar year 2013 – submission rate estimated at 100%. Chronic Obstructive Pulmonary
Disease National Audit
Data submission ongoing Adult Diabetes Audit Programme,
includes:
Adult Diabetes Audit
100% Retrospective data submission for 2012/13 of all patients seen in diabetes outpatient clinics
National Diabetes Inpatient Audit 100%
All eligible inpatients at the time of the audit
Pregnancy in Diabetes Audit 100%
Relates to eligible women who consented to take part in the audit
National Paediatric Diabetes Audit 100%
Retrospective data submission of all patients seen in diabetes outpatient clinics between January 2012 and March 2013.
Eligible National Audits WVT participated Percentage of required cases submitted Comments
Elective surgery (National Patient Reported Outcomes Measures Programme)
Data submission
ongoing
National Emergency Laparotomy Audit Data submission
ongoing Epilepsy 12 National Audit (Childhood
Epilepsy)
Data submission ongoing
Round Two
Falls and Fragility Fractures Audit Programme includes National Hip Fracture Database
Data submission
ongoing National Head and Neck Cancer Audit
Data submission
ongoing National Heart Failure Audit
Data submission
ongoing Inflammatory Bowel Disease National
Audit
100%
Eligible ulcerative colitis cases and organisational data
National Lung Cancer Audit
Data submission
ongoing National Audit of Moderate or Severe
Asthma in Children (Care provided in Emergency Departments)
100%
Maximum of 50 cases required
National Audit of Seizure Management 100%
National Cardiac Arrest Audit .
National Comparative Audit of Blood
Transfusion Programme
Data submission ongoing National Joint Registry
Data submission
ongoing Neonatal Intensive and Special Care
National Audit (National Neonatal Audit
Programme) 100% Data period by calendar year. All babies admitted to Special Care
Eligible National Audits WVT participated Percentage of required cases submitted Comments Baby Unit. National Oesophago-Gastric Cancer
Audit
Data submission ongoing Paediatric Asthma Audit (British
Thoracic Society) .
Paediatric Bronchiectasis Audit (British Thoracic Society)
Participated but the number of cases eligible for inclusion in the audit (3) was below the minimum number set
(5) for analysis and reporting. Paracetamol Overdose National Audit
(Care provided in Emergency Departments)
100%
Maximum of 50 cases required
Sentinel Stroke National Audit Programme
Data submission
ongoing
In latest national interim report the Trust is reported as 80-89% submission rate Severe Sepsis & Septic Shock National
Audit 100%
Maximum of 50 cases required Severe Trauma (Trauma Audit &
Research Network)
Data submission ongoing Rheumatoid and Early Inflammatory
Arthritis National Audit
Data submission ongoing Eligible National Confidential Enquiries
Child Health Clinical Outcome Review
Programme N/A
Maternal, Infant and Newborn Clinical Outcome Review Programme
Data submission ongoing Reported by national centre as 100% in December 2013 Medical and Surgical Clinical Outcome Review
Programme: National Confidential Enquiry into Patient Outcome and Death (NCEPOD).
Eligible National Audits WVT participated Percentage of required cases submitted Comments
Subarachnoid Haemorrhage Study 100%
Tracheostomy Study 100%
Lower Limb Amputation Study 100%
Gastrointestinal Bleeding Study Data submission
ongoing
Review of Clinical Audit Reports
Within Wye Valley NHS Trust the reports of national and local clinical audits are reviewed by the clinical teams involved in the audit. If the review indicates that improvements are
required action plans are devised and implemented. Reports and action plans of all audits are reviewed by the Service Units Governance Groups. Reports and action plans from national audits are reported to the Trust’s Quality Committee (sub-committee of the Trust Board). This Quality Account gives details below of reports and action plans that reached the stages of reporting to Quality Committee and/or Service Unit Governance Groups in 2013/14.
