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Emergency Admissions: A journey in the right direction? A report of the National Confidential Enquiry into Patient Outcome and Death (2007)

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Presentation on theme: "Emergency Admissions: A journey in the right direction? A report of the National Confidential Enquiry into Patient Outcome and Death (2007)"— Presentation transcript:

1 Emergency Admissions: A journey in the right direction? A report of the National Confidential Enquiry into Patient Outcome and Death (2007)

2 Study aim To identify remediable factors in the organisation of care of adult patients admitted as an emergency

3 Indicators of care Emergency admissions systems Access to investigations Bed management Timing of first consultant review Communication and information Quality and quantity of staff Preventable adverse events

4 Inclusions Died on or before midnight on day 7 Transferred to an adult critical care unit on or before midnight on day 7 Discharged on or before midnight on day 7 and subsequently died in the community within 7 days of discharge

5 Exclusions Patients who were brought in dead Patients who died within an hour of arrival Patients whose prime reason for admission was palliative care or a psychiatric diagnosis Obstetric cases

6 Data Admission questionnaire Ongoing care questionnaire Casenotes Organisational questionnaire Advisor groups peer reviewed all cases where casenotes were returned

7 Case assessment Good practice Room for improvement – clinical care Room for improvement – organisational care Room for improvement – clinical and organisational care Less than satisfactory

8 Data returned

9 Age range

10 Medical vs surgical admissions

11 Patient outcome

12 Overall assessment of care


14 Initial assessment

15 Prompt clinical assessment Differential diagnosis Clear management plan Appropriate investigations Early decision making Involvement of relevant specialties Timely review by an appropriately trained senior clinician The Society of Acute Medicine, 2007 Emergency Assessment Units – a Checklist, DH 2003 The interface of A&E and Acute Medicine, RCP 2002

16 Quality of initial assessment


18 Location of initial assessment

19 Type of EAU

20 Quality of initial assessment

21 Documentation Dates, times, designation, legibility Documentation of management plan Nursing notes better standard than medical notes Proforma documents generally better but lack standardisation

22 Quality of initial assessment Key findings Of those hospitals that had an EAU 98% (169/173) had a medical EAU and 60% (104/173) a surgical EAU The overall standard of initial assessment of emergency admissions was good or adequate but 7.1% (90/1275) were poor or unacceptable in the advisors’ opinions There were examples of poor medical documentation particularly in respect of basic information on the dates, times or designation of the person making an entry in the casenotes

23 Quality of initial assessment Recommendations The initial assessment of patients admitted as an emergency should include a doctor of sufficient experience and authority to implement a management plan. This should include triage of patients as well as formal clerking. The involvement of a more senior doctor should be clearly and recognisably documented within the notes (Clinical leads and heads of service) The quality of medical note keeping needs to improve. All entries in notes should be legible, contemporaneous and prompt. In addition they should be legibly signed, dated and timed with a clear designation attached (Medical directors)

24 First consultant review

25 Earlier diagnosis Earlier management plan Greater ability to recognise more severely ill patients Improve outcome Seward E et al Clin Med 2003;3:425–34 Safer care for the acutely ill patient: learning from critical incidents. NPSA 2007

26 First consultant review No evidence in casenotes of consultant review in 158 (12.4%) out of 1275 cases In 682 (53.5%) of cases unable to determine the time the patient was first reviewed by a consultant –Documentation issues

27 Current standards 90% of patients should be reviewed by a consultant within 24 hours of admission (Good medical practice for physicians, RCP, 2004) Acutely ill patients should be seen by critical care consultants within 12 hours of admission to AICU (Good medical practice for physicians, Intensive Care Medicine RCP 2004) Senior doctors should review patients admitted as an emergency within an hour of referral from the Emergency Department (Transforming Emergency Care DH 2004, The Emergency Department: Medicine and Surgery Interface Problems and Solutions. London, RCS) First consultant review



30 Unacceptable time to first consultant review by overall quality of care as viewed by the advisors

31 First consultant review Advisors’ opinion

32 First consultant review Delays in seeing a doctor of adequate seniority and experience may have a detrimental effect on patient care –more important for patients to be seen by a consultant within a reasonable time frame determined by clinical condition rather than by a consultant of appropriate specialty –can result in delayed definitive care and poor outcome Decision making by training grades –examples of lack of and poor decision making by trainees Ability of trainees to recognise critical ill patients is poor –examples of trainees underestimating the severity of physiological dysfunction

