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
Confidential Case Note Review
Surveillance
Linkage of Administrative Data
Use of Primary Care Data
Themed reviews using serious morbidity and
mortality data
Patient Stories
A. Child Health Programme
Part 1: Institute of Child Health, UCL
• A national, retrospective, epidemiological overview of deaths in children aged 118, 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
Birth
Preterm
Birth
asphyxia
Injury – cause
undetermined
Aspiration
pneumonia
Cerebral
palsy
Head 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.
• 59% avoidable factors in 2002
• Case reviews of children and young people with epilepsy who die or
suffer severe morbidity.
• The review will extend across the entire care pathway
including primary and emergency care.
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 , including thematic review
of cases where women and their babies survive serious illness.
• Topic based maternal and perinatal reports
 Maternal Sepsis
 Congenital Diaphragmatic Hernia
Maternal Mortality Pulmonary
Embolism UK 1985-2008
3.5
Rate per 100,000 maternities
3
2.5
2
1.5
1
0.5
0
1985-87
1988-90
1991-93
1994-96
1997-99
Year
2000-02
2003-05
2006-08
B. Maternal, Newborn and Infant Programme
….more to be done
• (2009) 4,100 stillbirths /11 per day, one of the
highest rates across all high income
countries.
• If you add newborn deaths to the above
figure this rate increases to 17 per day
• Up to 100 women die annually during or just
after pregnancy.
C. Medical and Surgical Programme
Study aim
To describe variability and identify remediable factors
in the process of care of adult patients who receive
resuscitation in an in-hospital setting (526 cases)
Appreciation of situation
• Almost 1 in 5 cases were not appreciated
• A safety concern
– An obstacle to rapid intervention / escalation
• A function of seniority?
Appreciation of situation
Escalation
• 1 in 5
• Delays and safety concerns
Impact of consultant review
• Changes in 6/10 cases
CPR status
• CPR status recorded in 44 patients only (10%)
• Remember population
– Age, comorbidity, functional status, acute disease
Case study
Recommendations
• Improved recognition and escalation
• Consultant review within 12 hours
• CPR status must be considered and recorded for all
acute admissions.
– Decisions not to resuscitate should not affect the provision of
active treatment
– The use of ‘ceilings of care’ documentation would facilitate decision making
and clarity of intent. There is need for a national project to lead this work.
C. NCEPOD Projects coming up
 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.
 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.
 Tracheostomy related complications during and following
critical care.
 Remedial factors in the processes of care
of patients who die following lower limb amputation.
D. Mental Health Programme
The Centre for Mental
Health and Risk
In-patient suicides (England)
In-patient suicide
Hanging/strangulation on the ward
Projected
250
214
191
200
188
196
183
179
Frequency
165
162
155
150
138
118
94
100
91
75
54
43
50
51
41
40
46
36
34
28
30
19
15
22
18
0
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Year
Source: National Confidential Inquiry into Suicide and Homicide by People with
Mental Illness
2009
The Centre for Mental
Health and Risk
Key service recommendations
•Removal of ligature points
•Assertive outreach
•24-hour crisis team
•7-day follow-up
•Multi-disciplinary review
•Training in suicide risk management
Safety First, 2001
12 Steps to a Safer Service
The Centre for Mental
Health and Risk
Do safety measures reduce suicide
rates?
Recommendation
Target group
Ligature points
In-patients
24%
Assertive outreach
‘Non-compliant’
community patients
32%
‘Missed appointment’
community patients
11%
24-hour crisis team
In-patients
29%
7-day follow-up
Patients within 3
months of discharge
21%
‘Non-compliant’
community patients
25%
Assertive outreach
Non-compliance
policy
Source: National Confidential Inquiry, Lancet, 2012
% fall in suicide
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
E. National Review of Asthma Deaths
• To improve the understanding of why
people die from asthma in order that
deaths can be prevented in the future
• Numbers less than anticipated.
• 102 cases have gone to panel.
• Family interviews
• Reports April 2014
F. Child Head Injury Project
•
•
•
Traumatic head injury is amongst the most common cause of
morbidity, mortality, disability and lost years of productive life in
children.
In 2009 CMACE collected data on approximately 6000 children who
attended hospital with head injury
Analysis by Cardiff aims to provide;
 A description of the mechanism of head injury to identify measures for
prevention
 Analysis of pre hospital care data
 An assessment of clinical decision making on the selection of head-injured
infants for CT scanning and compliance with NICE guidance on the early
management of head injury in infants and children.
 Head injury outcomes according to service provision, times to transfer and units
involved.
 A review of data relating to children who have suffered abusive head trauma.
Moving on......
• Translating recommendations into
improved outcomes.
• Vignettes of ‘what good looks like’.
• Electronic notification portals/Direct
data entry systems
• Audit tool kits/self assessment
(NCEPOD/NCISH)
• Linking to improvement programmes
Getting Involved
•
•
•
•
Use NCEPOD/NCISH audit toolkits
Nominate a topic
Local co ordinators/Ambassators
Quality Accounts
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