The reports of 13 national clinical audits were reviewed by Wye Valley NHS Trust in 2013/14 and the Trust intends to take the following actions to improve the quality of healthcare
provided:
Audit National Diabetes Audit (Adult) 2011/12
The National Diabetes Audit is repeated on an annual basis and includes primary and secondary care. For secondary care it includes data on all patients attending diabetes outpatient clinics. The report published in 2013/14 covered patients seen between January 2011 and March 2012.
Action The results were reported in two parts:
Part One - Care Processes and Treatment Targets
The need for foot examination to be carried out in primary care as part of the patients’ annual review is being clarified and agreed with the Clinical
Commissioning Group.
Further data to be collected on the delivery of structured education. Part Two – Complications and Mortality
No individual results given for regions or hospitals so no specific action can be identified.
Audit National Diabetes inpatient audit 2012 (reported 2013)
This audit is part of the wider national diabetes audit programme and is a snapshot audit of inpatient care on one particular day. Results published in July 2013 showed areas of good performance but the following actions are being taken to achieve further improvements.
Action The national ‘Think Glucose’ campaign will continue to be publicised within the Trust. This is to raise staff awareness of which patients, whilst in hospital, are to be reviewed by a member of the diabetes team. ‘Think Glucose’ will also be included in planned education sessions to clinical staff.
The importance of foot examination for hospitalised patients with diabetes will be highlighted to all members of the Department of Medicine at an education session.
To reduce the risk of any errors in insulin medications being made it will be mandatory for all hospital prescribers, ward pharmacists and trained nurses involved in administering insulin to complete the E-learning training on Safe Use of Insulin.
Audit National Paediatric Diabetes Audit
This national audit is repeated on an annual basis. During the year, three national reports have been issued.
Actions Annual report of care processes (2011/12)
Structured education and updates to continue, with events in 2014.
Complications report (2011/12)
The report has been reviewed but no hospital specific results are given. No specific actions identified by the review.
Patient and Parent Reported Experience Measures (2012/13)
Business Plan has been submitted and approved for the appointment of a second consultant paediatrician with an interest in diabetes and for dedicated psychology support.
Audit National audit of cardiac rhythm management
This national audit collects continuous data and reports annually. The most recent report, the 7th annual report, describes cardiac device implantation performance in each Cardiac Network in England and Wales for 2011.
Action To increase access rates for cardiac pacing, particularly from Accident and Emergency. A new Spacelab module is to be implemented, which will enable digital archiving of Electrocardiograms (ECGs). The intention is for all Accident and Emergency ECGs to be uploaded to the archive. This can then be used to identify ECGs with relevant abnormalities.
To make the syncope clinic more accessible Protocols and pathways for syncope clinic to be developed
To ensure correct interpretation in all healthcare settings of ECGs in patients who have had a collapse an educational/long term strategy will be developed for syncope and falls over the next 2-3 years, to include learning opportunities for both primary and secondary care. Education on syncope will be included in the annual cardiology education day.
Audit British Thoracic Society National Paediatric Asthma Audit 2012/13
This national audit included children admitted with acute asthma during November 2012. Data were collected by the paediatric respiratory team and analysed by the British Thoracic Society.
Action Results indicated improvements had been achieved on those of the previous year but further actions taken as follows:
Asthma pathway developed, to be used alongside normal clerking documentation and Paediatric Asthma Warning tool
Pre-printed drug chart developed to be used at admission of children with asthma/wheeze
Audit British Thoracic Society National Audit of Paediatric Pneumonia 2012/13
This national audit included children admitted with pneumonia over the three month period November 2012 – January 2013. Data were collected by the paediatric respiratory team and analysed by the British Thoracic Society.
