National Audit of Dementia Round 4 (2018) Sampling guidance for the Casenote Audit

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1 National Audit of Dementia Round 4 (2018) Sampling guidance for the Casenote Audit March 2018 HQIP 2018

2 Timeline for data collection The data collection period will be staggered as shown below. This is the sampling guidance for the casenote audit. The guidance for individual questions in the casenote audit will follow when the casenote audit has been finalised. Organisational checklist Casenote audit Carer questionnaire Staff questionnaire March Guidance issued April opens 16 April Guidance issued May opens 21 May (collecting data for discharges from April 2018) Guidance issued Guidance issued June Deadline:15 June opens 4 June opens 4 June July August September Deadline: 21 September closes: 21 September closes: 21 September October 2

3 Contacting the Project Team For any queries, please contact the project team: Website: Or you may contact the team individually: Chloë Hood, Programme Manager Chloë Snowdon, Deputy PM Samantha Ofili, Project Worker Lori Bourke, Project Worker Emily Rayfield, Project Administrator Please note that when contacting the project team about your casenotes, do not at any time include any identifiable data about patients (for example: name, NHS number, address). 3

4 Before you begin: Please make sure you TEST the online data collection link before data collection opens: This brings up Formic Web Forms. Click the Login button in the top left of the page to get to the login page. You will then need to enter the unique username and password for your hospital. These will be sent via post to your nominated audit lead. If you cannot access the Formic Web Forms page, this is probably due to your local IT settings and you will need to contact your IT department to ask them to approve the link. Anyone entering data for the organisational checklist or casenote audit, as well as all staff accessing the staff questionnaire online will need access to this website, so please do arrange for this as soon as possible. IDENTIFY the key people you are going to work with. This is a complex audit which should not be carried out by a single lead. The guidance for each tool gives some suggestions of colleagues who could help you to collect and co-ordinate the return of the different types of data required. Let us know if we can help. We are available to answer queries within office hours, or you can us, and we will respond as soon as we can. We look forward to working with you. 4

5 Completing the casenote audit Each hospital site is expected to submit an audit of casenotes of patients discharged with dementia, identified through ICD10 coding (listed at APPENDIX B). One form is to be submitted online per set of notes audited. opens 21 st May with a deadline of 21 st September Each hospital will be asked for: 1) The total number of eligible patients discharged from the hospital in April Please note this is a separate form to the casenote audit form and is a mandatory part of the audit. 2) An audit return of eligible casenotes, for which the minimum sample will be 50, and the maximum 100 patients. This will give larger hospitals the opportunity to return a larger sample. If your hospital cannot identify 50 patients discharged in April, you may continue to identify patients discharged in May. Input will be required from: Your local audit lead; The lead for dementia or a senior clinician working in this area; Staff who normally undertake casenote audit, i.e. audit department or information services staff, junior doctors, dementia champions or nursing staff. Data can be submitted online by persons other than the auditors. Estimated time to complete: We predict that 2-3 hours will be required to identify the sample and each casenote will take between 15 minutes and 50 minutes to submit, with the first couple of sets taking the longest to do, according to feedback from hospitals. Organising your sample 1) The casenotes identified should be from a single hospital site - and not trust wide. The number generated should be completed admissions, and not consultant episodes, as there will be many of these per patient. 5

6 2) A list of ICD10 codes used to generate HES data is provided (Appendix B). These codes indicate a diagnosis of dementia. They may appear in primary coding but are more likely to be a secondary or subsidiary code. Dementia may also appear in current history. All casenotes with any of the codings provided are eligible and should be used to generate a list. Patients should: Have been discharged between 1 April 30 April 2018 (you may continue into May if fewer than 50 patients were discharged in April); Have a diagnosis of dementia; Have been admitted to hospital for 72 or more hours; And, where the patient has had more than one admission, please include only the first admission for this patient in your patient list. 3) Submit the total number of patients identified via the short online form Total N patients identified for casenote audit. You will be asked to enter the total number identified from April (and May if enough casenotes could not be identified from April alone). This data should be submitted online from 21 May onwards. Please note this is compulsory. 4) Organise your list so that the patients identified are listed in date order that they were discharged from the hospital. 5) Allocate each casenote a number, from 1 to the total number of casenotes identified. This is the number you will use when entering number for patient on the data collection form. Please note: This is not the hospital patient number or NHS number. Please do not enter this information anywhere on the data collection form. 6) Online entry for each set of notes must be completed and submitted separately. 7) If, after patient number allocation, a set of notes is found to be ineligible for this audit (e.g. it is later understood that length of stay was less than 72 hours), exclude this set of notes from data entry. You should then go on to the next set of notes in the sequence, but do not reallocate the number. E.g. if number 2 is ineligible, go on to enter data for number 3 (so your inputted casenote patient numbers will follow as 1, 3, 4 and so on). 8) Continue to skip excluded records and move on to the next consecutively discharged and numbered patients in the series until you have reached your return total of ) Identify casenotes for the inter-rater reliability check (see Appendix A). 10) Please keep a copy of your list of audited patients. You will need this if your hospital is selected for quality assurance so that you can identify the notes again. 6

