National Clinical Audit and Outcome Review E-Bulletin
E-bulletin: May 2014
The National Clinical Audit and Outcome Review E-bulletin is published on behalf of the Welsh Government National Clinical Audit and Outcome Review Advisory Committee. Thepurpose of these E-bulletins is to highlight report findings and to provide information on the latest developments and plans for clinical audit and outcome reviews.
E-Governance Manual
NCA&OR information on the E-Governance Manual website has been updated. Information currently available includes:
- NCA&OR Advisory Committee
- Agenda & Notes from Committee meetings
- Copies of NCA&OR E-Bulletins
- Copy of current NCA&OR Annual Plan
- Links to information available on the HQIP website
- Library of published reports
- Timetable for the publication of future NCA reports
- Advice and guidance for Boards
A link to the website is provided here.
National Clinical Audit & Outcomes Review Advisory Committee
In the last meeting on the 28 March 2014,agenda itemsincluded:
- Draft Annual Plan for consideration and agreement
- Update on HQIP developments and future plans
- Discussion on the Advisory Committee’s role and membership
- Clinical audit / Review links to the NHS Wales Delivery Framework
The next meeting of the Committee is scheduled to take place on Friday 13 June 2014.
NCA&OR Annual Workshop
We were originally expecting to hold this year’s annual Workshop in North Wales in June, but due to circumstances beyond our control this hasn’t been possible and the next Workshop will probably be in Cardiff in the Autumn. This years Workshop is likely to focus on “Linking Audit and Review with Continuous Quality Improvement” and the date and venue for the event will be confirmed as soon as possible.
Recent Publications
Brief outlines of the findings from National Audit and Outcome Review reports published since September 2013 are provided below;
Title / Paediatric Intensive Care Units Audit Network (PicaNET) - (UK Wide Audit)Publication date / 15 September 2013
Background / PICANet is an international audit of paediatric intensive care which collects data on all children admitted to paediatric intensive care units (PICUs) in the UK and Ireland. It is coordinated by the Universities of Leeds and Leicester.
Welsh Participation / Cardiff and Vale is the only participating health board. Admission numbers increased from 261 in 2011 to 315 in 2012, while staffing levels dropped from 50 to 44.
Key Findings / Admission numbers have increased by nearly 5% between 2011 and 2012.
It is extremely rare for a child to die in paediatric intensive care and over 96% of children were discharged alive in 2010-2012.
Crude mortality was at an all-time low of 3.8% in 2012.
Almost all units (90%) achieved the medical consultant staffing levels recommended (one consultant per 8 to 10 beds available at all times) during daytime hours. Night cover was somewhat lower with only 60% achieving the recommended levels of cover as is weekend cover (33%).
More Information / Link to full report here
Title / Heavy Menstrual Bleeding Audit (Wales & England Audit)
Publication date / 18 September 2013
Background / Established in February 2010, the National HMB Audit’s overall aims are to describe the care received by those women with HMB who were referred to NHS outpatient gynaecology clinics in England and Wales and to assess their patient outcomes and experience of care.
Welsh Participation / Information in the report is provided on a combined basis and there is no specific information on Welsh services.
Key Findings / Over 80% of women reported receiving at least one treatment in the year following their firstoutpatient visit, with 37.3% of women having surgical treatment as their last likely treatment received. Women who stated they had received surgical treatment were more likely to be older, of white ethnicity, have a longer duration of symptoms reported at baseline, three or more reported GP visits and to have felt they were in severe or very severe pain at baseline. At follow-up, these women were more likely to report their overall health as good or better, with mild to no pain and one or no new symptoms.
More Information / Link to full report here
Title / Hip Fracture Database Audit (Wales, England and N. Ireland Audit)
Publication date / 18 September 2013
Background / Hip fracture is the commonest reason for a frail older person to need an anaesthetic and operation.
Key Findings / Six NHS trusts investigated as outliers for 30 day mortality (none in Wales).
50.2% of all reported patients admitted to an Orthopaedic ward within 4 hours (52% in 2012). In Wales the average is 35.0%
78.8% of all reported Welsh 85.8% of all reported patients received surgery within 48 hours (audit average 85.8%)
2.4% of Welsh patients reported as having developed pressure ulcers (audit average 3.5%)
26.9% of 52.9% all reported Welsh patients were assessed pre-operatively by an Orthogeriatrician (audit average 52.9%).
