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. The
purpose 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 items included:
 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
Publication date
Paediatric Intensive Care Units Audit Network (PicaNET) - (UK Wide Audit)
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.
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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.
More Information
Title
Publication date
Background
Welsh Participation
Key Findings
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%).
Link to full report here
Heavy Menstrual Bleeding Audit (Wales & England Audit)
18 September 2013
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.
Information in the report is provided on a combined basis and there is no specific
information on Welsh services.
Over 80% of women reported receiving at least one treatment in the year following
their first outpatient 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
Publication date
Background
Hip Fracture Database Audit (Wales, England and N. Ireland Audit)
18 September 2013
Hip fracture is the commonest reason for a frail older person to need an anaesthetic
and operation.
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%
Key Findings
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%)
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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
Publication date
Background
National Joints Registry Annual Report (Wales, England and N. Ireland Audit)
25 September 2013
Based on information collected in 2012, in 413 orthopaedic units across Wales, England
& N. Ireland.
100% participation by NHS Wales (all 18 units providing data)
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)
Welsh Participation
Key Findings
More Information
Title
Publication date
Background
Welsh Participation
Key Findings
Llandough Hospital - hip revision rate outlier
Withybush General - knee revision rate outlier
Link to full report here
Myocardial Ischaemia National Audit Project (MINAP) (Wales, England & N. Ireland
Audit)
16 October 2014
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.
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.
72% of eligible Welsh patients received PCI - improvement from 50% in previous
round, but only 8% 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 patients received 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 nSTEMI patients 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 nSTEMI patients referred or received an angiography (audit average
approx. 73%)
81% of Welsh patients received all eligible medication (audit average approx. 90%), but
there was significant variation by hospital
More Information
Link to full report here
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Title
Publication date
Background
Welsh Participation
Key Findings
Carotid Endarterectomy (Wales & England Audit)
23 October 2013
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.
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).
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
Publication date
Background
Pain Database (Wales and England Audit)
29 October 2013
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.
Little specific Welsh information, but the report confirms wide variation in availability
of services.
Link to full report here
Key Findings
More Information
Title
Publication date
Background
Welsh Participation
Key Findings
More Information
Heart Failure (Wales & England Audit)
21 November 2013
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.
Significant improvement in Welsh participation in this round of the audit (11% to 47%),
but still some way behind the audit average of 62%.
There is still considerable variation between LHBs e.g. ABMU 12.05% - Cardiff & Vale
80.4%.
Link to full report here
Title
Publication date
Background
Diabetes Care Processes (Wales & England audit)
30 October 2013
The National Diabetes Audit 2011-2012 covers data recorded by 88 per cent of GP
practices across England and Wales
Welsh Participation
Key Findings
Around 80% participation in Wales
The key findings show;
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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
More Information
Title
Publication date
Background
Key Findings
More Information
Title
Publication date
Background
Key Findings
Younger patients were less likely than older patients to receive all of the annual checks.
Link to full report here
National Vascular Registry (UK Report)
27 November 2013
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.
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.
Link to full report here
Psychological Therapies (Wales & England Audit)
28 November 2013
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.
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
Publication date
Background
Patient Suicide Review (England & Wales)
28 November 2013
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
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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
Publication date
Background
Lung Cancer Audit (England & Wales)
04 December 2013
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.
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.
Link to full report here
Key Findings
More Information
Title
Publication date
Background
Key Findings
More Information
Diabetes Adult Audit (Complications & Mortality) (England & Wales)
12 December 2013
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.
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.
Link to full report here
Title
Publication date
Background
Percutaneous Coronary Interventional Audit (UK Audit)
30 January 2014
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.
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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)
More Information
Title
Publication date
Background
Key Findings
More Information
Title
Publication date
Background
Key Findings
Risk adjusted analysis of mortality shows all Units performing well
Link to full report here
Sentinel Stroke National Audit Programme (SSNAP) Quarterly Report (Wales &
England Audit)
24 February 2014
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.
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,
Link to full report here
Paediatric Diabetes NCA Report (England & Wales Audit)
24 February 2014
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%).
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.
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More Information
Link to full report here
Title
Publication date
Background
Fall & Fragility Audit (Anaesthesia Sprint Audit of Practise) (England & Wales)
31 March 2014
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.
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.
Key Findings
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
Child Epilepsy Care Review - 23 September 2013 (UK report)
The report studied data from a total of 162 children with epilepsies aged one to 17 years
inclusive from across the UK and included 61 in-depth case reviews of mortality. The report
highlights substantial improvements in epilepsy care, but identifies the need for better
communications between health professionals, an epilepsy “passport” for children and
better adherence to NICE guidance.
Link to full report here
Subarachnoid Haemorrhage Review - 22 November 2013 (UK report)
The report confirms:
 Delays in assessment, diagnosis, referral, transfer and treatment of patients, which
was more marked if the patient was admitted over the weekend.
 In primary care, aSAH diagnosis was overlooked in almost half of patients.
 18% (62/344) of patients did not have a neurological examination in
secondary/acute care.
 Around one in three hospitals had no protocol for investigation and treatment of
acute onset headache.
 Treatment delays were more frequent following admission at the weekend and
interventional radiologists were available seven-days-a-week in less than half of
neurological centres.
 Only 39% of hospitals offered neuropsychological support for patients following a
procedure.
 Care was considered good in only 58% of the cases examined
Link to full report here
Advisory Committee News
In the last meeting of the Advisory Committee it was agreed Chairs of LHB / Trust Clinical
Audit or Quality Improvement Committee’s will be invited to give a presentation to future
meetings of the Advisory Committee confirming how information from clinical audit is used
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to change services and improve patient care. A letter from the Advisory Committee Chair
will be circulated to LHBs and Trusts shortly.
HQIP’s New Chief Executive confirmed
Jane Ingham was confirmed as the new substantive CEO of HQIP as of 1 December 2013.
Jane has been acting as the part time CEO at HQIP since April 2013 and has already attended
meeting of the Advisory Committee as a member. Jane was part of the original team which
helped establish HQIP in 2008 and has broad experience working in healthcare and quality
improvement.
Diabetes Audit – GP Practice Report
The Diabetes primary care audit will shortly be making available individual reports which GP
practices will be able to access with benchmarked information on how they are delivering
services. Further information on this process will be provided in future e-Bulletins.
My Local Health Service
Information from nine National clinical audits is now available on the website and can be
accessed via the attached link: http://mylocalhealthservice.wales.gov.uk/#/en
Further information about the Clinical Outcome Review Programmes is available here.
Contact Us
If you have any questions about any of the above or have suggestions for future additions of
this E-Bulletin please contact;
Shaun Chainey - shaun.chainey@wales.gsi.go.uk or
Geraint Jones - geraint.jones4@wales.gsi.gov.uk.
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