North Trent Critical Care Network · 2017-06-30 · NTCC ODN, 09 Mar 2017 1 Version History Version...

2015-16

North Trent Critical Care Network Annual Audit & Quality Report

Compiled by: Chris Scott Clinical Lead Kenneth Hindle-May Audit & Information Officer North Trent Adult Critical Care Operational Delivery Network Clock Tower Northern General Hospital Herries Road Sheffield

NTCC ODN, 09 Mar 2017 1

Version History

Version Date Summary of changes

V0.1 26 09 2016 First draft

V0.2 05 10 2016 Comments from David Harling and Nick Morgan-Hughes taken into

account.

V1.0 06 10 2016 Final Corrections and pdf version produced.

V1.1 22 12 2016

Final report, first draft.

Comments from Andy Temple taken into account:

Northern General HDU and RHH now reported as separate

units where possible.

Correction made to bed numbers at Northern General

HDU/ITU.

‘Cancelled Operations as a % of Admissions’ chart replaced with

‘Cancelled Operations as a % of Planned Surgical Admissions’.

‘ICNARC CMP Network Outcomes’ section added.

V1.2 01 02 2017

Comments from Lyndon Borrill taken into account:

Statement added to section 7.7 regarding RHH Neuro’s

intent to form new groups to investigate unit-acquired

infections.

Statement added to section 8.2 regarding VAP incidents and

case mix at RHH Neuro.

V2.0 09 03 2017

Changes made to Chesterfield’s unit names for consistency.

VAP data amended to include separate unit data from prior years.

Comment added re: Rotherham’s fall in L1 care days.

Comment added re: reporting of delayed discharges at Barnsley.

Final corrections & pdf version produced


CONTENTS Page

1. Introduction 4

2. Executive Summary 4

3. Activity 5 - 8

3.1 Unit Size

NTCCN Number of Funded Beds – Unit Totals

NTCCN Number of Funded Beds – North Trent Total

3.2 Admissions 6

Total Number of Critical Care Admissions

Total Number of Critical Care Patient Days

4. Organ Support 9 - 11

4.1 Levels of Care 9

Levels of Critical Care (%)

Change in Levels of Critical Care from 2014/15 (%)

5. Quality 12 - 17

5.1 Cancelled Operations 12

Total Cancelled Operations by Year

Total Cancelled Operations as a Percentage of Planned Surgical Admissions (%)

5.2 Early, Late & Night Discharges 14

Early, Late & Night Discharges as a Percentage of Unit Survivors (%)

Change in Late Discharges from 2014/15 (%)

5.3 Transfers 16

Summary of Critical Care Transfers In and Out

Summary of Critical Care Transfers: Network, Out of Network & UTG

6. Bed Availability 18

7. ICNARC Case Mix Programme - Network Outcomes 20 - 33

7.1 Participation in Case Mix Programme 20

7.2 Unplanned Readmissions within 48 hours 21


7.3 Risk-adjusted Acute Hospital Mortality – ICNARCH-2015 Model 23

7.4 Non-Clinical Transfers (Out) 25

7.5 Bed Days of Care, post-8hr Delay 27

7.6 Out of Hours Discharge to Ward (not delayed) 29

7.7 Infection: Unit acquired infections in blood 31

7.8 Continuous Renal Replacement Therapy (CRRT) 33

8. Other ICNARC Measures 34 - 35

8.1 Catheter-related Blood Stream Infections 34

8.2 Ventilator Associated Pneumonia (VAP) Rate 35

9. Appendix 1 – Definitions 36 - 37


1. Introduction

Following completion of the 2015/16 Interim Network Audit Report in October 2016, the ICNARC Network

Quality Report for 2015/16 was published on 23 Nov 2016, enabling comparison of network and unit

performance against national averages. Data from this is now included in section eight, complete with

comparison against network standards.

Data has once again been extracted from the Badgernet audit system provided by Clevermed, and thanks

must go to everyone involved in the collection, entry, upload and cleaning of what is a very complete and

robust dataset. All units have had the opportunity to feedback on the report and responses from

Rotherham and STH Cardiothoracic have been incorporated where appropriate. Where possible, data for

the Northern General Hospital’s High Dependency and General Intensive Therapy Units is now displayed

separately following feedback from the interim report.

2. Executive Summary

There was no change in the number of funded beds during the year. Overall, there was one fewer

Level 3 bed and nine more Level 2 beds across the network compared to 2014/15.

Network-wide, total demand in terms of admissions and occupancy has remained broadly the

same as last year.

The two Rotherham units are now treated as a combined unit for Badgernet reporting purposes.

This will give a more accurate picture of activity at the Trust but has for some metrics resulted in

unusually large changes when compared to 2014/15, when the units reported separately.

