Triage Serious Incidents Report The Serious Incident trend between 2014/15 and 2017/18 (up until end August 2017) shows a switch relating to incorrect triage from ambulance delay. The average number of incorrect triage Serious Incidents (SIs) between 2014/15 and 2016/17 stands at 8.3 cases per year. The trend in 2017/18 is currently 7 so has nearly breached the historic trend after only 5 months. When adding in the other triage related cases of inappropriate downgrade, incorrect triage/delay and delayed triage the total number of SIs reaches 10 which breaches the historical trend. During 2016/2017 the Trust reported a total of 9 serious incidents relating to triage, 2015/2016 was 9 and 2014/2015 shows 8. It is important to note that the historical trend for ambulance delays has however witnessed a significant decrease. The average number of ambulance delay SIs between 2014/15 and 2016/17 stands at 11.6 cases per year. The trend in 2017/18 currently stands at 4. This is due to the work we have done within the clincial hub to reduce risks to those experiencing delays
The triage related SIs reported in 2017/18 (up until end August 2017) do not show a clear trend in cause. The only discernible trend, 3 out of 10 cases, relates to cases whereby the initial disposition was a Green 2, whereby is should have been a Red 2. It can also be noted that other triage related cases fell within delayed triage, incorrect triage/delay and inappropriate downgrade. The overarching cause of these errors relates to human factors which is evidence towards the end of this report. It is also important to note that we have seen an overall 19% increase in calls handled on 111 and 999 between April and August 2017 against the same period in 2016 (534,331 against 448,255). The service involved in the cases fall into, 6 within 999, 3 within 111 and 1 within NDUC. Whilst it is recognised that breathing appears in a 3 of triage cases, it is important to note that each case followed a different pathway. As stated the overriding factor relates to human factors such as active listening skills and potential well-being bias. The individual cases do not show any trend for the individuals involved and does not show a wide spread issue.
2016/17 shows no clear trend at all. Each individual case was attributed to different pathways and errors.
2015/16 does not show a clear trend in cause. The only discernible trend relates to cases whereby scene safety issues occurred which created a delay in attending the patient. We addressed this by working collaboratively with our local police forces and introduced the Joint Operating Procedure.
2014/15 once again does not show any clear trend.
Triage Related Serious Incidents 2014/2015 The highest occurrence of triage related SIs has occurred in North Durham CCG area with 10 cases reported between 2014/15 and 2017/18. This is followed by Durham Dales, Easington & Sedgefield with 7 cases then Sunderland with 6 cases. The trend in North Durham and Sunderland
continues in 2017/18 with both showing 3 reported cases so far. Of the 3 cases reported in North Durham and Sunderland 2 in each relate to incorrect triage, 1 in North Durham relates to incorrect triage/delay and the other in Sunderland relates to inappropriate downgrade.
Drilling further into the CCG area and call handling area, it is clear that the majority of cases are generated within the 999 system. North Durham CCG has the most attributed to 999 triage whilst Sunderland CCG falls within 111 triage. The spread of cases within Sunderland CCG is however spread across all 3 areas
In relation to the specific time of day for triage related cases, the times which show a trend are 10:00hrs, 12:00hrs, 18:00hrs, 21:00hrs, 23:00hrs. Of these times the only clear trend in 2017/18 shows 21:00hrs with two cases occurring at this time. This is different to previous years as can be noted in the graph below. Because of the small numbers reported it is felt this is not significant in cause.
In relation to the day of the week when triage related SIs occur, historically, Saturday s show the highest trend which has increased during 2017/18 with double the amount of cases occurring on this day against the historical trend. This is also related to the increase in cases occurring on a Sunday which has noted a significant change. Tuesday, Wednesday, Thursday and Friday clearly show historical occurrence but no clear high trends.
Detailed Analysis of Triage Related Cases 111 Calls Answered Looking at call activity on a weekend against week days, the following averages apply for calls answered within the 111 Service during August 2017; Monday = 1944, Tuesday = 1737, Wednesday = 1708, Thursday = 1722, Friday = 1867, Saturday = 3444 and Sunday = 2932. In addition to the details above, Monday 28 th August was a Bank Holiday and recorded 3676 answered calls. It is clear to see that call activity significantly increases on a weekend and indeed Public Holidays. It is therefore expected that the likelihood of error increases due to the increase in activity. It is important to note that staffing levels are flexed to meet the increased activity therefore mitigating any increased risk. The increase in call activity between the average of the weekdays (excluding Bank Holiday) and weekends shows a 73.73% increase in calls answered during August 2017.
999 Calls Answered Looking at call activity on a weekend against week days, the following averages apply for calls answered within the 999 Service during August 2017; Monday = 1341, Tuesday = 1290, Wednesday = 1195, Thursday = 1235, Friday = 1362, Saturday = 1301 and Sunday = 1321. In addition to the details above, Monday 28 th August was a Bank Holiday and recorded 1111 answered calls. It is clear to see that call activity slightly increases on a weekend and indeed Public Holidays. It is therefore expected that the likelihood of error increases due to the increase in activity. It is important to note that staffing levels are flexed to meet the increased activity therefore mitigating any increased risk. The increase in call activity between the average of the weekdays (excluding Bank Holiday) and weekends shows a 5.98% increase in calls answered during August 2017.
Further detailed analysis of the triage related cases was conducted by the EOC Management team. In relation to the actual sites where the calls were handled, 6 of the call handlers involved are based in Hebburn and 12 in Newburn which is expected due to the fact Newburn is the main site. Of the staff involved, 10 are full time and 8 are part time (and with a range of shifts within that). 3 call handlers work an individual rota (for work / life balance) and that 5 work on the Flextra Plus full time rota In relation to the actual shifts when the cases occurred, 1 x first shift, 1 x only shift, 2 x second shift of two, 3 x second shift of four, 1 x second shift of three, 3 x third shift of three, 2 x third shift of four, 1 x fourth shift of four. (In summary, only 4 call handlers made their mistake in the last shift of that rota pattern). It was also noted that none of the staff had worked excessive overtime with no negative impact of overtime reported. So therefore not a contributory factor. It was noted that 2 of the incidents occurred over a Bank Holiday In the cases were Call Handlers did not seek a Clinician advice, all staff were asked why advice was not sort. None stated it was due to lack of Clinician availability. All said that they didn t refer to a clinician because they believed they had conducted a safe triage only one felt that they should have gone with instinct as they felt that the outcome was too low). And to make sure that we identified whether call handlers were just not saying that they felt they couldn t approach a clinician or that they had given up trying, we checked clinical support on each of the dates in question and there was no pattern. This would suggest that the call handlers don t have an issue asking for help they felt they didn t need to. Whilst we didn t achieve service level on all of the dates (particularly after 1 st April on 111), due to the significant service changes across the region, none of the call handlers said they felt pressured and this resulted in their mistake. Due to the low number of Serious Incidents against overall call activity, we cannot find any underlying issues which have caused the errors. It is too early in the financial year to draw a clear conclusion as the trend may revert during winter pressures which historically shows ambulance delays above triage issues. Whilst it is acknowledged that the Trust has witnessed a shift in the cause of serious incidents during 2017/2018, the analysis does not show a clear trend. A more detailed piece of work is planned with North of England Commissioning Support Unit (NECSU) whereby analysis will triangulate various data sets i.e. activity, sickness absence, staffing levels against plan etc.