The paper provides an update for the Trust Board on hospital mortality and presents the updated Trust Mortality Action Plan.

Transcription

1 ENC No 13 Meeting Trust Board Date 28 th November 2013 Title of Paper Lead Director Author Hospital Mortality Update Mr Amir Khan, Medical Director Mr Amir Khan, Medical Director PURPOSE OF THE PAPER The paper provides an update for the Trust Board on hospital mortality and presents the updated Trust Mortality Action Plan. SUMMARY OF THE KEY POINTS Improving hospital mortality is one of the Trust s key priorities as set out in the Quality & Safety Strategy. The Trust s latest available Standardised Hospital Mortality Index (SHMI) Apr 2012 March 2013 is This is marked as band 2 which is defined as expected this value represents a continued improvement. The Hospital Standardised Mortality Rate (HSMR) for the previous 12 months (September 12 August 2013) is This reflects a mortality rate below the national average. HSMR for the financial year to date (April August) 2013 is A phase 2 mortality reduction plan is in operation which includes surveillance, early warning in respect to mortality and overall quality alongside a programme of further improvement. This report provides surveillance information across Quality and Mortality indicators and highlights areas for attention RECOMMENDATIONS 1. NOTE the Trust s current hospital mortality rate & associated commentary For One and All Page 1 of 9

2 LINKS Strategic Objectives Safe, High Quality Care (Patient Promise: In Safe Hands) Annual objectives To reduce hospital mortality rates Monitor / CQC / Regulatory Requirements IMPACT Mortality rates are reviewed by both CQC and Monitor Patient Experience Quality & Safety Hospital mortality rate is a key measure of quality and safety of care Financial Resources have been invested in additional consultant and palliative care support Workforce A medical workforce review has been undertaken as part of this plan Equality & Diversity Estates IM&T Communications / Engagement RISKS Effective communication will be key to the success of the plan Failure to deliver continued improvements in hospital mortality risks damaging the reputation of the Trust with its stakeholders Failure to deliver improvements may present a risk to the continued progress of the Trust s Foundation Trust application PREVIOUS CONSIDERATION Mortality Review Group Quality & Safety Committee, 21 st November 2013 For One and All Page 2 of 9

3 MONTHLY MORTALITY REPORT November DEATHS (ALL) There were 89 deaths in October 2013 compared to 70 in September (70 October 2012) There were no deaths recorded for patients admitted for an elective procedure in October The table below provides mortality data from April 2012 to August 2013 in respect to deaths by month & HSMR 2013/ /13 HSMR 2013/14 Deaths in Hospital Crude Mortality HSMR 2012/13 Deaths in Hospital Crude Mortality Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total YTD YTD 608 YTD 1.62 YTD YTD Hospital Standardised Mortality Rate (HSMR) HSMR for August is whilst HSMR mortality for April August is The HED system shows a HSMR of 90. A predicted Year to date rebase suggests a HSMR of Standardised Hospital Mortality Index (SHMI) HED calculated SHMI for the period Q1 April to July 2013 is showing a continued trend of reduction National SHMI release for the period Apr 2012 March 2013 was released on 20 th October This shows a SHMI rate of banded as as expected This represents continued improvement. For One and All Page 3 of 9

4 Chart A. HSMR Acute Trust Comparator April 2013 to August 2013 Chart B. HSMR in a rebased position Sept 2012 Aug 2013 Chart C. HED HSMR April 2013 August 2013 rebased Chart D. SHMI Rating by Month Aug 2012 July 2013 For One and All Page 4 of 9

5 4. HSMR Diagnoses Tracking HSMR is comprised of mortality data from 56 Diagnosis which represent 80% of all hospital deaths within England. HSMR is shown below for the highest volume diagnosis groups. The 56 diagnosis groups continue to show a sustained picture of HSMR below expected levels however there is a need to investigate areas marked in the above table based on recent trends. This is in addition to the reviews relating to Respiratory failure, Fractured Femur & Myocardial Infarction due to be presented to the Mortality Meeting. For One and All Page 5 of 9