Cancelled operations data is still not fully robust and issues with submitting this metric to the

National Critical Care Dashboard have persisted. It is hoped the move to the new, fully online

Specialised Services Quality Dashboard portal from Q1 2016/17 will rectify this.

Late and night-time discharges continue to be a problem across the network, with the proportion

of late discharges continuing to rise at five of the units.

Winter time bed availability has worsened since 2014/15, which had in turn fallen markedly

compared to 2013/14.

CRBSI rates are low across the network and generally falling.

A full network audit and quality report will be generated once the ICNARC network-level report

becomes available, allowing comparison of units with national means.


3.1 Unit size

Critical Care beds are described as Level 2 (a single failing organ other than respiratory support requiring

invasive ventilation) and Level 3 beds (more than one failing organ or advanced respiratory support alone).

Full definitions are available in “Levels of Critical Care for Adult Patients” published by the Intensive Care

Society.

The hospitals in the NTCCN function in different ways, some separating their L2 and L3 patients into

separate geographical units, others combining L2 and L3 on the same unit. Hence direct comparisons are

not always valid due to the differences in case mix and varying proportions of level of care.

Combined Units:

STHFT – RHH General

Doncaster DCC

Bassetlaw Hospital (Barnsley ITU/HDU)

6

3

8

10

8

22

6 6

12

5 4

7

10

5

12

2

12

8

0

5

10

15

20

25

NTCCN Number of Funded Beds 2015-16

Level 2 Funded Beds

Level 3 Funded Beds


Points to Note:

The Barnsley ITU/HDU and SHDU are run as two separate units:

ITU/HDU 5 level 3 beds and 2 level 2 beds

SHDU 4 level 2 beds

STH Northern General Hospital’s General Critical Care unit is funded for:

12 Level 3 beds and 22 Level 2 beds Monday am to midday Saturday.

12 Level 3 beds and 18 level 2 beds from midday Saturday to Monday am.

STH Royal Hallamshire Hospitals General Critical Care unit is a combined unit with more Level 2 than Level

3 beds and is funded for:

2 Level 3 beds and 6 Level 2 beds Monday to Friday

2 Level 3 beds and 4 level 2 beds on weekends

STH Cardiothoracic Critical Care unit is funded for-

12 Level 3 beds (can be flexed to level 2 as required) Monday to Friday (usually only 11 used)

9 Level 3 beds (can be flexed to level 2 as required) on Saturdays

8 Level 3 beds (can be flexed to level 2 as required) on Sundays

6 Level 2 ‘Progressive Care Unit’ beds

Rotherham ITU and HDU are run as two separate units, but as of 2015-16 they have been combined for

data collection purposes:

5 Level 3 beds (one other can be used, flexibly) and 8 Level 2 beds

65 81

NTCCN Number of Funded Beds 2015-16

Level 3 Funded Beds Level 2 Funded Beds


3.2 Admissions

Note that that for the purposes of this report that where critical care episodes are sequential they will only

be counted as one admission. So if a patient has an admission to an ITU followed immediately by an

admission to HDU this will only count as one critical care admission for that provider. For more

information on definitions and calculations please refer to the Appendix at the end of the report:

2012-13 2013-14 2014-15 2015-16

Barnsley CCL 879 868 891 884

Bassetlaw ITU 215 273 262 253

Chesterfield ITU/HDU 1215 1233 1209 1265

Doncaster DCC 961 980 943 857

Rotherham ITU/HDU 663 651 544 615

STH - NGH HDU 1745 1856 1797 1757

STH - NGH GITU 797 844 845 795

STH - RHH CCD 709 682 709 709

STH - Cardiothoracic 1018 997 1152

STH - Neuro 1012 1066

NTCCN Average 898 934 921 935

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

Total Critical Care Admissions by Provider


The number of admissions has increased by 1.5% on the previous year. The average number of patient

days per unit for the North Trent CC network has fallen by 3% compared to 2014/15, however

Rotherham’s move to reporting data as a combined unit has resulted in a 22% fall in total critical care

days. Previously, patients moving from ITU to HDU would count as a critical care day for each unit and for

2015/16 this is no longer the case. Average patient days per unit has only fallen by 1.2% if Rotherham is

excluded.

It should be noted:-

Rotherham ITU/HDU are reporting data as a combined unit for the first time, and this impacts on

the critical care patient day numbers.

Activity at NGH GITU plateaued in 2015/16, after rising in the three previous years.

