Aim: To prospectively monitor performance in areas of high mortality or national clinical focus and employ evidence based clinical pathways and care bundles to enhance care. Targets in 9 key conditions, including sepsis 80% compliance with full pathway and Neck of Femur 80% compliance with full pathway.
Five years ago Blackpool Teaching Hospitals was one of a number of Hospitals highlighted as having ‘higher than expected’ standardised mortality rates as judged by the summary hospital-level mortality indicator (SHMI). The SHMI captures and compares the number of patients who die as an inpatient, or within 30 days of discharge from hospital, and is one statistical method of measuring if a hospital trust is seeing a ‘higher than’ or ‘lower than’ expected number of deaths. A ‘higher than expected’ mortality rate does not in itself tell us that a hospital is unsafe nor that deaths were avoidable. It does however signal to Trusts that they should investigate further to identify reasons and resolve any associated quality issues that may have contributed to this.
As a result of our SHMI, the trust was subject to a review led by Sir Bruce Keogh. The review advised us to focus on mission critical areas of work to ensure that improvements are implemented quickly and effectively. The trust also invited AQuA (Advancing Quality Alliance NW) to carry out a review of our services to identify how we may improve the quality of our care.
The Trust SHMI has improved from 123 in 2012 to 114 on latest national data (2017).
This improvement has come about after intensive work by clinicians and other staff. Among a number of initiatives, the Trust participated in ‘Sign Up To Safety’, a national campaign to improve patient safety across the NHS. One of the key elements of this work is to develop patient pathways and care bundles.
Over 3 years, this developed evidence based guidance in 9 key high mortality and morbidity conditions to act as a guide for best care and instituted an ongoing prospective audit process.
This allowed significant improvement in pathway delivery: examples include Pneumonia and COPD, with current figures showing over 80% of patients have the entire care bundle delivered.
Pathway development continues in all area, reflecting evolving national guidance and best practice, and responding to areas of mismatch between pathway compliance and outcomes for patients.
Case Study – Fractured Neck of Femur pathway
Early work focused on an area of difficulty (availability of orthogeriatric opinion) and allowed this need to be met, but overall compliance was still not at levels required. The pathway was realigned in 2017 to the national Best Practice tariff targets. This ongoing development of best practice acted as a focus for the pathway working group and with multiprofessional support, allowed change in service (offering 7 day operating on Neck of Femur), identification of key items to be completed to support wider rehabilitation early (mental state testing and orthogeriatrician involvement) and in the last 6 months has seen overall compliance climb from below 20% to above 80% (June-August 2017).
Case Study – Acute Kidney Injury Pathway
The pathway launch in 2015/16 has seen the trust SHMI drop from 122 (2015) to 107 (2016), but still identifying difficulty with outcomes for patients and areas of persistent pathway problems. This led to the launch of a quality improvement project in our Acute Medical Unit in 2017 that has developed a clearer pilot ‘SURVIVING AKI’ pathway. This work is ongoing and has allowed key areas for targeted improvement such as staff education. This has also allowed us to constantly realign with the moving national picture, with the national Renal Registry project developing and using different biochemical parameters for defining AKI. This has now been realigned and after work with colleagues in IT any patient whose blood results show evidence of AKI is immediately and automatically flagged on ward electronic boards. This means that the attending medical staff can act upon the concern in a more timely manner than previously.
Developments continue and in particular for the next 12 months, conditions such as stroke will have their pathways realigned and relaunched with associated quality improvement works. Additionally, pneumonia and COPD pathways will be realigned to allow other areas in the patient journey to be examined and further drive ongoing quality improvement. This will ensure the right evidence based care is always occurring through care bundles and pathways that always reflect the evolving best practice in the field.
We said we would measure the effectiveness of our actions by demonstrating:
Compliance with mission critical points for AKI pathway- these identify the standards of our care delivery (50% target). At the close of quarter 4 for in 2016/17 we achieved an average of 28.62% compliance
Compliance with mission critical points for AKI pathway- these identify the standards of our care delivery (40% target). At the close of quarter 4 for in 2016/17 we achieved an average of 11.98% compliance
A reduction in our mortality (SHMI) due to sepsis and AKI – Based on available information from Healthcare Evaluation Data (HED) up until the end of January 2016, the 12 month rolling SHMI for sepsis was 123.89 which is an improvement compared to the same data for the period ending January 2015 which was 126.28
For AKI this was 107.06 compared to the same data for the period ending January 2015 which was 113.43. This means both areas demonstrated an improvement.
Other improvements in 2016/17:
Introduction of electronic patient tracker in emergency admission wards – this allows staff easy identification of patients with sepsis or AKI that will require the key mission critical points of our clinical pathways to be implemented as a priority.
Review of Mission Critical points of the pathways – These are key areas where an intervention will have a positive affect on patient outcomes – we have reviewed them to make sure they are in line with best practise.
Fluid Balance Project – this is a project to improve fluid balance monitoring with a view to safely managing the care of patients with AKI
Sepsis trigger in A&E – we have introduced an identified nurse on each shift in the A&E department to initiate essential interventions on admission of the patient
Pathology blood analysis – we have introduced a blood test and flagging system to support staging of patients with AKI to allow facilitate an effective plan of care for our patient