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Promoting quality for better health services
Clinical Outcome Review Programmes
An overview
Jenny Mooney; Business Manager HQIP
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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
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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
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Patient Stories
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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
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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
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Trends in injury mortality by type of injury
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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
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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
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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
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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
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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
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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
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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
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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.
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Recent reports
2012 2012 2011
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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
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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
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D. Mental Health Programme
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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
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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
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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
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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
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Getting Involved
• Use NCEPOD/NCISH audit toolkits
• Nominate a topic
• Local coordinators/Ambassators
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Contact us
Healthcare Quality Improvement Partnership
4 Bury Street
London
EC3A 5AW
www.hqip.org.uk
Promoting quality improvement for better healthcare