2012-13 2013-14 2014-15 2015-16

Barnsley CCL 3412 3293 3329 3314

Bassetlaw ITU 1453 1321 1314 1411


Doncaster DCC 5421 5446 5736 5473


STH - NGH HDU 4973 4510 4659 4569

STH - NGH GITU 4063 5097 5203 5207

STH - RHH CCD 1459 1740 1803 1738

STH - Cardiothoracic 4122 3336 3398

STH - Neuro 6364 6338

NTCCN Average 3692 3787 4055 3933

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

Total Critical Care Patient Days by Provider


4.1 Levels of care

The definitions for levels of care are:

Level 0 Patients whose needs can be met through normal ward care

Level 1 Patients at risk of their condition deteriorating, or higher levels of care whose needs can be

met on advice and support from the critical care team

Level 2 Patients requiring more detailed observation or intervention, single failing organ system or

postoperative care, and higher levels of care

Level 3 Patients requiring advanced respiratory support alone or basic respiratory support together

with support of at least two organ systems. This level includes all complex patients

requiring support for multi-organ failure

For more information on definitions and calculations please refer to the Appendix at the end of the report.

Level 3 Level 2 Level 1 Level 0

Barnsley CCL 38.7% 59.9% 1.1% 0.3%

Bassetlaw ITU 64.0% 31.2% 4.9% 0.0%

Chesterfield ITU/HDU 33.3% 64.1% 2.6% 0.0%

Doncaster DCC 47.5% 44.6% 7.9% 0.0%

Rotherham ITU/HDU 26.0% 71.3% 2.6% 0.1%

STH - NGH HDU 3.7% 86.5% 9.8% 0.0%

STH - NGH GITU 70.4% 26.6% 3.1% 0.0%

STH - RHH CCD 21.6% 72.6% 5.8% 0.0%

STH - Cardiothoracic 73.2% 26.7% 0.1% 0.0%

STH - Neuro 30.8% 58.1% 11.1% 0.0%

NTCCN Average 39.6% 54.9% 5.5% 0.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Levels of Critical Care Support


Levels of Care: Some units (Doncaster, Bassetlaw, NGH HDU, RHH CCD and STH Neuro) have high

numbers of level 1 patients in their beds. This may reflect difficulties in discharging to a more appropriate

environment. This can lead to adverse situations where urgent critical care admissions are necessary.

The low count of level 0 and level 1 patients at units indicates correct use of resource (note patients with

no organ support can have other reasons for level 2 care recorded). Barnsley and Rotherham continue to

be the only units reporting any days at level 0. NGH Cardiothoracic reflects a relatively high proportion of

L3 days, presumably due to case mix.

-11%

-6%

-1%

4%

9%

14%

Level 3 - % change from 2014/15

-11%

-6%

-1%

4%

9%

14%



The move to reporting Rotherham ITU/HDU as a combined unit has impacted on levels of care as well as

total patient days, resulting in a marked decline in the number of Level 3 days and a sharp rise in level 2

days. The fall in L1 days is believed to be genuine, as critical care patients have been made a priority for

discharging to ward and the figure is unlikely to be influenced by the move to combined reporting.

Excluding Rotherham, there has been a 1.7% rise in level 3 care days and an almost corresponding fall

(1.5%) in level 2 days. Level 1 days have risen slightly at all STH units but fallen elsewhere. This may

represent increased difficulty in finding appropriate beds to discharge critical care patients across STH.

-11%

-6%

-1%

4%

9%

14%


1.6%

-1.6%

-0.1%

0.0%

-2.0%

-1.5%

-1.0%

-0.5%

0.0%

0.5%

1.0%

1.5%

2.0%

Level 3 Level 2 Level 1 Level 0

Change in Levels of Care from 2014/15

(Network Average exc. Rotherham)


5.1 Cancelled operations

For more information on definitions and calculations please refer to the Appendix at the end of the report:

Cancelled operations: This indicator forms part of the National Critical Care dashboard. Accuracy

and quality issues have continued into 2015/16, however this should be rectified following the move to

the online Specialised Services Quality Dashboard from Q1 2016/17 onwards.

Across the network, most units have experienced a fall in cancelled operations both in total and as a

percentage of admissions. The only units experiencing a rise are RHH CCD and Bassetlaw.

Bassetlaw’s apparent sharp rise is a result of the cancelled operations metric being incorrectly reported

as zero in previous years. This has now been rectified.

STH received additional funding to allow for extended recovery during the winter period. This may

have been effective, as although RHH CCD registered a small increase in cancelled operations, NGH

HDU experienced a substantially larger fall.

Due to uncertainty over the accuracy of STH Neuro’s 2014/15 cancelled operations figure, this has

been omitted.

