Overview July A&E Clinical Quality Indicators Stockport NHS Foundation Trust Page 1

Transcription

1 Accident & Emergency Clinical Quality Indicators These standards represent a summary view of key aspects of effective patient care. At Stockport NHS Foundation Trust we embrace the philosophy of any such standards being whole-systems standards, as opposed to departmental ones. Professionally and operationally we utilise the standards as a driver to improve performance. Whilst we recognise these are national standards, we use them in Stockport to help us to address issues of particular relevance to our local population, working collaboratively with other agencies, including commissioners, to ensure that we attend to them. We aspire to push standards higher and engage users in helping us to shape our services. Summary July 2011 Indicator key measure threshold met actual attendances detail Total time in A&E 95th percentile time 1 4 hours yes 4:00 7,102 Page 2 for admitted patients 95th percentile time 5:16 1,728 Page 3 for non-admitted patients 95th percentile time 3:54 5,374 Page 4 Time to Initial Assessment 2 95th percentile time 15 mins yes 0:11 2,019 Page 5 Time to Treatment median time 1 hour yes 1:00 6,572 Page 6 Left without being seen percentage 5% yes 0.2% 11 Page 7 Unplanned re-attendance rate 3 percentage 5% no 5.2% 372 Page 8 Ambulatory care quarterly information on cellulitis & deep vein thrombosis Page 9 Service experience quarterly report on improving A&E for patients and carers Page 10 Consultant sign-off six-monthly audit information on high-risk patients Page 10 Overview July 2011 The key challenge in this early report has centred upon the development of an effective data capture pathway, within systems which have historically had limited real-time functionality. There has been a need to identify, analyse and articulate data in a way which reflects a common understanding of the parameters we are attempting to measure. We continue to drive a process of raising awareness amongst clinicians to maximise every opportunity to accurately populate the data sets. We have been pleased to have met 4 of the 5 standards in this early phase, with confidence in our current data processes. This report is about the services we provide in the Emergency Department Stepping Hill Hospital Poplar Grove Hazel Grove Stockport SK2 7JE Telephone: We are a Major (type 1) A&E Department providing a consultant led 24 hour service with full resuscitation facilities and designated accommodation for the reception of Accident & Emergency patients. Services are provided by Stockport NHS Foundation Trust (NHS organisation code RWJ01) For further information please contact Richard Brownhill Unscheduled Care Leader, or Mr. Darren Kilroy Clinical Director Richard.Brownhill@stockport.nhs.uk Darren.Kilroy@stockport.nhs.uk Unless specified, information relates to the month of July 2011 Published on 26 August 2011 A&E Clinical Quality Indicators Stockport NHS Foundation Trust Page 1

2 The median, 95th percentile and longest total time spent by patients in the A&E department Aim: To improve the timeless and monitoring of care to ensure patients do not have excessive waits in A&E before leaving the department Time spent within an Emergency Department is arguably the most important criterion by which patients judge the quality of their experience. Some aspects of waiting will be inevitable, though we are attempting to do all we can to minimise any time delays. This requires an analysis of internal departmental processes, as well as those other departments and services which interface with us. Intelligent use of the data which informs this standard enables us to identify particular problems and bottlenecks, and develop improved pathways and services as a result. In this first quarter, our good performance reflects a significant amount of service improvement work which has been undertaken. We have launched a comprehensive project to refresh many of the internal pathways and ways of working within the Emergency Department, including nursing and medical job planning, task allocation, methods of assessment, and documentation. Supporting this is a significant project to enable real-time data capture. It should be noted that activity has been reduced in the quarter, which has enabled a smoother implementation of these significant amendments. The full benefit of the service redesign we are undertaking will appear through the next six to twelve months. Total time in A&E (hours) 7:00 6:00 5:00 4:00 3:00 2:00 1:00 0:00 95th percentile time Median time Threshold (4hrs) 95th percentile time 4:00 2:07 In March 2011 the 95th percentile time for all A&E attendances in England was 4 hours 59 minutes, for the North West of England it was 4 hours 27 minutes 4. In July we treated 7,102 patient attendances. We have seen a reduction in the number of patients attending A&E in recent months. 81 patients (1.1% of all attendances) spent more than 6 hours in A&E, 8 patients (0.1%) spent more than 12 hours in A&E. Overall the data quality for this indicator is good. All attendances should have a start and end time recorded. For all the indicators in this report, we have excluded all follow-up attendances from the data (where a patient has been asked to return to A&E for the same incident). All our A&E follow-up attendances should be planned 5. A&E Clinical Quality Indicators Stockport NHS Foundation Trust Summary on Page 1 Page 2

