Promoting quality for better health services

Clinical Outcome Review Programmes

An overview

Jenny Mooney; Business Manager HQIP

Current Suppliers

A. Child Health Programme ~ CHR-UK, Child Health Reviews-UK, Royal College

of Paediatrics and Child Health

B. Maternal, Newborn and Infant Programme ~ MBRRACE-UK, National

Perinatal Epidemiology Unit, University of Oxford.

C. Medical & Surgical Programme ~ NCEPOD (National Confidential Enquiry for

Patient Outcome & Death)

D. Mental Health Programme ~ NCISH, (National Confidential Inquiry into Suicide

and Homicide by Patients with Mental Illness) University of Manchester

E. *National Review of Asthma Deaths~ NRAD ~ Royal College of Physicians

F. *Child Head Injury Project ~ University of Cardiff

Clinical Outcome Review Programmes

Surveillance

Linkage of Administrative Data

Use of Primary Care Data

Themed reviews using serious morbidity and mortality data

Confidential Case Note Review

Patient Stories

A. Child Health Programme

Part 1: Institute of Child Health, UCL

• A national, retrospective, epidemiological overview of deaths in children aged 1-

18, using existing data sets.

• Linking ONS death certification data with HES admission data.

• Trends in what children die with (not die of)

• Are there important groups in contact with healthcare in whom

anticipatory/preventive management might reduce risk of death?

Child death

Aspiration

pneumonia

Birth

Preterm

Birth

asphyxia

Head injuryInjury – cause

undetermined

Cerebral

palsy

Early messages

• Injuries remain most common cause of death in 1-18

year age group (no decline in intentional injuries)

• 74% of children who die have presented with a

chronic condition up to a year before death – around

50% have multiple chronic conditions

• Among chronic conditions, neurodevelopmental

problems are the most common

Trends in injury mortality by type of injury

A. Child Health Programme

Part 2: RCPCH

• Around 1 in 200 children in the UK has a form of epilepsy.

• 40 to 80 children a year die as a result.

• Case reviews of children and young people with epilepsy who die or

suffer severe morbidity. (Children receiving intensive or high

dependency care for prolonged seizures)

• To identify and learn from clinical, organisational, management or

personal issues that may have contributed to adverse outcomes

• Looking at the entire care pathway, from initial diagnosis through to the

reported adverse incident

• Mixed methods approach

• Questionnaire based clinical and epidemiological data

• Explicit ‘criterion-based’ assessment

• In-depth ‘holistic’ review

Preliminary Findings

•High levels of comorbidity (complex

disability)

•Deaths are predominately from

conditions related to the epilepsy

•Subgroup of children with early onset,

difficult to control epilepsy

B. Maternal, Newborn and Infant

Programme

• Surveillance of all maternal deaths and deaths of babies from

24 weeks to 1 Year (28 days currently)

• Case review of all maternal deaths

• Thematic review of cases serious maternal morbidity and

perinatal mortality and morbidity.

– Congenital diaphragmatic hernia in 2013

– Unexpected antepartum stillbirth in 2014

– Sepsis in 2013 (Welsh 1000 Lives/Transforming Maternity Services

Programme)

– Women with artificial heart valves and peripartum psychosis in 2014 &

2015

Maternal, Newborn and Infant Clinical Outcome Review Programme

Led by a collaboration from Universities of Oxford, Leicester, Liverpool & Birmingham, UCL & Imperial

The Stillbirth and Neonatal Deaths Charity - Sands

Stillbirths and infant deaths UK-wide figures 2011

• 807,776 total births Wales: 35,598

• 4,201 stillbirths Wales: 167

• 3,373 infant deaths Wales: 130

– 2,382 neonatal deaths Wales: 98

– 991 post-neonatal deaths Wales: 32

Stillbirth and infant programme of work• Surveillance of late fetal losses, stillbirths, neonatal and post-neonatal

deaths

• Confidential enquiries of a rolling programme of infant mortality and serious infant morbidity –

– Congenital diaphragmatic hernia in 2013

– Unexpected antepartum stillbirth in normally formed term infants in 2014

Maternal mortality UK-wide figures

• ~ 100 maternal deaths per year

Maternal programme of work• Surveillance and confidential enquiries of all maternal deaths (1 year

post-pregnancy completion)