2012-13 2013-14 2014-15 2015-16

Barnsley CCL 10 24 28 14

Bassetlaw DCC 0 0 0 15




STH - NGH HDU 38 95 99 73

STH - NGH ICU 2 3 0 0

STH - RHH CCD 41 29 20 23

STH - Neuro 10


-20

0

20

40

60

80

100

120

Total Cancelled Operations by Year


2012-13 2013-14 2014-15 2015-16

Barnsley CCL 3.6% 8.2% 10.6% 6.3%

Bassetlaw ITU 0.0% 0.0% 0.0% 18.3%

Chesterfield ITU/HDU 16.3% 4.3% 6.5% 3.6%

Doncaster DCC 11.7% 7.2% 14.3% 13.0%

Rotherham ITU/HDU 15.6% 6.2% 5.6% 1.7%

STH - NGH HDU 3.7% 7.8% 8.6% 7.1%

STH - NGH ICU 8.3% 10.0% 0.0% 0.0%

STH - RHH CCD 8.2% 6.4% 5.0% 5.3%

STH - Neuro 2.0%

NTCCN Average 8.4% 6.3% 6.3% 6.4%

-1%

4%

9%

14%

19%

24%

Cancelled Operations as a % of Planned Surgical Admissions


5.2 Early, Late & Night Discharges

For more information on definitions and calculations please refer to the Appendix at the end of the report:

2015/16

Night Discharges

to Ward as % of

Unit Survivors

Early Discharges

as % of Unit

Survivors

Late Discharges

as % of Unit

Survivors

Barnsley CCL 2.0% 2.1% 21.9%

Bassetlaw ITU 3.9% 10.1% 18.4%

Chesterfield ITU/HDU 7.0% 5.5% 13.0%

Doncaster DCC 3.6% 1.2% 56.4%

Rotherham ITU/HDU 1.3% 1.3% 28.3%

STH - NGH General 6.3% 3.7% 60.8%

STH - RHH CCD 0.9% 0.6% 40.4%

STH - Cardiothoracic 3.1% 1.7% 32.1%

STH - Neuro 3.4% 2.8% 36.4%

NTCCN Average 3.5% 3.2% 34.2%

0%

10%

20%

30%

40%

50%

60%

70%

Barnsley Bassetlaw Chesterfield Doncaster Rotherham NGH HDU NGH GITU RHH CCD Cardio Neuro

Early, Late & Night Discharges

Night Discharges to Ward as % of Unit

Survivors

Early Discharges as % of Unit Survivors

Late Discharges as % of Unit Survivors


Discharges: Significant numbers of patients are not receiving timely discharges. The worrying

proportion of late discharges across the network may reflect a need for further investment in the

bed base of either the hospital, to facilitate timely critical care discharges, or the unit itself to

manage demand appropriately.

Late discharges are especially high for Doncaster and NGH HDU. Both units in the Doncaster &

Bassetlaw Trust and three of the five units at STH experienced increases in late discharges

compared to 2014/15.

The large drop in late discharges at Rotherham is believed to be genuine and not a result of the

move to report as a single unit, as it follows a drive to tackle the issue starting early in the year.

Barnsley, Chesterfield and NGH GITU also experienced a substantial fall in late discharge numbers.

However, it has been found that late discharges have been underreported at Barnsley. Numbers of

delayed discharges at this provider are expected to rise significantly from 2016/17.

-35%

-30%

-25%

-20%

-15%

-10%

-5%

0%

5%

10%

15%

Late Discharges - % change from 2014/15


5.3 Transfers

For more information on definitions and calculations please refer to the Appendix at the end of the report

Denominator = Total Number of Hospital Admissions

Data obtained from Combined Unit Reports – Transfers in/ out

A non-clinical transfer should be avoided at all costs.

Transfers: Sheffield Neuro CCD. The high level of non-clinical transfers in to Sheffield Neuro CCD

relate to the emergency transfers this unit is receiving. Transfers from outside the trust as a result of

an accident or injury are coded as 'non clinical' even though they are transferred in for a 'clinical'

reason. Though counter intuitive this is in line with the ICNARC definition. It does not reflect on bed

capacity elsewhere in the network.

0%

2%

4%

6%

8%

10%

12%

14%

Critical Care Transfers in 2015-16

Clinical Non-clinical Repatriation


Denominator = Total Number of Hospital Admissions

Data obtained from Combined Unit Reports – Transfers in/ out

A non-clinical transfer should be avoided at all costs.

Denominator = Total Number of Network Admissions

Data obtained from Combined Unit Reports - Transfers by type

0%

2%

4%

6%

8%

10%

12%

14%

Critical Care Transfers out 2015-16

Clinical Non-clinical Repatriation

43%

6% 2%

41%

5% 3%

Transfers: Network & Unique Transfer Group 2015-16

Transfers in - Network

Transfers in - Non UTG

Transfers in - UTG

Transfers out - Network

Transfers out - Non UTG

Transfers out - UTG


6. Bed Availability

It is reasonable to expect a bed to be available in the Network for a critically ill patient at all times

except during periods of surge.

Yorkshire Ambulance Service monitor the number of available beds across the network and the

number of days per month when there were <5 beds available is then plotted as a measure of

capacity.