6 5. HSMR by Day of Admission Weekday Admission HSMR April 2013 August 2013 The table below reflects HSMR for each day of the week since April ALL Monday Tuesday Wednesday Thursday Friday Saturday Sunday Apr May Jun Jul Aug For August, the data appears to demonstrate the previously identified spike for Monday admissions has been rested but at there is a substantial increase in the number of mortalities for patients admitted on Saturdays. 6. Palliative Care Tracking Palliative care coding within the HSMR diagnosis group April July 2013 equals 2.8% against a national average of 2.7%. The table below reflects palliative care coding both within the HSMR analysis and all diagnosis groups. Month Spells HSMR Spells All ALL Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug ALERTS. No alerts have been received. 8.REVIEWS Reviews undertaken by Dr T Constable Mr T Muscroft in respect to deaths in September were presented to the mortality meeting a summary is contained within the meeting minutes Data & commentary contained within this report will be presented to the Mortality Review Group 6th September 2013 and confirmed by the Medical Director: Signed: Amir Khan Medical Director Date: 08 / November / 2013 For One and All Page 6 of 9

7 Myocardial Infarction Review 10 patients reviewed regarding the recent increase in respiratory failure mortality Issues highlighted: Coding of MI when none actually found. This relates to absence of KMR and treatment for AMI documented in notes which is then coded as per guidance. Use of a KMR will allow consultant sign off for primary diagnosis. Late presentation of AMI. Late presentations of MI does not have a code and wont then feature in what is increased mortality risk UNLESS cardiogenic shock is documented. Alert to GP s, Cardiac rehab Service & Public health should be considered re late presentation in chest pain The short LOS of the patients is notable need to be sure all comorbidities and primary diagnosis are clearly documented ( KMR) Age DOA DOD Primary Diag Case Summary Delay or failure in care Outcome Classification Comment 96 11/07/12 17/07/12 AKI Care Home Resident, GP Referral Hb7 Renal Failure, CXR Globular Heart IHD CCDF CKD FRAIL Likely AKI GI BLEED secondary to medication Unlikely AMI Coding review needed 63 29/04/13 30/04/13 Cardiogenic Shock Bradycardia Hypotensive and coma Received balloon pump and pacing 3 vessel disease Transferred to NX for PCI did not recover cerebral event Admitted in extremis appropriate care given 86 17/04/13 20/04/13 Sepsis Known severe lung disease SOB Unlikely MI For One and All Page 7 of 9

8 83 08/06/13 08/06/13 Acute Heart Failure 91 06/12/12 07/12/12 Multi organ failure Lung sepsis source likely Admitted abdo pain CXR poor LV with oedema Cardiogenic Shock Cheyne stokes respirations LVSD CPR in ITU ECG shows late presentation of MI resulting in poor LV DNAR in place 79 27/05/13 09/06/13 Inf MI Late Presentation Inf MI Late Presentation LVSD LRTI 81 08/04/13 09/04/13 VT AMI Collapse, VT Acute MI Diabetes 85 20/03/13 24/03/13 Cardiogenic Shock Found on floor CV Decompensation No clear AMI 55 05/01/13 05/01/13 VF Arrest CPR 45minuites Intubated, Inotrope support 89 13/06/13 22/06/13 AMI Collapse found by carer, CT Head NAD Chest pain as IP Decision to treat medically not PTCA VF as consequence of AMI No Comments added For One and All Page 8 of 9

9 Respiratory Failure Review 6 Patients in low risk groups assessed Clearly all with significant comorbidity & unwell on admission. No delay or failure in care noted Non-invasive ventilation used within HDU. NOTE: this is not routinely available in AMU Age DOA DOD Primary Diag 61 06/10/13 07/10/13 Respiratory failure Case Summary History of obstructive sleep apnea, Home CPAP & Parkinson s disease IT review and decision taken not for ventilation. LCP Used 34 04/4/13 06/04/13 Sepsis Known ALD & Substance Late presentation in sepsis probably due to pneumonia Multi organ failure. ARDS Did not respond to escalation in treatment and decision taken to withdraw 65 15/04/13 24/04/13 Sepsis Pt transferred from Stafford A&E History of COPD IHD Found to be septic Unresponsive with possible cardiac event pre-hospital, ischaemic liver. +ve Pneumococcal urine sample Respiratory & Neurological function did not improve despite treatment Treatment withdrawn to symptomatic support 65 03/01/13 07/01/13 MI Admitted in respiratory arrest Ventilated History of Dementia Found to have lung ca Did not respond to treatment 73 07/06/13 09/06/13 COPD Exacerbatio n Admitted with Fast AF, COPD exacerbation Type II Respiratory failure History of pulmonary fibrosis Bronchiectasis, Stroke Non Invasive Ventilation given No response to treatment 62 01/05/13/ 12/05/13 CCF History of renal impairment, CCF, Diabetes type II Respiratory Failure Received NIV in HDU Did not respond and worsening CCF Delay or Outcome failure in care Class For One and All Page 9 of 9