74.8% of Welsh patients 83.8% are discharged on bone protection medication (unchanged from 2012) (audit average 83.8%)
74.1% of Welsh patients 94.5% received a falls assessment prior to discharge (audit average 94.5%)
The mean (SD) total length of stay (acute + post acute days) was 20.0 (17.8) days overall. In Wales the mean was 33.2 (30.6) days
More Information / Link to full report here
Title / National Joints Registry Annual Report(Wales, England and N. Ireland Audit)
Publication date / 25 September 2013
Background / Based on information collected in 2012, in 413 orthopaedic units across Wales, England & N. Ireland.
Welsh Participation / 100% participation by NHS Wales (all 18 units providing data)
Key Findings / Welsh services are generally comparable, but there are some variances across services;
Nevill Hall Hospital - Outlier with regard to hip revision rates
Ysbyty Ystrad Fawr - Identified as an outlier for consent rates - Less than 80% of patients have given consent for their data to be used (only 4 procedures in 2012)
Llandough Hospital - hip revision rate outlier
Withybush General - knee revision rate outlier
More Information / Link to full report here
Title / Myocardial Ischaemia National Audit Project (MINAP) (Wales, England & N. Ireland Audit)
Publication date / 16 October 2014
Background / MINAP was established in 1999, in response to the national service framework (NSF) for coronary heart disease, to examine the quality of management of heart attacks (myocardial infarction) in hospitals in England and Wales.
Welsh Participation / 3,680 patients in Wales reported as having a heart attack - 73% were first heart attack patients and 42% were STEMI (both figures higher than audit average). The report also confirms a larger proportion of patients in Wales presenting with their first heart attack had a prior diagnosis of hypertension, as was the proportion being prescribed lipid lowering therapy.
Key Findings / 72% ofeligible Welsh patientsreceivedPCI -improvement from50% in previous round,but only8%in North Wales(audit average approx. 97%)
85% of Welsh patients received PCI within 90mins of arrival in hospital(audit average approx. 92%)
70% of Welsh patients received PCI within 150mins of calling for help (audit average approx. 82%)
48% of Welsh patientsreceived PCI within the more stringent 120mins "Call to balloon time"(audit average approx. 60%)
80% of patients in Wales and England were admitted directly to a Heart Attack Centre (77% in Belfast)
61% of Welsh nSTEMIpatients were admitted to a cardiac ward or unit (audit average approx. 52%)
83% of Welsh nSTEMI patients were seen by a cardiologist of member of the team (audit average approx. 94%)
80% of Welsh nSTEMIpatients referred or received an angiography (audit average approx. 73%)
81% of Welsh patients received all eligible medication (audit average approx. 90%), but there wassignificant variation by hospital
More Information / Link to full report here
Title / Carotid Endarterectomy (Wales & England Audit)
Publication date / 23 October 2013
Background / Relatively little change in comparison with previous rounds of the audit which is disappointing as the Welsh Government wrote to the service in July 2011 calling for an improvement in performance and better participation in the audit. Cardiff and Vale UHB submitted only six cases into Round 4 of the audit and none in Round 5.
Welsh Participation / The National median length of time between symptom and surgery continues to fall and is 13 days in this round of the report. There is considerable variation between services however, and two Welsh HBs appear to significantly exceed this figure (Aneurin Bevan 20 days and Betsi Cadwaladr 32 days).
Key Findings / In comparison with the rest of the UK, average Welsh case ascertainment is still poor at 69%.
39% of Welsh patients received surgery within 7 days of referral. This varied between 16% (8 patients) in Aneurin Bevan and 53% (48 patients) in ABM.
44% of Welsh patients received surgery within 14 days of symptoms (45% in Round 4). This varied significantly between LHB’s (19% in Betsi Cadwaladr - 55% in ABM).
More Information / Link to full report here
Title / Pain Database (Wales and England Audit)
Publication date / 29 October 2013
Background / The National Pain Audit was set up in response to findings from successive reports that specialist pain services
were struggling to keep up with demand. There was clear variation in provision of service, a lack of visibility and
no agreed standards of care.
Key Findings / Little specific Welsh information, but the report confirms wide variation in availability of services.
More Information / Link to full report here
Title / Heart Failure (Wales & England Audit)
Publication date / 21 November 2013
Background / The sixth annual report for the National Heart Failure Audit presents findings and recommendations based on patients discharged with a diagnosis of heart failure between 1 April 2012 and 31 March 2013. The report covers all NHS Trusts in England and Health Boards in Wales which admit patients with acute heart failure.