The network is under most pressure during the winter months. Units may need to plan in

increased capacity between December and March.

The number of days with <5 beds available during the winter peak appears to have increased in

each of the last two winters, suggesting rising demand.

At present it is not established whether NHS England will provide additional funding to bolster

capacity for the forthcoming winter period.

0

5

10

15

20

25

30

Apr13

Jun13

Aug13

Oct13

Dec13

Feb14

Apr14

Jun14

Aug14

Oct14

Dec14

Feb15

Apr15

Jun15

Aug15

Oct15

Dec15

Feb16

Apr16

No

. o

f d

ays

NTCCTN - Bed availability <5

Apr 2013 to May 2016


7. ICNARC Case Mix Programme North Trent Regional Outcomes For the ICNARC data the hospitals are identified in the following chart. It should be noted that the unit with ‘0’ admissions did not submit data to ICNARC.

Identifier Unit name Admissions

A Barnsley Hospital - Intensive Care / High Dependency Unit 427

B Barnsley Hospital - Surgical High Dependency Unit 452

C Bassetlaw District General Hospital - Department of Critical Care 247

D Chesterfield Royal Hospital - High Dependency Unit 895

E Chesterfield Royal Hospital - Intensive Care Unit 451

F Doncaster Royal Infirmary - Department of Critical Care 821

G Northern General Hospital - General Intensive Therapy Unit 746

H Northern General Hospital - High Dependency Unit 1132

J Rotherham General Hospital - Intensive Care Unit/High Dependency Unit 585

K Royal Hallamshire Hospital - Intensive Care Unit 678

L Royal Hallamshire Hospital - Neuro Critical Care Unit 1002

M Northern General Hospital – Cardiac Critical Care Unit 0

Nb. Admission figures will not match figures quoted in some sections of this report, as they have been reflected as combined units. Also note that unit identifiers have changed since the previous year – so care must be taken when comparing this annual report against previous publications. The Northern General Hospital High Dependency Unit did not submit to ICNARC for Q1 2015/16. Any interpretation should be seen in this light. The previous section contains data on the full complement of admissions for this unit.


7.1 Participation in Case Mix Programme

Standard: Maintain up to date database. All Level 2-3 units must participate in case mix adjusted

programme.

Questions: Is ICNARC data collected on all adult Level 2-3 critical care patients in North Trent?

Source: ICNARC Case Mix Programme

Results: Units meeting the standard

General Intensive Care Units.

All patients on designated general intensive care units (L3) and mixed units (L2/3) are

recorded in the case mix program. All high dependency units (L2) are now meeting the

standard, with Northern General Hospital HDU successfully submitted to ICNARC from

Q2 2015/16 onwards.

Specialist Intensive Care Units.

Royal Hallamshire Hospital – Neuro Critical Care Unit

Units not meeting the standard

Specialist intensive care units:

Northern General Hospital - Cardiothoracic Intensive Care Unit

(expecting to submit for 2016/17)

Comment: Rotherham now is a combined unit (for data purposes) and began collecting ICNARC data

on all patients in April 2015. Northern General HDU began collecting full data in April 2015.

It should be noted that these figures are taken from the ICNARC report and thus exclude

some of the level 2 patients that are included in the network analysis (from Badgernet)

above.


7.2 Unplanned Readmissions within 48 hours

Standard: The number of patients discharged from Critical Care to a ward who are readmitted within

48 hours should be at or below the CMP average.

Questions: Is the rate of readmissions in Network units at or below the Case-mix Program average?

Source: ICNARC Network Quality Report 2015-16 (pg 8)

Results:


Unit Critical care unit Eligible Numerator Denominator Result (%)

A Barnsley ITU/HDU 215 5 215 2.3

B Barnsley SHDU 427 3 427 0.7

C Bassetlaw DCC 160 0 160 0

D Chesterfield HDU 749 8 749 1.1

E Chesterfield ICU 174 0 174 0

F Doncaster DCC 560 5 560 0.9

G NGH - GITU 370 4 370 1.1

H NGH - HDU 1044 4 1044 0.4

J Rotherham ICU/HDU 455 7 455 1.5

K RHH - ICU 571 6 571 1.1

L RHH - Neuro 851 11 851 1.3

Eligible: Critical care unit survivors discharged to a ward within the same hospital.

Numerator: No. of eligible admissions subsequently readmitted (unplanned) to the same critical care unit within 48hrs of discharge.

Denominator: No. of eligible admissions.

Comment:

All units are within 2 SDs of the national average except Bassetlaw and Chesterfield ICU (2-3 SDs below the

average), and NGH HDU (>3 SDs below the average). The network average has improved to 1.0%, down

from 1.2% in 2014/15, with the national average falling from 1.3% to 1.2% over the same period.