3 For admitted patients the median, 95th percentile and longest total time spent by patients in the A&E department Aim: To improve the timeless and monitoring of care to ensure patients do not have excessive waits in A&E before leaving the department The data underpinning this particular standard helps us in several ways. Firstly, by being able to identify particularly long episodes of care for patients who were admitted, we are able to track back that data to enable us to investigate in detail what contributed to the duration of those episodes. It may well be the case that a patient s care was so complex, and involved several teams managing the patient in the Emergency Department, that a long period of A&E care was entirely appropriate. We acknowledge that the analysis can help to identify those experiencing Emergency Department delay, as well as other sources including diagnostic tests, specialist review etc. With greater understanding we are able to utilise the data to explore sustainable solutions inside and outside of the Emergency Department. Evaluating our longest waits within a context of median and 95th percentile activity enables us to take a more whole-systems view of the efficiency of our admissions pathways. It enables us to appreciate that, although our data quality is good, there is room for improvement. Our median time [see graph opposite] reflects how well our internal departmental processes match our external ones in terms of hospital admission practices. We can see that there has been a good overall performance in the quarter. This has been achieved against a backdrop of standards implementation, as mentioned in the overview above. Activity in the next quarter has often been higher, based upon historical trends. In light of this, we are working to bring forward revised admission pathways, which should strengthen our ability to mitigate any decrease in performance. Our performance against this standard is paramount in determining how well we serve those patients whose care needs are amongst the highest of all those who attend. Total time in A&E (hours) for admitted patients 9:00 8:00 7:00 6:00 5:00 4:00 3:00 2:00 1:00 0:00 95th percentile time Median time 5:16 3:09 In March 2011 the 95th percentile time for all admitted A&E attendances in England was 7 hours 23 minutes, for the North West of England it was 6 hours 22 minutes 4. In July we admitted 1,728 patients following an A&E attendance, this represents 24% of all our A&E attendances. The longest recorded total time in the Emergency Department for an admitted patient in July was 14 hours 17 minutes. Overall the data quality for this indicator is good. All attendances should have a start and end time recorded. A&E Clinical Quality Indicators Stockport NHS Foundation Trust Summary on Page 1 Page 3

4 For non-admitted patients the median, 95th percentile and longest total time spent by patients in the A&E department Aim: To improve the timeless and monitoring of care to ensure patients do not have excessive waits in A&E before leaving the department The data within this standard primarily helps us to understand how our internal processes function, but it also has an important message about how external agencies support what we do. We recognise the scale of internal process changes which need to occur and are refining our A&E initial assessment methodology. We have revised our senior medical job plans to provide for shop-floor supervision later into the evening. We have instigated a front-of-house ambulance patient transport service to facilitate timely discharge from A&E. We have altered the capacity of our nurse-led (ENP) minor injury service to better meet patterns of activity. Some of this has been necessary due to the national difficulty of recruiting sufficient middle tier medical staff. Whilst it is difficult to fully explain June s data, it has contributed to our drive to refine the activities described above, which were already being pursued. We recognise that safely and effectively managing many attendances per day within a four-hour care time-frame can be challenging, and we undertake a meaningful and robust clinical risk score on all attendances. We also put into place management plans for all patients who, whilst not requiring admission, do require the input of the ambulance service, social care teams, mental health teams, physiotherapy, occupational therapy, outpatient diagnostics, outpatient specialty clinics and/or their own general practitioner. Our ability to meet this standard requires the support of all these agencies, and we continue to increase the effectiveness of our working relationships with them all. The comments made earlier in relation to data capture, apply equally here. We are working toward an improved, harmonised and real-time data entry methodology which will enable us to better track the progress of patients through the Department. Although not captured within the standard, the quality of discharge coding data is important as part of our description of what happens to non-admitted patients, and we are working equally hard to improve. Total time in A&E (hours) for non-admitted patients 5:00 95th percentile time 4:00 3:00 2:00 1:00 0:00 Median time 3:54 1:50 In March 2011 the 95th percentile time for all non-admitted A&E attendances in England was 3 hours 59 minutes, for the North West of England it was 3 hours 57 minutes 4. In July we admitted 5,374 patients following an A&E attendance, this represents 76% of all our A&E attendances. The longest recorded total time in the Emergency Department for a nonadmitted patient in July was 16 hours 33 minutes. Overall the data quality for this indicator is good. All attendances should have a start and end time recorded. A&E Clinical Quality Indicators Stockport NHS Foundation Trust Summary on Page 1 Page 4