7 Appendix A Inter-rater reliability check As part of the reporting process for this audit, we are asking sites to collect inter-rater data to establish reliability. The process requires two different people to extract and enter the data from the first five casenotes in order of discharge date onto the data collection forms. The process for identifying casenotes for audit is described earlier in this document. Inter-rater reliability check Identifying the cases to be double audited: Follow instructions in Organising your sample and select the first five casenotes eligible to be entered into the data collection system (first five discharges). These casenotes will be re-audited. Extracting the data: Identify two separate people ( first and repeat auditor) who will extract information from the casenotes and enter data via the online casenote audit data submission form. First auditor on their data collection form: - Ticks Yes to Has this casenote been selected as data reliability check? - For the first case, enter 1 in the box which says, Enter number for this patient - Collect all the information for this patient - Do not involve the repeat auditor(s) - Repeat the process for patients 2, 3, 4 and 5. Repeat auditor on their data collection form: - Using the same five cases in the same order as the first auditor(s) - Ticks Yes to Has this casenote been selected as data reliability check? - Add Rel at the end of the number (so number 1 of the first auditor s casenotes, is numbered 1Rel by the repeat auditor) - Collect all the information for this patient - Do not involve the first auditor(s) - Repeat the process for patients 2, 3, 4 and 5, numbering them 2Rel, 3 Rel etc. N.B. If you have excluded any notes from your list due to wrong coding etc. so that (for example) your notes are numbers 1, 3, 4, 5, 6, then your second auditor notes should be numbered the same; 1Rel, 3Rel, 4Rel, 5Rel, 6Rel. 7

8 Appendix B List of Eligible ICD 10 codes A81.0 Creutzfeldt-Jakob disease Subacute spongiform encephalopathy F00* Dementia in Alzheimer's disease F00.0* Dementia in Alzheimer's disease with early onset Alzheimer's disease, type 2 Presenile dementia, Alzheimer's type Primary degenerative dementia of the Alzheimer's type, presenile onset F00.1* Dementia in Alzheimer's disease with late onset Alzheimer's disease, type 1 Primary degenerative dementia of the Alzheimer's type, senile onset Senile dementia, Alzheimer's type F00.2* Dementia in Alzheimer's disease, atypical or mixed type Atypical dementia, Alzheimer's type F00.9* F01 Dementia in Alzheimer's disease, unspecified Vascular dementia F01.0 Vascular dementia of acute onset F01.1 Multi-infarct dementia F01.2 Subcortical vascular dementia F01.3 Mixed cortical and subcortical vascular dementia F01.8 Other vascular dementia F01.9 Vascular dementia, unspecified F02* Dementia in other diseases classified elsewhere F02.0* F02.1* F02.2* F02.3* Dementia in Pick's disease Dementia in Creutzfeldt-Jakob disease Dementia in Huntington's disease Dementia in Parkinson's disease 8

9 Dementia in: paralysis agitans parkinsonism F02.4* F02.8* Dementia in human immunodeficiency virus [HIV] disease Dementia in other specified diseases classified elsewhere Dementia in: cerebral lipidosis epilepsy hepatolenticular degeneration hypercalcaemia hypothyroidism, acquired intoxications multiple sclerosis neurosyphilis niacin deficiency [pellagra] polyarteritis nodosa systemic lupus erythematosus trypanosomiasis vitamin B 12 deficiency F03 Unspecified dementia Presenile: dementia NOS psychosis NOS Primary degenerative dementia NOS Senile: dementia: NOS depressed or paranoid type psychosis NOS F04 Organic amnesic syndrome, not induced by alcohol and other psychoactive substances Korsakov's psychosis or syndrome, nonalcoholic F05.1 Delirium superimposed on dementia F07.2 Postconcussional syndrome Postcontusional syndrome (encephalopathy) Post-traumatic brain syndrome, nonpsychotic 9

10 F10.6 F11.6 F13.6 F14.6 F15.6 F16.6 F17.6 F18.6 F19.6 Amnestic disorder, alcohol- or drug-induced Korsakov's psychosis or syndrome, alcohol- or other psychoactive substance-induced or unspecified G30.0 Alzheimer's disease with early onset G30.1 Alzheimer's disease with late onset G30.8 Other Alzheimer's disease G30.9 Alzheimer's disease, unspecified G31.0 Circumscribed brain atrophy Pick's disease Progressive isolated aphasia G31.1 Senile degeneration of brain, not elsewhere classified G31.8 Other specified degenerative diseases of nervous system Grey-matter degeneration [Alpers] Lewy body(ies)(dementia)(disease) Subacute necrotizing encephalopathy [Leigh] I67.3 Progressive vascular leukoencephalopathy Binswanger's disease 10

11 National Audit of Dementia Royal College of Psychiatrists 21 Prescot Street London E1 8BB

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