It should be noted that these figures are taken from the ICNARC report and thus exclude some of the level

2 patients that are included in the network analysis (from Badgernet) above.

Re-audit date: Annual data 2016/17


7.3 Risk-adjusted Acute Hospital Mortality – ICNARCH-2015 Model

Standard: Units should be less than two standard deviations from the median standardised mortality

ratio (SMR) for the CMP if SMR >1

Questions: Are all units less than two standard deviations from the case-mix program median if SMR

>1?


Results:


Unit Critical care unit Eligible Numerator Denominator Result

A Barnsley ITU/HDU 427 101 93.7 1.08

B Barnsley SHDU 452 31 33.3 0.93

C Bassetlaw DCC 247 60 54.5 1.1

D Chesterfield HDU 895 172 167.4 1.03

E Chesterfield ICU 451 149 150.8 0.99


G NGH - GITU 746 189 188 1.01

H NGH - HDU 1132 78 94.9 0.82

J Rotherham ICU/HDU 585 101 114.6 0.88

K RHH - ICU 678 72 62.6 1.15

L RHH Neuro 1002 69 113.9 0.61

Eligible: All critical care admissions excluding readmissions, patients dead on admission and admissions to facilitate organ donation

Numerator: Observed number of eligible admissions that died before ultimate discharge from acute hospital.

Denominator: Expected number of acute hospital deaths among eligible admissions from the ICNARCH-2015 model.

Comment:

All units are within 2 SDs of the national median except NGH HDU (2-3 SDs below) and RHH Neuro (>3

SDs below). Network-wide SMR for 2015/16 was 0.97, increasingly slightly from 0.93 in 2014/15.



7.4 Non-Clinical Transfers (Out)

Standard: Units should fall within two standard deviations of the CMP mean.

Questions: Are the number of transfers from a hospital to a Level 3 critical care bed in another hospital,

that may be in the same Trust, due to lack of capacity in the transferring hospital and

involves the patient being moved by ambulance, within 2 SDs of the case mix program

mean?


Results:




B Barnsley SHDU 484 0 484 0

C Bassetlaw DCC 252 15 252 6


E Chesterfield ICU 479 5 479 1


G NGH - GITU 795 13 795 1.6

H NGH - HDU 1190 3 1190 0.3


K RHH - ICU 709 3 709 0.4

L RHH Neuro 1066 20 1066 1.9

Eligible: All critical care admissions.

Numerator: Number of critical care unit survivors receiving Level 3 care (for HDUs, Level 2 care) on discharge and discharged for

comparable critical care to a Level 3 bed (for HDUs, a Level 2 bed) in a critical care unit in another acute hospital.

Denominator: Number of eligible admissions.

Comment:

All units are within 2 SDs of the CMP mean except Bassetlaw and RHH Neuro (2-3 SDs above). Due to a

coding problem within Badgernet whereby RHH Neuro’s repatriations were being incorrectly recorded as

‘comparable critical care’, numbers of non-clinical transfers are likely to be artificially high. This issue was

corrected in April 2016. Bassetlaw’s rate of non-clinical transfers is very nearly 3 SDs above the mean,

making this unit a clear outlier within the network.

The network average was the same as 2014/15 at 0.9%, with the national mean falling to 0.4% from 0.5%

the previous year.



7.5 Bed Days of Care, post-8hr Delay

Standard: Delayed discharges should be at or below the CMP mean.

Questions: Are unit outcomes or confidence intervals for unit survivors with a recorded delay of 8

hours or more below the national CMP mean? (The delay commences 8 hours after the

patient is ready for discharge and bed was requested).


Results:



A Barnsley ITU/HDU 453 3.8 2562 0.1

B Barnsley SHDU 484 2.4 1464 0.2

C Bassetlaw DCC 252 49.8 2196 2.3

D Chesterfield HDU 959 55.4 2928 1.9

E Chesterfield ICU 479 17.9 2562 0.7

F Doncaster DCC 857 457.9 7320 6.3

G NGH - GITU 793 129.4 5856 2.2

H NGH - HDU 1188 209.5 3904 5.4

J Rotherham ICU/HDU 615 89.2 5124 1.7

K RHH - ICU 708 29.3 2928 1

L RHH Neuro 1057 604.6 7320 8.3

Eligible: All critical care unit admissions.

Numerator: Bed days of care provided for critical care unit survivors more than 8 hours after the reported time fully ready for discharge

Denominator: Total number of available bed days in the critical care unit.

Comment:

All units are below the national mean except NGH HDU, Doncaster DCC and RHH Neuro. NGH HDU is

only fractionally above the national mean (0.1%), whereas Doncaster DCC and RHH Neuro are 1% and 3%

over, respectively.

The network average has increased by 0.5% from 2014/15, with the national mean increasing by only 0.1%

in the same period. The network mean remains 1.6% below the national mean.