Welsh Participation / Significant improvement in Welsh participation in this round of the audit (11% to 47%), but still some way behind the audit average of 62%.
Key Findings / There is still considerable variation between LHBs e.g. ABMU 12.05% - Cardiff & Vale 80.4%.
More Information / Link to full report here
Title / Diabetes Care Processes (Wales & England audit)
Publication date / 30 October 2013
Background / The National Diabetes Audit 2011-2012 covers data recorded by 88 per cent of GP practices across England and Wales
Welsh Participation / Around 80% participation in Wales
Key Findings / The key findings show;
Over half of patients diagnosed with Type 1 diabetes did not receive all diabetes checks and over a third of Type 2 diabetes patients did not receive all checks
Younger patients were less likely than older patients to receive all of the annual checks.
More Information / Link to full report here
Title / National Vascular Registry (UK Report)
Publication date / 27 November 2013
Background / As part of the NHS Commissioning Board’s publication “Everyone Counts: Planning for Patients 2013/14”, ten national clinical audits were asked to report on surgical outcomes by consultant surgeons by the summer of 2013. In this report, we describe postoperative outcomes for elective repair of infra-renal abdominal aortic aneurysms and carotid endarterectomy.
Key Findings / The report confirms in-hospital mortality rate over the last three years have fallen from 2.4% in the first report to 1.8%. It also confirms no surgical units are considered to be mortality outliers and that any apparent variation in mortality rates is a statistical anomaly.
More Information / Link to full report here
Title / Psychological Therapies (Wales & England Audit)
Publication date / 28 November 2013
Background / This national audit is currently the only means of measuring and comparing the wide range of services providing psychological therapies for adults with anxiety and depression in England and Wales. In total, the national audit has collected over 8,000 questionnaires from therapists, 25,000 questionnaires from service users and extracted data from over 170,000 anonymised individual case records.
Key Findings / The reports key findings include:
Older people are less likely to receive psychological therapy than younger people.
The waiting time standard, both from referral to assessment and from referral to treatment, was met for 85% of patients for whom data were returned. However, there is considerable variation between services.
Ninety percent of patients who returned a questionnaire reported a positive therapeutic alliance with their therapist.
Seventy percent of patients who had high intensity therapy did not receive the minimum number of treatment sessions that NICE recommends.
More Information / Link to full report here
Title / Patient Suicide Review (England & Wales)
Publication date / 28 November 2013
Background / Previous reports have shown that around 1,585 mental health patients die by suicide in the UK each year. However, there is little evidence for how services reduce suicide. However, this study shows a link between changes to mental health care in England and Wales between 1997 and 2006, and a reduction in patient suicide rates.
Key Findings / To improve safety, services should;
Provide specialist community services such as crisis resolution / home treatment, assertive outreach and services for patients with dual diagnosis
Implement NICE guidance on depression
Share information with criminal justice agencies
Ensure physical safety and reduce absconding on in-patient wards
Create a learning culture based on multi-disciplinary review
Trusts that implemented more than 10 recommendations from previous reports or service change had lower suicide rates than those that implemented 10 or fewer.
More Information / Link to full report here
Title / Lung Cancer Audit (England & Wales)
Publication date / 04 December 2013
Background / The purpose of this document, the ninth Annual Report of the National Lung Cancer Audit, is to summarise the
key findings of the audit for patients diagnosed with lung cancer who were first seen in 2012.
Key Findings / Just over half (51.9 per cent) of the 40,200 lung cancer patients in England and
Wales covered by the National Lung Cancer Audit were confirmed as having
“non small cell lung cancer”, for which surgery offers the best chance of a cure when caught early enough8. Among these patients, 22 per cent had surgery as part of their treatment, compared to 14 per cent in 2008. Historically, the low number of patients undergoing surgery relative to other Western European healthcare systems has been considered as part of the explanation for poorer survival of lung cancer patients in the UK. The report also confirms survival variations of between 179 and 280 days between Networks.
More Information / Link to full report here
Title / Diabetes Adult Audit (Complications & Mortality) (England & Wales)
Publication date / 12 December 2013
Background / The National Diabetes Audit (NDA) now includes nearly 2.5 million people with diabetes, from 88 per cent of
GP practices in England and Wales. The NDA is considered to be the largest annual clinical audit in the world. It provides an infrastructure for the collation, analysis, benchmarking and feedback of local clinical data to support effective clinical audit across the NHS.