• Confidential enquiries of a rolling programme of severe maternal morbidity

– Sepsis in 2013

– Women with artificial heart valves and peripartum psychosis in 2014 & 2015

• Produce annual reports – three year rolling average mortality rates reported each year with topic specific chapters so all causes covered in a 3yr cycle

Maternal mortality rate per million maternities 2000-

2008

Progress since June 2012:• Secure electronic web-based data entry system – for the late fetal losses,

stillbirths and infant mortality data– Developed a secure web-based data entry system – data collection via the internet

– Identified the information to be collected (reducing the items where possible)

– Selected a new mortality classification system

• Added value of electronic data capture– Ongoing assessment of data quality and completeness

– Unit based reports

– With access to appropriate denominator data – produce Unit-based risk adjusted mortality rates to reflect variations in outcomes and not simply case mix

– Identification of outliers; work with Units to resolve data errors before escalation

• Started the catch-up confidential enquiry work on maternal deaths from 2009 (n 450)

• Planning the confidential enquiry process

• Recruited assessors with the help of the Royal Colleges and Professional Associations

C. Medical and Surgical Programme

To review the provision of medical and

surgical care to patients in secondary

care through the use of confidential

enquiry/case note review methodology

across a range of clinical areas.

Recent reports

2012 2012 2011

C. NCEPOD Projects coming up

Remediable factors in the quality of care provided to patients treated for alcohol-

related liver disease and the degree to which its mortality is amenable to health

care intervention. (Friday 14th June launch)

To explore remediable factors in the process of care of patients admitted with the

diagnosis of subarachnoid haemorrhage, looking both at patients that

underwent an interventional procedure and those managed conservatively

Tracheostomy related complications during and following critical care.

Remedial factors in the processes of care of patients who die following lower

limb amputation.

Remediable factors in the process of in-patient hospital care for patients with

sepsis

Explore remediable factors in the processes of care of patients admitted to

hospital with lower gastrointestinal haemorrhage

Impact

• An Acute Problem– NICE Clinical Guideline 50 – recognition of the acutely ill patient

• Trauma: Who cares?– Appointment of a new National Clinical Director for Trauma care

• For better, for worse? (systemic cancer treatments)– DH put recs into a new policy to all hospitals in England

• A Sickle Crisis?– NICE guidelines developed in pain management for sickle patients

• Adding Insult to Injury (acute kidney injury)– NICE guidelines recently published

– Recognition of AKI implemented in medical training

D. Mental Health Programme

Mental Health Programme Remit

• Collection and analysis of surveillance data on suicides and homicides

by patients with a mental illness in contact with secondary care

services.

• Patient Suicides (England) 788 (M) & 399 (F) (2010)

• Patient Suicides (Wales) 57 (M) & 13 (F) (2010)

• Account for 27% of general population suicides and 10% of homicides

• In-patient suicides have shown a sustained fall across all countries

over the past 10 years.

• Deaths under crisis resolution/home treatment are now more frequent

than under in-patient care in England and Wales

D. Mental Health Programme: Topics

• Quality of risk assessment prior to fatal

outcome

• Models of Care Delivery

• A population based investigation of

suicide by patients in contact with

primary care

PATIENT SUICIDE IN DIFFERENT SETTINGS

0

50

100

150

200

250

300

350

400

1 2 3 4 5 6 7 8 9 10 11 12 13

Post discharge suicides

Weeks between discharge and suicide

Nu

mb

er

0

50

100

150

200

250

In-patient suicide

Hanging/strangulation on the ward

Crisis Resolution Home Treatment

Nu

mb

er

Recommendation Target group % fall in

suicide

Ligature points In-patients 24%

Assertive outreach ‘Non-compliant’

community

patients

32%

Assertive outreach ‘Missed

appointment’

community

patients

11%

24-hour crisis team In-patients 29%

7-day follow-up Patients within 3

months of

discharge

21%

Non-compliance

policy

‘Non-compliant’

community

patients

25%

DO SAFETY MEASURES REDUCE SUICIDE RATES?

Significant decrease in suicide

rates following implementation

Specific impactWhile et al., Lancet, 2012

Getting Involved

• Use NCEPOD/NCISH audit toolkits

• Nominate a topic

• Local coordinators/Ambassators

Contact us

Healthcare Quality Improvement Partnership

4 Bury Street

London

EC3A 5AW

www.hqip.org.uk

jenny.mooney@hqip.org.uk

Promoting quality improvement for better healthcare