SHFA280301

Information about SHFA280301

Published on November 28, 2007

Author: Mee12

Source: authorstream.com

Content

THE SCOTTISH HIP FRACTURE AUDIT: outcomes monitoring and feedback to improve care:  THE SCOTTISH HIP FRACTURE AUDIT: outcomes monitoring and feedback to improve care AUDIT and CHANGE:  AUDIT and CHANGE Audit is useful only if it effects change - and confirms that change is for the better. Beware St Augustine! “For so it is, O Lord my God, I measure it; But what it is I measure, I do not know.” Hip Fracture common:  Hip Fracture common increasing eg.Edinburgh: 1988 n = 580 1999 900 (+55%) approx. 6,000 annually in Scotland Scottish Hip Fracture Audit - future Hip Fracture common:  Hip Fracture common increasing elderly population overall population in Scotland set to fall (to less than 5 million by 2020), but elderly population will rise to peak in 2015 frail elderly population rising fastest Scottish Hip Fracture Audit - future Hip Fracture costly:  Hip Fracture costly 200,000 bed days, av. length of stay 32 days estimated £5,000 per patient (in 1995) hospital costs £30 million /year downstream costs comparable Scottish Hip Fracture Audit - future Scottish Hip Fracture Audit:  Scottish Hip Fracture Audit central funding for 4 units (1993-99) strong local demand /support from 1993-2000 18 out of possible 25 units are/ have been involved 3 stopped/stopping (no funding) 5 want to start (no funding) collects data on > 5,000 hip fractures /year >80% Scottish total follow up at 4 months 98% datasets >95% complete Scottish Hip Fracture Audit - future Average number of Hip Fracture Admissions annually per Hospital:  Average number of Hip Fracture Admissions annually per Hospital THE SCOTTISH HIP FRACTURE AUDIT: outcomes monitoring and feedback to improve care:  THE SCOTTISH HIP FRACTURE AUDIT: outcomes monitoring and feedback to improve care Slide11:  Hip Fracture: Survival for 30 days after admission Threshold of 200 admissions annually includes all adult Orthopaedic Trauma units in Scotland except Elgin and Western Isles Slide12:  Time to Death after Hip Fracture ABERDEEN 1984 - 1993 5,000 hip fractures 50% @ 50 days Lu-Yao GL, Keller RB, Littenberg B et al. (1994) J Bone Joint Surg 76A: 15-25 Outcomes after displaced fractures of the femoral neck. A meta-analysis of one hundred and six published reports:  30 day mortality rate 6 - 13% 1 year mortality rate 18 - 36% Lu-Yao GL, Keller RB, Littenberg B et al. (1994) J Bone Joint Surg 76A: 15-25 Outcomes after displaced fractures of the femoral neck. A meta-analysis of one hundred and six published reports Slide15:  Glasgow Western & Edinburgh & Dundee Slide16:  Glasgow & Aberdeen Royal Infirmaries Aberdeen Royal Infirmary (11/97 to 5/98; n = 335; mean age 80y):  Aberdeen Royal Infirmary (11/97 to 5/98; n = 335; mean age 80y) 30 day mortality * “non-home (institution) origin” includes all categories except “own home” and “other” Aberdeen Royal Infirmary (11/97 to 5/98; n = 335; mean age 80y):  Aberdeen Royal Infirmary (11/97 to 5/98; n = 335; mean age 80y) 30 day mortality * “non-home (institution) origin” includes all categories except “own home” and “other” Glasgow Royal Infirmary (11/97 to 5/98; n = 202; mean age 78y):  Glasgow Royal Infirmary (11/97 to 5/98; n = 202; mean age 78y) 30 day mortality * “non-home (institution) origin” includes all categories except “own home” and “other” Glasgow Royal Infirmary (11/97 to 5/98; n = 202; mean age 78y):  Glasgow Royal Infirmary (11/97 to 5/98; n = 202; mean age 78y) 30 day mortality * “non-home (institution) origin” includes all categories except “own home” and “other” Aberdeen Royal Infirmary:  Aberdeen Royal Infirmary Glasgow Royal Infirmary cf. Nov 1997 to May 1998 Aberdeen RI Glasgow RI patients admitted n = 335 202 mean age 80y 78y admitted from: home 166 (50%) 142 (70%) institutional care 168 (50%) 51 (25%) other 1 (0.3%) 9 (4%) 30 day mortality 46 (14%) 16 (8%) lost to follow up n = 6 17 4 month mortality 76 (23%) 37 (20%) Aberdeen Royal Infirmary:  Aberdeen Royal Infirmary Glasgow Royal Infirmary cf. Nov 1997 to May 1998 Aberdeen RI Glasgow RI patients admitted n = 335 202 mean age 80y 78y admitted from: home 166 (50%) 142 (70%) institutional care 168 (50%) 51 (25%) other 1 (0.3%) 9 (4%) 30 day mortality 