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High SMR- What Happens Next?

High SMR- What Happens Next?. Brian Cook. Critical Care Outcomes in 2007- Scottish Unit SMR’s. High SMR- SICSAG Definition. > 2SD difference from Scottish SMR Unit lower 95% CI > Scottish upper 95% CI Consistent definition in all SICSAG reports

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High SMR- What Happens Next?

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  1. High SMR- What Happens Next? Brian Cook

  2. Critical Care Outcomes in 2007- Scottish Unit SMR’s

  3. High SMR- SICSAG Definition • > 2SD difference from Scottish SMR • Unit lower 95% CI > Scottish upper 95% CI • Consistent definition in all SICSAG reports • ICNARC > 3SD difference in 4 consecutive quarters • > 2SD “may be” different • > 3SD “is” different

  4. High SMR- SICSAG Definition > 2SD “may be” different > 3SD “is” different

  5. High SMR- Communication from SICSAG • As soon as known- unit audit lead letter • 1 week later- MD and Chief Exec letter • 2008 completed 9th May • 10 days before publication full SICSAG report to: Unit leads, Hospital, Health Board Chief Execs, MD’s, CMO. • Friday before publication- Statistical Publication Notice placed on ISD website • Publication- Tuesday paper and web (29/7/08)

  6. Responses to High SMR?

  7. Responses to High SMR- Unit and Hospital • Data?? • Are we different? • Case mix • How have we performed over the years? • Care might be sub-standard? • Internal review • Critical Care +/- Other Specialties • Other Audits and Governance Evidence • External Review

  8. Data?? • SICSAG will reanalyse data • But we need focused questions! • Data Quality? • APACHE II, Diagnoses • Case note review v WardWatcher • Data Completion? • APACHE II NB GCS accurate and complete

  9. Data?? • Random case-note sample • 58% APACHE II score wrong • 47% underscored • Data completion • 93 missing GCS or presedation GCS • 67 filled in for re-analysis • SMR decreased 1.18 to 1.04 • Lower 95% CI overlaps Scottish upper

  10. How have we performed over the years?

  11. Internal Review • Involve other specialties? • Any particular patient group look a problem? • Consultant from another local ICU? • Governance structures • M+M reports? • Incident reports? • Risk Register? • Quality Improvement Programmes?

  12. Internal Review • Case Note Review • Target low mortality prediction deaths • 35 neuro patients who died with MP <25% • ICU • Referring specialty- useful perspective and advice

  13. External Audits • SASM • ACON’s? • 11 reported • 2 ACON’s graded “there were areas of concern that may have contributed to this patient’s death” • Both referred to incidents during transfer to WGH

  14. External Review • Who? ICS • Service • Facilities • Staff • Procedures and Guidelines • Referral and Admission Population and Policies • Referring Specialties • Management • Case Note Review

  15. Afterwards OR

  16. Afterwards • Positive Experience? • Report • Division Governance Committee • Medical Directors • Chief Executives • Press Office • Action Plan • Data quality is an issue

  17. How can we prevent data causing problems? • Local data quality assurance • Clerical support for data entry • Clinical staff interest and involvement • Don’t assume it is just happening • SICSAG • Quality Assurance Manager- Moranne • Data validation • Monthly feedback • An early warning system?

  18. CUSUM Track Charts

  19. CUSUM Track Charts- Early Warning?

  20. CUSUM Track Charts- Early Warning?

  21. High SMR Summary • SICSAG will warn you as early as possible • SICSAG will help where possible • Explain why you are different • Others may be interested • You may gain from the experience • DATA!!

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