1. Improving the quality of medical and surgical care WELCOME

2. Improving the quality of medical and surgical care NCEPOD Neil Smith

3. Improving the quality of medical and surgical care 3 Remit To review medical and surgical practice and to make recommendations to improve the quality of the delivery of care.

4. Improving the quality of medical and surgical care 4 Remit By undertaking confidential surveys covering many different aspects of medical care and making recommendations for clinicians and management to implement.

5. Improving the quality of medical and surgical care 5 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

6. Improving the quality of medical and surgical care 6 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

7. Improving the quality of medical and surgical care 7 NCEPOD Observers Coroners’ Society RCS Ed RCP Ed HQIP

8. Improving the quality of medical and surgical care 8 Independent Advisory Group AoMRC Funders Lay Nursing Colleges

9. Improving the quality of medical and surgical care 9 Structure 11Non-clinical staff 7Clinical Co-ordinators 550+Local Reporters 100+Ambassadors

10. Improving the quality of medical and surgical care 10 The role of the Local Reporter History and evolution of the role What the role involves Handing on the baton

11. Improving the quality of medical and surgical care 11 The role of the Ambassador History of the role What the role involves Support provided

12. Improving the quality of medical and surgical care 12 Why it works Peer review Independence Put into a report what people already suspect…

13. Improving the quality of medical and surgical care 13 Coverage England, Wales, Northern Ireland Offshore Islands Independent sector

14. Improving the quality of medical and surgical care 14 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

15. Improving the quality of medical and surgical care 15 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

16. Improving the quality of medical and surgical care

18. Trauma: Who cares?

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25. Improving the quality of medical and surgical care 25 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

26. Improving the quality of medical and surgical care 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

27. Improving the quality of medical and surgical care 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 1997WOW II 2003 ** Further improvement to 87% identified in 2009 report (Caring to the end)

28. Improving the quality of medical and surgical care Impact – focussed studies

29. Improving the quality of medical and surgical care 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

30. Improving the quality of medical and surgical care Impact – focussed studies

31. Improving the quality of medical and surgical care 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

32. Improving the quality of medical and surgical care 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.

33. Improving the quality of medical and surgical care 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

34. Improving the quality of medical and surgical care 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.

35. Improving the quality of medical and surgical care 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.

36. Improving the quality of medical and surgical care AKI – NICE Guidance Acute kidney injury Prevention, detection and management of acute kidney injury up to the point of renal replacement therapy NICE Clinical Guideline 169 (issued August 2013)

37. Improving the quality of medical and surgical care 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.

38. Improving the quality of medical and surgical care 38 Local impact Stake holder survey NCEPOD talks Poster competitions Checklists/audit tools

39. Improving the quality of medical and surgical care Running a study Kathryn Kelly

40. Improving the quality of medical and surgical care 40 Topic selection Call for topics made to all our stakeholders 1 st review made by NCEPOD Co-ordinators 2 nd review made by NCEPOD Steering Group Consensus exercise performed

41. Improving the quality of medical and surgical care 41 Questionnaire development Expert group –Identify study themes –Determine what questions need to be asked –Clinical q. or advisor assessment form Questionnaires developed Pilot*

42. Improving the quality of medical and surgical care Running the study Eva Nwosu

43. Improving the quality of medical and surgical care 43 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*

44. Improving the quality of medical and surgical care Return of questionnaires and case notes Dolores Jarman

45. Improving the quality of medical and surgical care 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 45

46. Improving the quality of medical and surgical care 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 46

47. Improving the quality of medical and surgical care Case Review Meetings, Analysis and Report Launch Hannah Shotton

48. Improving the quality of medical and surgical care 48 Who are NCEPOD Case Reviewers? Active working clinicians Review other clinicians work Assess cases Common themes Recommendations

49. Improving the quality of medical and surgical care 49 Case Reviewers Multidisciplinary Group Specialties Hospitals Recruitment *

50. Improving the quality of medical and surgical care 50 Case Reviewer meetings 8-10 advisors 5 cases – CNs & Q Assessment Form

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52. Improving the quality of medical and surgical care 52 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

53. Improving the quality of medical and surgical care 53 Analysis Not statistical (scientific) research Qualitative analysis of Case Reviewer opinion of quality of care- AF Supplemented by data from OQ & CQ

54. Improving the quality of medical and surgical care 54 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

55. Improving the quality of medical and surgical care 55 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

56. Improving the quality of medical and surgical care 56 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

57. Improving the quality of medical and surgical care Data Security Robert Alleway

58. Improving the quality of medical and surgical care 58 Confidentiality It applies to the patient data It applies to the doctor and the hospital Section 251 DPA 1998 Ethics

59. Improving the quality of medical and surgical care 59 What we would like to avoid at NCEPOD

60. Improving the quality of medical and surgical care 60 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

61. Improving the quality of medical and surgical care Current Studies

62. Improving the quality of medical and surgical care 62 Gastrointestinal Bleeds

63. Improving the quality of medical and surgical care 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 63

64. Improving the quality of medical and surgical care 64 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

65. Improving the quality of medical and surgical care Gastrointestinal Bleeds Method: Population/Inclusions All patients aged 16 or over who were admitted between the 1 st January 2013 and the 30 th 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 65

66. Improving the quality of medical and surgical care Gastrointestinal Bleeds 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 66

67. Improving the quality of medical and surgical care Gastrointestinal Bleeds 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 67