7.6 Out of Hours Discharge to Ward (not delayed)

Standard: Patients should not normally be discharged from Critical Care areas to a ward between

22:00 and 06:59.

Questions: What is the percentage rate of out of hours discharge to a ward for your unit?


Results:





C Bassetlaw DCC 160 6 160 3.8


E Chesterfield ICU 174 11 174 6.3


G NGH - GITU 370 11 370 3

H NGH - HDU 1044 11 1044 1.1


K RHH - ICU 571 3 571 0.5

L RHH Neuro 851 26 851 3.1

Eligible: Critical care unit survivors discharged to a ward in the same hospital.

Numerator: Number of eligible admissions discharged between 22:00 and 06:59 and not delayed (i.e. not declared fully ready for

discharge by 18:00 on that day).

Denominator: Number of eligible admissions.

Comment:

Although network mean and national means have fallen compared to the previous year (2.4% and 2.5%,

compared to 2.9% and 2.8% in 2014/15), five units are now above the mean compared to only three in

2014/15. Bassetlaw DCC, Chesterfield ICU, NGH GITU and RHH Neuro are all within 2 SDs of the mean,

while Chesterfield HDU is 2-3 SDs above the mean.



7.7 Infection: Unit-acquired infections in blood

Standard: The CMP mean should be within two standard deviations for the number of unit-acquired

infections for each unit.

Questions: What is the number of unit-acquired infections per 1,000 patient days?


Results:


Unit Critical care unit Eligible Numerator Denominator Result

A Barnsley ITU/HDU 230 0 1886 0


C Bassetlaw DCC 120 3 1332 2.3

D Chesterfield HDU 465 0 2462 0

E Chesterfield ICU 251 3 2159 1.4


G NGH - GITU 528 12 5411 2.2

H NGH - HDU 572 3 2873 1

J Rotherham ICU/HDU 363 0 3051 0

K RHH - ICU 230 7 1531 4.6

L RHH Neuro 530 31 6328 4.9

Eligible: Critical care admissions staying at least 48 hours.

Numerator: Number of unit-acquired infections in blood, defined as the presence of infection in any blood sample taken for

microbiological culture after 48 hours following admission.

Denominator: Total number of patient days that eligible admissions

stayed in the critical care unit.

Comment:

All units are within 2 SDs of the national mean except RHH Neuro, which is 2-3 SDs above the mean. The

network average increased from 1.8 to 2.4 infections per 1,000 patient days while the national average

remained at 1.5.

RHH Neuro are currently establishing a CVC group and, after this is established, will look to start A-Line

and VAP groups as well.



7.8 Continuous Renal Replacement Therapy (CRRT)

Standard: Units should be treating the equivalent of 100 patient days.

Questions: On how many patient days did your unit provide renal support in the last financial year?

Source: Badgernet Activity Report – Organ Support by Month

Results:

Comment:

Outside of STH, all units are meeting the target except Bassetlaw, which is nominally below it. At STH,

NGH HDU and RHH Neuro have few/no renal support days due to case mix. RHH CCD’s number of CRRT

days has fallen sharply compared to 2014/15. This is mirrored by a rise in CRRT days at NGH GITU, so may

reflect changes in clinical practice.


2012-13 2013-14 2014-15 2015-16

Barnsley CCL 183 194 230 232

Bassetlaw DCC 91 94 135 98




STH - NGH HDU 6 6 16 15

STH - NGH GITU 674 714 665 805

STH - RHH CCD 121 131 129 25

STH - NGH Cardiothoracic 422 572 535

STH - RHH Neuro 0 0


0

100

200

300

400

500

600

700

800

900

Continuous Renal Replacement Therapy Days


8. Other ICNARC Measures

8.1 Catheter-related Blood Stream Infections

Units should have a rate of CVC related infections of less, or equal to 1.4 CRBSIs per 1,000 catheter

days

At the beginning of the 15/16 financial year, NGH ICU and both Chesterfield units were above the

standard, but all three units improved and had CRBSI rates of <1 by the end of the year.

A single CBRSI caused Bassetlaw’s rate to rise to 1.1 at the end of the year.

The network average remains well below the target of 1.4 CRBSIs per 1,000 catheter days, peaking

at 0.7 in May 2015 and falling to 0.23 by the end of the year.

0

1

2

3

4

5

6

7

8

9

10

Ap

r-13

May-1

3

Jun

-13

Jul-

13

Au

g-1

3

Sep

-13

Oct

-13

No

v-1

3

Dec-

13

Jan

-14

Feb

-14

Mar-

14

Ap

r-14

May-1

4

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-1

4

Dec-

14

Jan

-15

Feb

-15

Mar-

15

Ap

r-15

May-1

5

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec-

15

Jan

-16

Feb

-16

Mar-

16

CRBSI Rate per 1,000 CVC line days (last rolling year)

Barnsley ITU/HDU Barnsley SHDU Bassetlaw ITU Chesterfield HDU

Chesterfield ITU STH - NGH ICU NTCCN Average


8.2 Ventilator Associated Pneumonia (VAP) Rate

In the absence of an agreed national standard network units should a) input their VAP rates into

Badgernet and b) show a declining or low static trend for VAP.