Key Findings / Welsh statistics in the report generally indicate services achieving slightly better outcomes than the average. The report calls for a renewed focus on reducing the adverse outcomes of vascular disease in people with diabetes and makes four recommendations for improvement.
More Information / Link to full report here
Title / Percutaneous Coronary Interventional Audit (UK Audit)
Publication date / 30 January 2014
Background / Coronary heart disease (CHD) is the largest cause of death and disability in the United Kingdom. CHD causes around 94,000 deaths in the UK each year and around one in five men and one in seven women will die from the disease.
Key Findings / Reports on the care provided to patients in 2012. The report confirms;
Good participation in the audit by all Welsh Units
Welsh PCI rates remain the lowest in the UK, but Wales achieved the largest improvement in the UK (over 70%). N. Ireland continues to perform the highest number of operations per head of population.
24/7 services available in around 55% of UK centres (no Welsh breakdown).
Centres dealing with 400+ operations a year show better outcomes, but 22% of centres doing less.
65% of procedures across the audit undertaken via the radial artery which has 50% less complication (no Welsh breakdown)
Risk adjusted analysis of mortality shows all Units performing well
More Information / Link to full report here
Title / Sentinel Stroke National Audit Programme (SSNAP) Quarterly Report (Wales & England Audit)
Publication date / 24 February 2014
Background / SSNAP measures the entire patient care pathway, from admission to hospital through to six months post-stroke. Hospitals are compared against evidence based standards and the national average. The audit began in January 2013, but NHS Wales only joined mid-year and this quarterly report covering the period July – Sept 2013 contain only limited Welsh data.
Key Findings / The audit has set extremely high standards (the highest in the world) with the aim of stimulating hospitals to identify where improvements are needed and drive change. No hospital in England or Wales has achieved the top overall performance level this quarter.
The main Welsh issues highlighted in the report are;
Low standard levels of participation and case ascertainment
Timely scanning
Specialist bed access
Access to the early assessments,
More Information / Link to full report here
Title / Paediatric Diabetes NCA Report (England & Wales Audit)
Publication date / 24 February 2014
Background / Based on data collected in 2011-12. As with previous reports, NHS Wales participation in the audit was excellent at 100%. Small improvement in the percentage of children and young people recorded as receiving all of the NICE recommended care processes – from 5.8% to 6.7%. This falls well short of the figure achieved in the Adult Diabetes Audit (over 60%).
Key Findings / There has also been a small improvement in the percentage of children and young people with diabetes achieving a well managed HbA1c <58 mmol/mol (7.5%). However, this still leaves well over 50% with HbA1c levels above 7.5% and, more than 25% with unacceptable levels above HbA1c of >80 mmol/mol (9.5%).
Some of the key findings identified in the report are;
Admissions with Diabetic Ketoacidosis (DKA) remain high but there is some evidence that this may have declined slightly in some age groups and particularly in girls.
There were 2,694 children and young people reported to the NPDA who were diagnosed with diabetes in 2011-12; of these 15.7% (427) had DKA at diagnosis.
Nearly 1 in 10 admissions to hospital of children and young people with diabetes is as a result of a hypoglycaemic episode.
Over half of all hospital admissions in children and young people with diabetes are coded 'without complications' so the cause of admissions is unknown.
More Information / Link to full report here
Title / Fall & Fragility Audit (Anaesthesia Sprint Audit of Practise) (England & Wales)
Publication date / 31 March 2014
Background / The aim of this Anaesthetic Sprint Audit of Practice (ASAP) was to profile individual hospitals’ compliance with standards for peri-operative care described in the Association of Anaesthetists of Great Britain and Ireland (AAGBI) guideline The Management of Proximal Femoral Fracture.
Key Findings / Where the seniority of both the surgeon and the anaesthetist present in theatre was recorded, it is encouraging to find that in over 90% of cases both were consultants or specialists, and that in only 0.4% of cases were both unsupervised trainees.
Pain relieving nerve blocks were administered to 56% of patients.
Some units administered spinal anaesthesia in over 80% of cases, while others used this approach in less than 10%.
More Information / Link to full report here
Outcome Review (Confidential Enquiry) Reports