33 Case study 4 A very elderly patient was admitted to the emergency department from a nursing home at 02:00 with pneumonia. The patient had a known history of ischaemic heart disease and Parkinson’s disease. A medical SHO made a comprehensive initial assessment but no management plan was documented. The patient was not re-assessed again until the first consultant review 17 hours after arrival in the emergency department. By this time the patient had deteriorated and had a heart rate of 120 and a respiratory rate of 30 with overt signs of sepsis. Despite aggressive therapy with IV antibiotics the patient died 24 hours later.

34 Advisors’ concerns Lack of a clear management plan on admission Long duration to the first consultant review Delay of the initiation of medical treatment All contributed to the patient’s eventual demise

35 First consultant review Key findings 60.1% (298/496) of patients were seen by a consultant within 12 hours of admission; 92.3% (458/496) were seen within the first 24 hours In 12.4% (158/1275) of cases there was a lack of documentary evidence of patients being reviewed by consultants following admission to hospital It was not possible to determine the time to the first consultant review in 682 (53.5%) of cases due to lack of documentation of time or date in the casenotes

36 First consultant review Recommendations Patients admitted as an emergency should be seen by a consultant at the earliest opportunity. Ideally this should be within 12 hours and should not be longer than 24 hours. Compliance with this standard will inevitably vary with case complexity (Clinical directors) Documentation of the first consultant review should be clearly indicated in the casenotes and should be subject to local audit (Clinical directors)

37 First consultant review Recommendation Trainees need to have adequate training and experience to recognise critically ill patients and make clinical decisions. This is an issue not only of medical education but also of ensuring an appropriate balance between a training and service role; exposing trainees to real acute clinical problems with appropriate mid-level and senior support for their decision making (Clinical directors)

38 Consultant commitments while on-take

39 Priority to emergency admissions –Improves continuity of care –Improves decision making –Better supervision of trainees The interface of Accident and Emergency and Acute Medicine, RCP 2002 Good Medical Practice, RCP 2004 The Emergency Department: Medicine and Surgery Interface Problems and Solutions, RCS 2004 Good Surgical Practice, RCS 2005

40 Consultant commitments while on-take



43 68.8% (943/1370) of patients were under the care of consultants who had more than one duty when on-take. These may be consistent with their on-take activity but even so 21.2% (298/1370) of consultants were undertaking more than three duties Some consultants undertake non-emergency clinical care while on-take and this may have delayed their response to the management of emergency admissions Consultant commitments while on-take Key findings

44 Recommendation Consultants’ job plans need to be arranged so that, when on-take, they are available to deal with emergency admissions without undue delay. Limiting the number of duties that consultants undertake when on-take should be a priority for acute trusts (Medical directors) Consultant commitments while on-take

45 Necessity for admission

46 75/1275 (5.9%) unnecessary admissions No difference in time of arrival No difference in grade of initial reviewer Social admissions Untreatable terminal conditions

47 Key findings 5.9% of emergency admissions considered unnecessary Most of these admissions were for people who could have been cared for in the community Necessity for admission

48 Recommendation Appropriate mechanisms, both in terms of community medicine and palliative care, should be in place so that unnecessary admissions can be avoided (Primary care trusts and strategic health authorities) Necessity for admission

49 Availability of investigations and notes

50 Availability of investigations in the first 24 hours Access to basic investigations and timely return of results essential Comprehensive investigation should be available for all emergencies Delayed discharges can be avoided



53 Delay in obtaining results 61/1275 (4.8%) there was a delay in getting results 193/1275 (15.1%) not possible to form an opinion owing to poor documentation



56 Grade of care vs delay in results

57 Case study 7 An elderly patient with chronic obstructive pulmonary disease was admitted with a probable infective exacerbation. They were considered to be “coping” by the clerking PRHO. A chest x-ray was requested and oral antibiotics were commenced. Three hours after admission arterial blood gas analysis revealed: pH 7.38, PaCO 2 8.5 KPa and PaO 2 10 KPa on 28% FiO 2. The chest x-ray was not performed until 12 hours and result not recorded until 24 hours post-admission. As it showed left lower lobe collapse/consolidation intravenous antibiotics were commenced. The patient deteriorated and, following review by ICU outreach team, non-invasive ventilation was commenced on the ward. Twelve hours later the patient was transferred to ICU and still required non invasive ventilation on day 7 following admission.

