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Quality and Safety – The UK Landscape

Quality and Safety – The UK Landscape. John Heyworth. Vox Pop. All patients All ages All illness All injury All hours. Missed diagnoses iceberg tip Myocardial infarction Pulmonary embolus Ischemic bowel in the elderly Subarachnoid haemorrhage Meningitis in children.

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Quality and Safety – The UK Landscape

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  1. Quality and Safety – The UK Landscape John Heyworth

  2. Vox Pop

  3. All patients • All ages • All illness • All injury • All hours

  4. Missed diagnoses iceberg tip • Myocardial infarction • Pulmonary embolus • Ischemic bowel in the elderly • Subarachnoid haemorrhage • Meningitis in children

  5. Forbidden diagnoses in Southampton ED • New onset migraine • Anxiety • Hyperventilation • Indigestion • Constipation

  6. Previously in ER……the legendary 4 hour target • Good idea • Became dysfunctional at 98% • Evidence lite • Unreliable measure of quality and safety • Some good points • Some bad points • Target culture/industry

  7. QIs • Much needed • Measures of time, quality and safety • Outcomes vs process measures • Drive continuous improvement in emergency care • Position emergency care at the top of the commissioning agenda

  8. Current Iteration • DH plus clinical expert groups plus lay group • Intuitively good – limited evidence • Challenging • Not immediately achievable • Open to variable interpretation • Not 5 x 4 hour target

  9. Ambulatory Emergency Care • % of ED attendances with exemplar conditions • Cellulitis 60-90% suitable • DVT >90% • System wide • ED-CDU-community • Tariff

  10. Unplanned Re-attendance • Useful surrogate of quality • Within 7 days of original attendance • Not 0% • Probably <5% • <1% risk averse approach • >5% intervention trigger • Review by different/senior clinician • Vulnerable adults – mental health

  11. Total Time in the ED • Not (quite) the 4 hour standard • Adverse outcomes if > 4-6 hrs • Intervention trigger

  12. NB • “Single longest wait should be no more than 6 hours” • Mental health • ICU/HDU

  13. Left without being seen • Before being seen by a clinical decision maker • Multifactorial • Proxy of patient satisfaction • <5% • >5% intervention trigger

  14. Service Experience • Patients • Carers • Staff • Mid Staffs • Quarterly feedback • How to measure? • CEM Lay Group

  15. Time to Initial Assessment • Meaningful • Not “hello” nurse • Vital signs • Pain score • 95th centile >15 mins intervention trigger

  16. Time to Treatment • Time to see decision making clinician • Audit for exemplars e.g. pain relief, antibiotics in sepsis, CT for stroke • Within 60 mins • Less than 30 mins for time critical presentations • Median >60 mins intervention trigger • Move towards more senior EM service

  17. Consultant Sign Off • Shift towards senior delivered service • Adults with non traumatic chest pain • Febrile children <1 yr • Unscheduled returns within 72 hrs of discharge • Prior to discharge • Headache, abdominal pain etc. asap • Review in person • Drive for consultant expansion

  18. Audits • IT • Data quality

  19. Complementary set – not single targets • Local audits • Continuous improvement • Arbitrary standards dilutes pursuit of perfection • Data must be supported by knowledge and understanding of the underlying processes Cooke M

  20. System Wide Indicators

  21. Bar is set high • Indicators • NOT targets • NOT standards • Ergo levers • NOT sticks • But must have teeth to drive change • Edentulous QIs impotent www.collemergencymed.ac.uk

  22. How to Make a Difference? • Unanimous support for principles • Indicators vs Targets • Accreditation • Commissioning • Financial penalties • Prioritise Emergency Care

  23. Implementation • Performance management evolution • Bench mark • Incentivise • “Unsafe”

  24. Simple is good • Understand • Measure • Interpret results • Improve

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