Annexure 7
Title
Author
Date of meeting
Action Required
Critical Care Performance Report
Network Manager
1 st July 2008
To receive the Critical Care Minimum Data Set reports
To receive Care Bundle compliance
To consider key issues in Critical Care performance
Purpose
The role of a Network is described as “to support and advise its stakeholders on the implementation of the national quality requirements, to monitor service performance and use this information to inform the commissioning process”.
The purpose of this report is to provide the Network Board with performance reports from the Critical Care Minimum Data (CCMDS) set information whilst a comprehensive Network Performance Monitoring Framework is under development.
CCMDS - Summary of main issues
CCCMDS was mandated in Wales from April 2007. The Welsh CCMDS adopted the majority of the English CCMDS data fields and definitions in order to use the CCMDS to benchmark Critical care activity information across England and Wales.
A number of standard CCMDS reports have been developed and published through
Health Solutions Wales. A final mechanism and process for reporting CCMDS information has yet to be finalised by the Welsh Assembly Government with HSW and in the interim CCMDS reports are available via Networks.
The Network Manager provides the Critical Care Units with monthly CCMDS reports and which have been discussed at the Service Improvement Group and within the
Task & Finish group to review CCMDS compliance.
The report attached as Appendix A provides CCMDS information for January,
February and March 2008, a summary of the Quarter and an annual summary for the period April 2007 to March 2008. Four worksheets provide information on:-

Activity

Admissions & discharges

Transfers

Bed utilisation
Key issues to highlight within the CCMDS reports are:-
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1. Data Quality

CCMDS is reported on completed episodes therefore long stay patients will only be identified within the reports when discharged.

Royal Glamorgan hospital identified duplicate reporting in the early months as
CCMDS were completed when patients transferred between levels of care. 1
CCMDS record should be completed for a complete episode of care and identify movements between levels of care during the episode.

Llandough Hospital are not completing all CCMDS information

Royal Glamorgan Hospital have identified a coding error affecting Tertiary transfers which was resolved in February 2008

Prince Charles Hospital – not recording Lower Level of care days
2. Activity report

UHW Average Length of stay for full year 134.2 hrs

Prince Charles Hospital average length of stay for full year 127.4 hrs

Royal Glamorgan 466 of 661 episodes which were less than 1 day admission
(full year)
3. Admissions & Discharges

Royal Glamorgan planned admissions 39.8% (full year) (263 of 661)

Nevill Hall planned admissions 14.9% (full year) (81 of 542)

UHW Delayed Discharges 23.7% (full year) (332 of 1398(

Royal Gwent Hospital Delayed Discharges 28.5% (full year) (290 of 1017)

Nevill Hall Hospital – early discharges 7.6% (41 of 542)

Royal Glamorgan – early discharges 6.7% (44 of 661)
4. Transfers

Royal Glamorgan 17.2% Tertiary transfers (114 of 661) – coding error
5. Bed Utilisation
April 2007 – March 2008
Hospital
Llandough
UHW
Nevill Hall
Level 2 Days
1492
2104
846
Level 3 Days
1260
6592
1499
Lower level days
18
305
62
Royal Gwent
Prince Charles
2688
494
1623
1160
42
1
Royal Glamorgan 438 360 1447
Implementation of Ward Watcher will assist critical care units in improving their
CCMDS information reporting.
The Network has identified areas for local training to improve compliance with the data definitions.
The Network Manager is meeting with Audit clerks to discuss what guidance would assist them and the development of “Frequently Asked Questions”
Care Bundle Compliance
The report attached at Appendix B provides a 12 month summary of the Critical Care bundle compliance data. Critical Care Units record this information into a database
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established & supported by NLIAH as part of the Welsh Critical Care Improvement
Programme.

Gaps in completion are due to recent problems with the IT system to enable
Trusts to access the database

Bundle compliance is measured daily but frequency of reporting is at the Trust discretion

The Network will need to work with NLIAH to sustain care bundle reporting within critical care as this forms part of the Key Quality Indicators agreed by the All Wales Critical Care Advisory group
Recommendation
The Network Board is recommended to:-

Note the issues raised regarding CCMDS data quality

Note that Ward Watcher will assist compliance and completion of CCMDS reporting

Note the key performance issues identified within the CCMDS reports

Note that a sustainable solution to the reporting of care bundles needs to be developed
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