46 (14%) 16 (8%) lost to follow up n = 6 17 4 month mortality 76 (23%) 37 (20%) Slide23:  Survival Graph - 120 days post hip fracture Aberdeen (n=329):  Aberdeen (n=329) Aberdeen Royal Infirmary:  Aberdeen Royal Infirmary Glasgow Royal Infirmary cf. ASA Grades for patients admitted with hip fracture (proxy measure of overall frailty) Aberdeen RI Glasgow RI ASA  2 27% 45% 3 52% 46%  4 21% 9% Statistical Analysis and Linkage of Audit Database:  Statistical Analysis and Linkage of Audit Database n = 12,046 hip fractures validation of CRAG Clinical Outcome Indicators facilitated by re-structuring and links with ISD Scottish Hip Fracture Audit - future Statistical Analysis and Linkage of Audit Database:  Statistical Analysis and Linkage of Audit Database CSO funded project n = 12,046 hip fractures preliminary (but complex!) analysis of case mix, process of care and outcome Scottish Hip Fracture Audit - future Hospital 2 (n=238):  Hospital 2 (n=238) Hospital 3 (n=252):  Hospital 3 (n=252) THE SCOTTISH HIP FRACTURE AUDIT: outcomes monitoring and feedback to improve care:  THE SCOTTISH HIP FRACTURE AUDIT: outcomes monitoring and feedback to improve care Slide35:  Mean time spent in A&E Slide36:  Mean hours to operation (excluding patients who were unfit for operation at time of admission to orthopaedic ward) Major differences noted in a clinically and politically important stage of care. Differences attributable largely to resource issues (hospitals 1 and 10 facing serious problems, hospitals 4 and 14 probably appropriately resourced). Slide37:  Percentage of operations performed by grades of operator by hospital Slide38:  Percentage of anaesthetics performed by grades of anaesthetist by hospital Slide39:  Proportion of different types of anaesthetic by hospital THE SCOTTISH HIP FRACTURE AUDIT: outcomes monitoring and feedback to improve care:  THE SCOTTISH HIP FRACTURE AUDIT: outcomes monitoring and feedback to improve care Statistical Analysis and Linkage of Audit Database:  Statistical Analysis and Linkage of Audit Database CSO funded project n = 12,046 hip fractures preliminary (but complex!) analysis of case mix, process of care and outcome Scottish Hip Fracture Audit - future Statistical Analysis and Linkage of Audit Database:  Statistical Analysis and Linkage of Audit Database Aims: to use this data to address in a preliminary way questions relating to case-mix, surgical care, service structure, effectiveness of care and aspects of hip fracture outcome to explore the potential for further, more detailed and more sophisticated research studies using the SHFA National Data Base, and to facilitate the use of the Scottish data in comparative international studies Scottish Hip Fracture Audit - future Females 65 : % residential origin within age group:  Females 65 : % residential origin within age group Scottish Hip Fracture Audit - statistical analysis of database Females  65 : mortality at 4 months by age group & walking aids:  Females  65 : mortality at 4 months by age group & walking aids Scottish Hip Fracture Audit - statistical analysis of database Females  65 : mortality at 4 months by walking aids & residential origin:  Females  65 : mortality at 4 months by walking aids & residential origin Scottish Hip Fracture Audit - statistical analysis of database Tree predicting death within 4 months (admitted from home only) using complete data set, females only, age >65y, ASA excluded :  Tree predicting death within 4 months (admitted from home only) using complete data set, females only, age >65y, ASA excluded Each node shows (deaths within 4m / number in category & %) 764/5354 = 14% age <90y 580/4648 = 12% 184/706 = 26% 0,1,2 aids frame, wheelchair, bedbound not wheelchair or bedbound wheelchair or bedbound 6/10 = 60% 178/696 = 26% 137/603 = 23% 443/4045 = 11% frame wheelchair or bedbound 106/451 = 20% 31/62 = 50% age >90y age <75y age >75y 9/23 = 39% 22/39 = 56% Tree predicting returned home by 30 days (admitted from home only) using SAHFE data set, females only, age >65y, ASA included :  Tree predicting returned home by 30 days (admitted from home only) using SAHFE data set, females only, age >65y, ASA included Each node shows (number home by 30 days / number in category & %) 655/1669 = 39% age <75y 217/327 = 66% 