NGU ICU, Chesterfield ITU, Doncaster and Rotherham all exhibited downward trends in VAP rate

over the course of the year, continuing good progress made in previous years.

The network’s average VAP rate 1.65 incidents per 1,000 ventilator days, down from a high of 3.95

incidents in Apr 2014.

RHH CCD recorded VAP incidents in 2015/16, after not experiencing any in 2014/15.

RHH Neuro are not currently reporting VAP incidents, however there are plans to form a group to

review VAP incidents in the future. The application of specific guidance to measuring VAP must be

discussed at great length due to the specialist patient demographic at this unit.

0

2

4

6

8

10

12

14

16

18

20

Ap

r-12

Jun

-12

Au

g-1

2

Oct

-12

Dec-

12

Feb

-13

Ap

r-13

Jun

-13

Au

g-1

3

Oct

-13

Dec-

13

Feb

-14

Ap

r-14

Jun

-14

Au

g-1

4

Oct

-14

Dec-

14

Feb

-15

Ap

r-15

Jun

-15

Au

g-1

5

Oct

-15

Dec-

15

Feb

-16

VA

P r

ate

per

1,0

00 v

en

tila

tor

days

(last

ro

llin

g y

ear)

VAP rate per 1,000 Ventilator days (last rolling year)

Apr 2012 - Mar 2016

Barnsley ITU/HDU Bassetlaw ITU Chesterfield ITU Doncaster DCC

Rotherham ITU STH - NGH GITU STH - RHH CCD NTCCN Average


Appendix 1 - Definitions

Admissions:

The number of patients admitted from 1st April (00:00) to 31st March (23:59) in any given financial year.

Patients admitted prior to 1st April who were still in the unit on the 1st April are not included in these

figures (but would be included in discharges).

Number of patient days:

This is the sum of the total number of hours each patient has been in the unit divided by 24 (hours) to give

the number of actual occupancy days, rather than elapsed days (e.g. a patient admitted on 1st of the

month, then discharged on the 3rd – has not necessarily accrued a 2 days LoS, this metric deals with that

issue).

Midnight bed count:

This is the percentage occupancy of funded beds at midnight - a count of the total patients in the unit at

midnight divided by the number of funded bed days available per unit in the period.

Funded beds:

Beds that Commissioners have agreed, with the Trust, to pay for through contractual agreement.

Levels of care:

Levels of care are counted when they are recorded during the period selected. For the avoidance of

doubt, there is also a count of the days where a level of care should be recorded but hasn't yet been

entered. All values shown are in Days.

Levels of Support Calculation:

The total number of occurrences where a final level of care was recorded against a patient’s admission

shown as a percentage of the total count.

Cancelled operations:

Operations cancelled due to the lack of general ICU or HDU beds. If a cancelled operation is re-booked

and cancelled a second time, this would count as a separate cancelled operation. The number of cancelled

operations is shown as a percentage of total admissions.

Early readmissions:

Unit survivors that are subsequently readmitted to a unit within 48 hours of discharge but within the same

hospital stay. Figures are shown as a percentage of the total unit survivors in the hospital for the same

period.


Late readmissions:

Unit survivors that are subsequently readmitted to a unit later than 48 hours following discharge but

within the same hospital stay. Figures are shown as a percentage of the total unit survivors in the hospital

for the same period.

Night time/ Out of hours discharges:

Discharges to the ward between the hours of 22.00 and 06.59. Percentage values are calculated on the

total unit survivors for the hospital for the period selected.

Early discharges:

Discharges due to shortage of Level 3 & 2 beds, for example to a ward within the same hospital. These

could be at any time of the day so include night time discharges. Early discharges exclude self-discharges.

Delayed discharges:

Discharges that have been recorded as having been discharged late due to a shortage of beds in another

area.

Transfers in:

Transfers in are counted where the patient was admitted between the relevant dates with the CCMDS

Admission Type is 02 (clinical), 03 (non-clinical) or 06 (repatriation). Figures are shown as a percentage of

the total admissions.

Transfers out:

Transfers out are counted where the patient was discharged between the relevant dates and the CCMDS

Discharge Type is 02 (clinical), 03 (non-clinical) or 06 (repatriation). Figures are shown as a percentage of

the total admissions.

Infections

Total number of MRSA, C-Difficile and other infections acquired during a patients stay on the unit.

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