Action Results of audit and areas where improvements required presented at Paediatric audit meeting, with handouts summarising BTS guidelines on management of paediatric pneumonia
Teaching sessions by paediatric respiratory team to include appropriate indications for investigations, chest physiotherapy and follow-up appointments and chest X-ray
Review of the Wye Valley Trust antibiotic policy in the light of British Thoracic Society guidelines
Make British Thoracic Society guidelines on paediatric pneumonia available on the Trust intranet
Audit British Thoracic Society National Audit of Chronic Obstructive Pulmonary Disease discharges. Data were collected from patients with a diagnosis of COPD
who were discharged from hospital during a two month period in 2012. Results were reviewed by the Respiratory Medicine Team and actions developed: Actions COPD care bundle, based on the British Thoracic Society Care Bundle,
developed for use in the Trust.
COPD Personalised Care Plan developed for use by Neighbourhood Teams for patients being seen in their homes.
Increase the checking and recording of inhaler techniques by group training on inhaler technique to all existing trained staff on medical wards in the acute and community hospitals; new trained staff to attend Respiratory Nurse-led study day which includes inhaler technique; up to date inhaler technique file including written instruction on inhaler technique to be kept on each medical ward. Liaise with ambulance service to make them aware of patients on the
respiratory database
Audit British Thoracic Society, National Audit of Emergency Oxygen (2012/13)
The British Thoracic Society audit of emergency oxygen involved collecting data on inpatients using oxygen at the time of the audit, to assess whether oxygen had been prescribed in accordance with the Trust’s policy. Data were collected by the Trust’s Respiratory Clinical Nurse Specialists, with analysis and reporting by the British Thoracic Society.
Action Feedback given to nursing and medical teams in all areas to highlight that oxygen is to be prescribed, signed for and reassessed in keeping with past medical history.
All ward sisters asked to nominate a staff nurse to be oxygen link nurse for the ward. Role of link nurse is to help with training to ward staff on the use of oxygen and to keep staff updated.
Staff nominated as “Oxygen champions” to explore options for making oxygen prescribing part of mandatory training.
Audit Acute coronary syndrome or acute myocardial infarction national audit (MINAP)
The twelfth MINAP annual report, published in October 2013, contained analyses from all hospitals and ambulance services in England, Wales and Belfast that provided care for patients with suspected heart attacks between April 2012 and March 2013.
Action Review of the results did not identify the need for any specific action to be taken. Audit National Bowel Cancer Audit
Results of this continuous national audit are published annually. The report published in August 2013 included the results of data collected on patients diagnosed with bowel cancer in 2011/12.
Action To improve the completion and accuracy of electronic data uploaded to the national system, an application has been made to appoint a General Surgery/Colerectal coder.
To reduce the average length of stay in hospital for patients with bowel cancer and reduce unnecessary readmissions, an application has been submitted for a treatment room to allow rapid assessment of patients discharged after major surgery.
Increasing the average yield of lymph nodes has been discussed with site specific pathologist.
Audit Trauma Audit & Research Network (TARN)
This on-going national audit looks at aspects of the care given to patients with severe trauma, including before arrival in hospital, and measures survival rates according to severity of trauma.
Action The Trust’s Trauma Sub-group reviews each 4-monthly report to assess whether any improvement actions are required.
Results on time to CT scanning led to the review of outliers to check on data accuracy
The reports are used to inform the content of multi-disciplinary trauma meetings.
Audit National Heart Failure Audit
This audit was established in 2007 to monitor and improve the care and treatment of patients with an unscheduled admission to hospital in England and Wales with acute heart failure. The sixth annual report included patients discharged from hospital between April 2012 and March 2013.
Actions Following a review of the report by the Heart Failure Team, actions have been taken to ensure that relevant patients with heart failure are admitted to the appropriate clinical area and are under the care of Cardiologists where required: Heart Failure Nurses can now directly refer patients under the care of other
specialties to the cardiologists
Heart Failure Nurses can now initiate a patient move to the Cardiology Ward Heart Failure Multidisciplinary Group established, to improve the triage of
patients to the appropriate area of care
A trial of regular meetings held in order to help enhance the transfer of patients to the appropriate areas of care and to be seen by the right teams during their stay in hospital.