438/1342 = 33% 168/713 = 24% 270/629 = 43% age >75y no walking aids any walking aids ASA = 3,4,5 ASA = 1,2 97/297 = 33% 173/332 = 52% age 75-85y age >85y 47/117 = 40% 126/215 = 59% Re-operation for displaced intracapsular hip fractures (“The unsolved fracture” K Speed, 1935):  Re-operation for displaced intracapsular hip fractures (“The unsolved fracture” K Speed, 1935) Scottish Hip Fracture Audit - statistical analysis of database Re-operation for displaced intracapsular hip fractures (“The unsolved fracture” K Speed, 1935):  Re-operation for displaced intracapsular hip fractures (“The unsolved fracture” K Speed, 1935) Scottish Hip Fracture Audit - statistical analysis of database after internal fixation - 17% (n=44/254) after hemiarthroplasty - 5% (n=158/3119) [p<0.0001] Statistical Analysis and Linkage of Audit Database:  Statistical Analysis and Linkage of Audit Database casemix modelling associations with death within 4 months discharge home by 30 days institutional outcome influence of process factors, etc. outcomes serial data clinical change and service development Scottish Hip Fracture Audit - future Slide51:  These data reflect service structures (eg. pressure on acute beds, access to ESD, access to GORU, and other downstream beds). Serial analysis may pick up impact of ESD, eg. in Aberdeen. Mean length of stay in acute orthopaedic ward by hospital Slide52:  Deep wound infection rates !! Type of operation by hospital:  Type of operation by hospital Striking differences in conservative (no operation management) ranging from 1.6% to 12.5%. Rate of total hip replacement varies from 0% to 7.1%. THE SCOTTISH HIP FRACTURE AUDIT: outcomes monitoring and feedback to improve care:  THE SCOTTISH HIP FRACTURE AUDIT: outcomes monitoring and feedback to improve care AUDIT and CHANGE:  AUDIT and CHANGE local reports /action dissemination of local results and lessons annual HIPFEST: a showcase for ideas specialty meetings Comparative Report 2000 Annual Report 2001 Scottish Hip Fracture Audit - future Scottish Hip Fracture Audit:  Scottish Hip Fracture Audit although National Audit, very much a locally supported project local audit of local care by local clinicians generating credible local data local information and change very much with local funding changes effected eg. : Scottish Hip Fracture Audit - future Scottish Hip Fracture Audit:  Scottish Hip Fracture Audit Scottish Hip Fracture Audit:  Scottish Hip Fracture Audit Scottish Hip Fracture Audit:  Scottish Hip Fracture Audit Scottish Hip Fracture Audit:  Scottish Hip Fracture Audit SIGN Guideline on hip fracture care:  SIGN Guideline on hip fracture care SIGN Guideline 15 launched in 1997 - broadly acknowledged second edition due for publication 2001 informed by Audit data and analysis very close multidisciplinary links with Scottish Hip Fracture Audit Steering Group Scottish Hip Fracture Audit - future Integrated Care Pathways in hip fracture care:  Integrated Care Pathways in hip fracture care working well in acute care, but patchy developed in rehabilitation - keen interest Steering Group ICP sub-group potential for merging routine clinical service data and audit data collection potential for linking Guideline with Audit Scottish Hip Fracture Audit - future Slide63:  Hip Fracture: a tracer condition for Clinical Governance SIGN Guideline Scottish Hip Fracture Audit Integrated Care Pathway THE SCOTTISH HIP FRACTURE AUDIT: outcomes monitoring and feedback to improve care:  THE SCOTTISH HIP FRACTURE AUDIT: outcomes monitoring and feedback to improve care THE SCOTTISH HIP FRACTURE AUDIT: outcomes monitoring and feedback to improve care:  THE SCOTTISH HIP FRACTURE AUDIT: outcomes monitoring and feedback to improve care Scottish Hip Fracture Audit - the future:  Scottish Hip Fracture Audit - the future Audit and Guideline: working together to support Clinical Governance, clinical effectiveness and quality of care. Scottish Hip Fracture Audit:  on behalf of Scottish Hip Fracture Audit Steering Group Acknowledgements: Jenny Mountain (Audit Co-ordinator) and data collection staff Steve Kendrick, Jillian Campbell, Dave Clark, Ann Gould (Information & Statistics Division, NHSiS) and all participating clinicians Scottish Hip Fracture Audit The 3 great lies ::  The 3 great lies : The cheque’s in the post. Yes, I’ll still love you in the morning. I’m from the Scottish Office and I’m here to help you. Increasing the Focus on Rehabilitation:  Increasing the Focus on Rehabilitation diversity in structure and effectiveness potential for improvement Rehabilitation Sub-group of Audit Steering Group rehabilitation data set being piloted Rehabilitation ICP being piloted Scottish Hip Fracture Audit - future Medical Care Issues and Co-morbidity:  Medical Care Issues and Co-morbidity co-morbidity data collection being piloted, but difficult ASA grade robust descriptor pilot of ISD co-morbidity recording? very variable Medical input into Trauma Units fluid and electrolyte balance Scottish Hip Fracture Audit - future Role in Clinical Governance:  Role in Clinical Governance elderly patient with hip fracture: tracer condition /indicator procedure /journey of care multidisciplinary care: testing different specialties, different professions, different institutions - and their interfaces Scottish Hip Fracture Audit - future Slide73:  Nursing General Medicine Rehabilitation A&E Triage Geriatric Medicine Orthopaedic Surgery Portering Physiotherapy Occupational Therapy Speech and Language Throughcare Supported Discharge Day Hospital Radiology Anaesthetics Hip Fracture - a ‘tracer’ condition Laboratory services Social services Primary Care Role in Clinical Governance:  Role in Clinical Governance Audit + Guideline generates upward pressure on quality and efficiency benchmarking for national (and international) comparison “No clinical governance without clinical audit.” (RCSEd March 2000) Scottish Hip Fracture Audit - future Scottish Hip Fracture Audit:  Scottish Hip Fracture Audit Since 1993, the Audit has: expanded to capture the great majority of cases annually raised the profile of hip fracture care both locally and nationally provided a framework for related research and development projects Scottish Hip Fracture Audit:  Scottish Hip Fracture Audit Since 1993, the Audit has: prompted and monitored developments in clinical care and service organisation brought together broad multidisciplinary coalition on hip fracture care jointly led Standardisation of Audit of Hip Fracture in Europe (SAHFE) project, establishing standard data sets and links throughout Europe Scottish Hip Fracture Audit:  Scottish Hip Fracture Audit From 2000, the Audit could: support clinical standards and implement clinical governance by providing national comparative data on a common, life-threatening and economically significant injury continue to document complex care crossing specialty, Trust and agency boundaries Scottish Hip Fracture Audit:  Scottish Hip Fracture Audit From 2000, the Audit could: increase specific audit information available on rehabilitation process, probably extending use of Early Supported Discharge continue to prompt and monitor developments in prevention, clinical care and service development work with Guidelines via ICPs to provide patient-focussed evidence-based care Scottish Hip Fracture Audit:  Scottish Hip Fracture Audit From 2000, the Audit could: use ICPs for cost-effective hospital-based data capture explore spectrum of depth/detail of data collection, with increasing liaison with ISD explore clinical role of the Audit Nurse as outreach/ quality assurance Hip Fracture nurse collecting follow up and community data Hip Fracture common:  Hip Fracture common cf. polytrauma patients 1988 n = 130 1998 90 (-31%) Scottish Hip Fracture Audit - future “Warning: this information should be interpreted strictly in accordance with the general and the specific guidance given in this report.” “It is stressed that no direct inference about quality of care should be drawn from these indicators. They are intended rather to highlight issues which may require further investigation.” “… trigger useful further enquiry.”:  “Warning: this information should be interpreted strictly in accordance with the general and the specific guidance given in this report.” “It is stressed that no direct inference about quality of care should be drawn from these indicators. They are intended rather to highlight issues which may require further investigation.” “… trigger useful further enquiry.”

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