5 Time from arrival to start of full initial assessment 6 for all patients arriving by ambulance Aim: To reduce the clinical risk associated with the time the patient spends unassessed in A&E This standard reflects the timeliness with which we clinically assess patients who are brought into the Emergency Department by ambulance. What matters most in patient care terms here is, paradoxically, not simply the speed with which that assessment occurs, but the quality of the assessment. On this basis, we have designed and implemented a robust initial assessment package which not only incorporates the mandatory national requirements of the assessment, but provides staff with a dedicated physical space for the assessment, a structured senior medical assessment alongside the nursing one, and a clear onward management plan for assessed patients. We have amended our existing stand-alone software to better enable us to capture activity in this domain. This is in line with our larger data entry project mentioned elsewhere. Our performance to date has been excellent. This reflects, to a degree, the reality that factors affecting performance in relation to this standard are entirely internal to the Emergency Department, enabling us to effect change and improvement very rapidly. Building upon our initial success, we are now rolling out a similar methodology to severely ill patients who arrive on foot or by car, enabling us to enhance our risk management activity and at the same time improve flow in relation to ambulatory patient demand. Time to Initial Assessement, arrivals by ambulance 0:20 0:15 0:10 0:05 0:00 95th percentile time Median time Threshold (15 mins) 95th percentile time 0:11 0:02 In common with many trusts we have only been routinely recording and sending data on the initial assessment time since the April 2011, therefore there is a lack of accurate benchmarking data for this indicator. In July we had 2,027 A&E patients arriving by ambulance, this represents 29% of all our A&E attendances. Overall the data quality for this indicator is fairly good, although 7 ambulance attendances (0.3%) had no initial assessment time recorded. Further analysis needs to be done to verify the longest time to initial assessment. A&E Clinical Quality Indicators Stockport NHS Foundation Trust Summary on Page 1 Page 5

6 Time from arrival to see a decision making clinician 7 Aim: To reduce the clinical risk and discomfort associated with the time the patient spends before their treatment begins in A&E Patient care is fundamentally determined by the timeliness and quality of decision-making. This standard reflects a need to capture and understand how quickly we can provide that initial decision-maker (which is a separate element to initial assessment). Early definitive decisions lead to shorter lengths of stay and reduced morbidity and mortality. Locally, we have addressed the challenge by recognising that the different clinical streams within the Department have different decision-making requirements: minor injury cases require a specialist nurse to decide their care needs; complex medical patients require a senior clinician; mental health patients require their own form of special decision-making. By focusing attention on these streams, we have divided them more explicitly to manage them more efficiently. As a result, for example, we now streamline all minor injury cases into a nurse-led rapid injury assessment pathway. A key challenge to success for this standard is the degree to which A&E overcrowding acts as a major contributor to A&E performance, but which is due to factors out of its control - consuming resources which would and should actually be deployed in front-line assessment and decision-making. We are addressing these issues within the whole-systems review of admission and bed management practice which is currently being undertaken. Where additional resources remain to be recruited despite these changes, then we will bring forwards an action plan describing what resources are required, when, and why. Time to Treatment (hours) 4:00 95th percentile time 3:00 2:00 1:00 0:00 Median time Threshold (1 hour) median time 2:54 1:00 In March 2011 the median time to treatment for all A&E attendances in England was 59 minutes, for the North West of England 55 minutes 4. In July 2011, our longest recorded time to start of treatment was 7 hours 1 minute. Overall the data quality for this indicator is fairly good. Excluding patients who left before their treatment began 8 or refused treatment, we didn t record a treatment start time on 4.8% of A&E attendances. A&E Clinical Quality Indicators Stockport NHS Foundation Trust Summary on Page 1 Page 6