Audit Intensive Care National Audit
This national audit has been running since 1994 and now collects data from 90% of adult critical care units in England, Wales and Northern Ireland. Data on patient activity and outcomes of all patients admitted to critical care are submitted to ICNARC for analysis and reporting. Intensive Care and National Audit Research Centre (CMP) Case Mix Programme Annual Quality Report 2012/13 was published December 2013
Actions Multi-disciplinary meetings established on monthly basis
Every death that appears on the ICNARC registry is reviewed at the monthly multi-disciplinary meeting. All deaths were reviewed for 2012-13 and raised no specific concerns.
The reports of 40 local clinical audits were reviewed by Wye Valley NHS Trust in 2013/14 and Wye Valley intends to take the following actions to improve the quality of healthcare provided. .
Local Clinical Audits where actions are required:
Audit Cardiac Arrests and Emergency Calls
A continuous audit of all cardiac arrests and other emergency calls made to the Resuscitation Team is performed in the Trust. Results are reported quarterly and reviewed by the Trust’s Resuscitation Committee for identification of action, before being reported to the Trust’s Quality Committee.
Action The patient booklet ‘Your guide to decisions about cardiopulmonary resuscitation’ has been sent to all local General Practices and Community hospitals, as well as being made available on relevant wards at the acute hospital
To prevent duplication of calls to maternity, staff have been reminded of the indications for calls to be made to the obstetric team and those to the neonatal team.
Audit Audit of ‘Do Not Attempt Cardio-Pulmonary Resuscitation’ (DNACPR) documentation within the acute and community settings
The audit assessed whether the Trust’s policy on DNACPR was being followed in respect to staff knowing the DNACPR status of patients; appropriate completion
and location of DNACPR documentation.
Action Any DNACPR forms to be filed at the front of the patient’s notes so that it is clearly visible to staff caring for the patient.
The nurse in charge of the ward at the time of a DNACPR decision being made is to document the decision in the nursing notes.
All DNACPR forms completed by doctors below Consultant level to be countersigned by a Consultant-level doctor within 24 hours
Audit Audit of Care Bundles
Care bundles specify evidence-based interventions to be performed for patients with specific conditions. Each bundle has between three and five specified
interventions. Six new care bundles were introduced in the Trust in 2013/14. Use of these new care bundles, and an existing bundle, are audited on a regular basis to assess whether they are being used and completed.
Action Awareness of care bundles raised through medical and surgical meetings Care bundle for Chronic Pulmonary Disease and Community Acquired
Pneumonia redesigned
Audit to continue with monthly data collection Audit Audit of National Early Warning Score
The National Early Warning Score (NEWS) is a standardised track-and-trigger system for acute illness in people presenting to, or within hospitals. Audit was carried out following implementation of the system in the Trust in 2013.
Action Present results of the NEWS audit at Senior Nurse meetings and Medical staff meetings
Roll out audit results and recommendations to all Trust staff through Team Brief
Explore the potential for incorporating NEWS into the electronic data system used in Accident and Emergency
Develop competency-based training packages for qualified nursing staff, healthcare assistances and junior medical staff
Weekly review of the use of NEWS to be carried out on a sample of ward based patients
Feedback to be provided to any individuals who fail to use the NEWS tool appropriately
Any instances where an escalation request has not resulted in an appropriate response will be reported through the Trust’s incident reporting system and used to provide monthly feedback of generic issues
Weekly review by consultants on ward rounds in relation to documentation of NEWS and medical management plans
Audit Use of the SSKIN bundle in District Nursing - SSKIN (Skin, Surface, Keep
moving, Incontinence and Nutrition) Bundle - audit was carried out to specifically look at the use of the SSKIN Bundle and the implementation of care plans. This was also to inform the review of current district nursing documentation.
Action Areas of good practice were identified but further work is underway to identify why