68. Improving the quality of medical and surgical care Gastrointestinal Bleeds Exclusions Coded incorrectly for GI Bleed Did not have a transfusion of over 4 units 68

69. Improving the quality of medical and surgical care Current Status 69 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

70. Improving the quality of medical and surgical care Sepsis Hannah Shotton

71. Improving the quality of medical and surgical care 71 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

72. Improving the quality of medical and surgical care 72 SEPSIS: Aim “To identify and explore avoidable and remediable factors in the process of care for patients with sepsis”

73. Improving the quality of medical and surgical care 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 73

74. Improving the quality of medical and surgical care 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 74

75. Improving the quality of medical and surgical care 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: 6 th - 20 th May 2014 75

76. Improving the quality of medical and surgical care 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 76

77. Improving the quality of medical and surgical care 77 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

78. Improving the quality of medical and surgical care 78 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

79. Improving the quality of medical and surgical care 79 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

80. Improving the quality of medical and surgical care 80 Study timeline Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Form the EG Write the protocol Design the questionnaires Write the strategy of analysis Write the database Advertise the study Advertise for Advisors Test data collection methods Meet with EG Final protocol to SG + IAG Start data collection Run Advisor meetings Data analysis Presentation to EG and Advisors Presentation to SG CORP IAG Write the report First draft to reviewers Second draft to reviewers Report design and print Embargo copies sent Publish the report Disseminate findings

81. Improving the quality of medical and surgical care 81 Acute Pancreatitis

82. Improving the quality of medical and surgical care 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

83. Improving the quality of medical and surgical care 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 2 o 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

84. Improving the quality of medical and surgical care 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

85. Improving the quality of medical and surgical care 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

86. Improving the quality of medical and surgical care 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

87. Improving the quality of medical and surgical care Study Advisory Group Ms Joanne BishopHepato-Pancreatico-Biliary Nurse Specialist, Leicester Mr Tim BrownPancreatico-biliary Surgeon, Swansea Dr Mark CallawayRadiologist, Bristol Dr David CresseyIntensivist, Newcastle Mr Chris HalloranSurgeon, Liverpool Ms Jill HendersonPancreatitis Nurse Specialist, Newcastle Dr Mike MitchellGastroenterologist, Belfast Mr Murali ParthaSurgeon (joint proposer of study), Ipswich Dr Stephen PereiraGastroenterologist, London Ms Mary PhillipsHepato-Pancreatico-Biliary Specialist Dietitian, Guildford Dr Pat TwomeyChemical Pathologist, Bury St Edmunds Ms Marion ThompsonLay rep 87

88. Improving the quality of medical and surgical care 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 88

89. Improving the quality of medical and surgical care 89 Study timeline Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Form Study Advisory Group (SAG) Write the protocol Design the questionnaires Advertise the study Advertise for case reviewers Create the database Test data collection methods Meet SAG Final protocol to SG, IAG, ROCR & HRA Start data collection Run Advisor meetings Data analysis Presentation to SAG and case reviewers. Presentation to SG CORP IAG Write the report First draft to reviewers Second draft to reviewers Report design and print Embargo copies sent Publish the report

90. Improving the quality of medical and surgical care Provision for Mental Health in Acute Care Hannah Shotton

91. Improving the quality of medical and surgical care 91 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

92. Improving the quality of medical and surgical care 92 Mental Health in Acute Care: Aim Study Advisory Group meeting 12 th February 2015 Pilot study April/May 2015 Data collection will begin May 2015 Publication November 2016

93. Improving the quality of medical and surgical care 93 Mental Health in Acute Care: Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 1st EG meeting Write the protocol Design the questionnaires Advertise the study Advertise for Advisors Create the database Test data collection methods 2nd EG meeting Final protocol to SG, IAG, ROCR & HRA Start data collection Run Advisor meetings Data analysis Presentation to EG and Adv. Presentation to SG CORP IAG Write the report First draft to reviewers Second draft to reviewers Report design and print Embargo copies sent Publish the report

94. Improving the quality of medical and surgical care 94 NCEPOD Checklists

95. Improving the quality of medical and surgical care 95 Purpose To allow Trusts/hospitals to benchmark themselves against NCEPOD report recommendations

96. Improving the quality of medical and surgical care 96 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

97. Improving the quality of medical and surgical care 97 Audit Tool

98. Improving the quality of medical and surgical care 98 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

99. Improving the quality of medical and surgical care 99 Format Audit pack Introduction and method Overall quality of care Key findings and recommendations Data collection tool Data comparison tool

100. Improving the quality of medical and surgical care 100 Data collection tool

101. Improving the quality of medical and surgical care 101 Data comparison tool

102. Improving the quality of medical and surgical care 102 Audit tools

103. Improving the quality of medical and surgical care 103 Audit tools

104. Improving the quality of medical and surgical care 104 Audit tools

105. Improving the quality of medical and surgical care 105 Audit tool On website Rolled out for each new study and being back dated for previous studies Feedback appreciated

106. Improving the quality of medical and surgical care The Surgical Outcome Risk Tool (SORT)

107. Improving the quality of medical and surgical care 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

108. Improving the quality of medical and surgical care The Surgical Outcome Risk Tool (SORT) 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

109. Improving the quality of medical and surgical care The Surgical Outcome Risk Tool (SORT)

110. Improving the quality of medical and surgical care The Surgical Outcome Risk Tool (SORT) 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.uk www.sortsurgery.com

111. Improving the quality of medical and surgical care 111 Thank you Have we missed anything??