7 The percentage of people who leave the A&E department without being seen Aim: To improve patient experience and reduce the clinical risk to patients with high risk conditions who leave A&E before receiving the care they need It is well recognised that there is a significant risk to those patients who, having attended A&E for care, chose to leave before any assessment or care has been delivered. The philosophy of this standard is to enable quantification and analysis of those patients and then to build an understanding of why they choose to leave in our own unit. Patients may choose to leave almost immediately following arrival, or at some later, but still premature time within the attendance. The standard acts as a useful proxy for systems and processes within the Emergency Department, since where high numbers of patients leave without being seen, it tends to reflect delayed assessment times, poor staff-patient communication, and slow, unresponsive streaming of care. Within our own unit, we enjoy relatively low levels of early self-discharge in this fashion. However we are not complacent, and we will be using this data to understand whether those patients who do leave of their own accord represent a small group of regularly-attending people requiring active case management, or whether there are pressure-points within the daily cycle at which times people are more likely to leave. To date, our data suggests that people tend to leave when the ambulatory parts of the Emergency Department are at their busiest weekend afternoons, and night-times toward the end of the working week. We have used this data alongside other information to amend our staffing during those times, and we will report any significant changes to the data on a rolling basis within this report. Left without being seen rate 5% 4% 3% 2% 1% 0% % of all attendances Threshold (5%) 0.15% In March 2011 the rate of all A&E attendances in England who left without being seen was 3.3%, for the North West of England 3.7% 4. Starting in April 2011 we are recording patients as left without being seen 9 only where they leave before their initial assessment. In July 2011 another 4.1% of our attendances were recorded with a disposal of Call No Reply where the patient did not complete their treatment in A&E. Overall the data quality for this indicator is good. All attendances should have a disposal recorded. A&E Clinical Quality Indicators Stockport NHS Foundation Trust Summary on Page 1 Page 7

8 Unplanned re-attendance at A&E within 7 days of original attendance 10 Aim: To reduce avoidable re-attendances at A&E by improving the care and communication delivered during the first attendance The basis of this standard is to enable a clearer understanding of why people choose to re-attend our Department following their first visit. It does not imply that care during that initial attendance was necessarily deficient. However, where large numbers of patients re-attend within a few days of first being seen, it is appropriate to scrutinise that population and analyse the reasons for their decision. The degree to which existing data systems can accurately capture this activity is a current issue for us and other units. Because this is a new metric of activity, it has been a challenge to devise and implement a suitable tool to capture truly unplanned cases, as opposed to patients whose follow-up was actually planned through a review clinic. It has also been difficult to tell apart which patients re-attend in relation to the same problem which led to their first visit, as opposed to those who attend again but with an entirely separate problem. Of interest within this group are those patients who attend frequently. We analysed a representative sample week s data and found that a significant proportion of return attendances within 7 days were in relation to mental health and alcohol problems. A significant minority of cases were composed of very recent discharges from medical wards, returning to A&E with unresolved symptoms. We are using this clinical data to inform discussions with internal and external stakeholders. 7 day unplanned re-attendance rate 7% 6% 5% 4% 3% 2% 1% 0% % of all attendances Threshold (5%) 5.2% We have calculated our 7 day unplanned re-attendances where a patient comes back to A&E within 7 days of leaving the Department without being told to return 11. This will include attendances for different complaints. Benchmarking data is not available using this method of calculating unplanned re-attendances. Overall the data quality for this indicator is good, although more detailed, manual investigation is required to understand the meaningfulness of this indicator. A&E Clinical Quality Indicators Stockport NHS Foundation Trust Summary on Page 1 Page 8

9 The number of admissions for cellulitis and deep vein thrombosis per head of weighted population Aim: To reduce avoidable hospital admissions by improving the provision of ambulatory care Ambulatory care describes a system of care where patients do not need, based upon their diagnosed or suspected condition, to be managed as an in-patient in a hospital bed. Two key conditions which are recognised as being suitable for outpatient ambulatory care are cellulitis and deep vein thrombosis, though there are many others. We have developed dedicated multi-agency work-streams to describe and launch out-of-hospital care pathways for both these conditions, and future reports will build upon this work as we outline the progress we are making. Cellulitis For April to June 2011 we (as Stockport NHS Foundation Trust) admitted 116 Stockport PCT patients as an emergency where cellulitis was recorded as the main reason for their admission 12. This represents a rate of 0.53 per 1,000 head 13. Of the 116 emergency admissions, 67 were admitted via A&E. Stockport NHS Foundation Trust is the provider of about 78% of Stockport PCT s total emergency admissions, and so the Stockport PCT rate is used here as a proxy measure. Nationally in 2009/10, the median rate for PCTs for admissions for cellulitis was 1.20 per 1,000 head 14. Deep vein thrombosis In the same period we admitted 29 patients for deep vein thrombosis 12 as an emergency from Stockport PCT. This represents a rate of 0.13 per 1,000 head of these 29 patients were admitted via A&E. Nationally in 2009/10, the median rate for PCTs for admissions for deep vein thrombosis was 0.42 per 1,000 head 14. The percentage of A&E attendances for cellulitis and deep vein thrombosis that end in admission Aim: To reduce avoidable hospital admissions by improving the provision of ambulatory care The conversion rate of A&E attendances into traditional admissions for these two sentinel conditions acts as a proxy for how well an acute care environment can recognise the importance of an ambulatory approach to case management. Locally, our key challenge has been the bringingtogether of community agencies and diagnostics in the design of a seamless pathway. We also have work to do in relation to how activity is coded and tariffs applied. Future reports will describe these challenges, and how we have addressed them, in detail. Cellulitis For April to June 2011 we made a diagnosis of cellulitis during an A&E attendance on 158 patients, of which we admitted 40 (25.3%). Deep vein thrombosis In the same period we diagnosed 20 patients with deep vein thrombosis during their A&E attendances, of which we admitted 4 (20%). This A&E attendance data is based on a clinical diagnosis being made in the Department; many patients may have definitively diagnosed with these conditions after referral from the Emergency Department. The A&E diagnosis is produced from local codes on the records of patients and will not be available on our nationally submitted data. We record up to six diagnoses for each A&E attendance, without classifying one as the main condition being treated or investigated in the A&E attendance. A&E Clinical Quality Indicators Stockport NHS Foundation Trust Summary on Page 1 Page 9

10 Narrative description of what has been done to assess the experience of patients using A&E services and their carers, what the results were, and what has been done to improve services in light of the results Aim: To improve the experience of patients who use A&E services and their carers We are committed to meaningful and regular engagement with the community we serve in relation to A&E services at Stockport NHS Foundation Trust. With that in mind, through the course of the summer we are establishing a user group with representation from our key populations children, the elderly, those with complex medical needs, and those with alcohol and mental health challenges. In future reports we will describe the outcomes of our group meetings, and also the results of regular user surveys. An important part of these meetings will be a transparent account of how we have tackled particular points raised by users. Where questions and issues are put to us about any element of our service, we will report the steps we have taken to address them. The percentage of patients presenting at type 1 and 2 (major) A&E departments in certain high-risk patient groups 15 who are reviewed by an emergency medicine consultant before being discharged Aim: To improve clinical processes and outcomes and reduce the risk patients are exposed to This indicator is to be measured using an audit managed by the College of Emergency Medicine. Data on consultant sign-off should be available after October Notes for report 1 95 th percentile time 95% of A&E attendances were seen within this time. 50% for median time. 2 Time to Initial Assessment for patients arriving by ambulance only 3 Unplanned re-attendance at A&E within 7 days of original attendance 4 Benchmarking data from the Department of Health Urgent & Emergency Care team based on data submitted by NHS provider Trusts 5 A technical issue means some will be classified as unplanned follow-ups when the data is transferred to other organisations 6 Full initial assessment, which includes a pain score and early warning score 7 Someone who can define the management plan and discharge the patient. Recorded nationally as A&E Time Seen for Treatment. 8 Patients recorded locally with attendance disposal Left Before Initial Assessment or Call No Reply 9 Patients recorded nationally with attendance disposal of Left department before being treated (code 12) 10 Including if referred back by another health professional 11 See Q6 of the Department of Health s A&E Clinical Quality Indicators Frequently Asked Questions document 12 Primary diagnosis of first finished consultant episode, with an emergency method of admission. Includes, for example, emergency GP admissions, not just admissions via A&E. 13 Stockport PCT s Unified weighted population for 2011/12 is 281,645, denominator used is 78% of this. 14 Benchmarking data from A&E Clinical Quality Indicators Implementation Guidance 15 Adults with non-traumatic chest pain, febrile children less than 1 year old and patients making an unscheduled return visit with the same condition within 72 hours of discharge A&E Clinical Quality Indicators Stockport NHS Foundation Trust Summary on Page 1 Page 10