58 Advisors’ concerns The delay in obtaining and reporting on the chest x-ray was unacceptable This delayed the decision to start intravenous antibiotics If the results had been available more quickly non invasive ventilation may have been instituted earlier




62 Omission of appropriate investigations vs Overall quality of care

63 Inappropriate investigations vs Overall quality of care

64 Inappropriate investigations Chest x-ray in terminal metastatic bone cancer (absence of chest symptoms) Liver function tests in terminal illness Amylase in melaena

65 Availability of casenotes Only 12 instances were reported of problematic delays Patient treated at alternative site Notes stored off site Notes unavailable out of hours

66 Key findings 15.1% (45/298) of EAUs that admitted patients as an emergency did not have access to CT scans 24 hours a day 6.7% (20/298) of EAUs that admitted patients as an emergency did not have access to conventional radiology 24 hours a day In 4.8% (61/1275) there was a delay in obtaining investigations; adversely affecting the overall quality of care of some of these patients

67 Key findings In 7.5% (91/1218) of cases appropriate investigations were not performed In 7.4% (94/1275) of cases inappropriate investigations were performed

68 Recommendations Hospitals which admit patients as an emergency must have access to both conventional radiology and CT scanning 24 hours a day, with immediate reporting (Medical directors and clinical directors) There should be no systems delay in returning of the results of investigations (Clinical directors) There should be a clear rationale for the ordering of investigations. Omission of appropriate investigations can have a deleterious effect on patient care (Lead clinicians) All investigation results should be recorded with a date and time in the patient notes (Clinical audit)

69 Placement and transfers

70 Placements: doctors’ views


72 Overall quality of care vs Inappropriate first inpatient ward

73 Ward transfers

74 Transfers: advisors’ opinions 38/1275 transfers considered excessive 18/38 excessive transfers affected outcome

75 Placement and transfers Vast majority sent to appropriate ward 12.9% placed on an inappropriate ward were thought to have received less than satisfactory care Excessive transfers were thought to have affected the diagnosis and outcome in a small cohort of patients Key findings

76 Recommendations Following initial assessment and treatment patients should be transferred to a ward appropriate for their condition in terms of specialty and complaint (Clinical directors) Excessive transfers should be avoided as these may be detrimental (Clinical directors) Placement and transfers

77 Handovers

78 Key findings 50.7% of hospitals did not have a written handover protocol A proportion of clinicians were unaware of existing protocols 92.8% of emergency admissions had a recognisable handover procedure between shifts Handover problems were infrequent

79 Recommendations Robust handover systems need to be put into place between clinical teams (Heads of service) Readily identifiable and protocol based (Heads of service) Clinicians should be made aware of protocols and mechanisms (Heads of service)

80 Reviews and observations

81 Clinical reviews: advisor opinion



84 Observations: advisor opinion


86 Only 63.4% of patients received an appropriate frequency of observations despite being on an appropriate ward

87 Case study 8 An elderly patient was admitted during the daytime on a weekday, via the emergency department, to an emergency assessment unit with a one day history of abdominal pain. The initial assessment, by an SHO, reported a palpable pulsatile abdominal mass. No differential diagnosis was documented. A CT scan was arranged for the next day. The patient was found “cold and stiff” the next morning less than 24 hours after admission.

88 Advisors’ concerns Quality of documentation received Unclear whether the patient was reviewed by a consultant NCEPOD did not receive any nursing observation charts The patient was found in rigor mortis suggesting the frequency of observations may have been inappropriate No evidence in the notes that an autopsy was either requested or performed Did this patient have a leaking abdominal aortic aneurysm that was missed by the admitting doctor?

89 Key findings Level of clinical review generally adequate Where clinical review was inadequate it did affect both diagnosis and outcome in some patients Difficult to find clear evidence of adequate clinical observations both in type and frequency – however clear evidence exists that 6.8% did not Appropriate observations performed less often than desirable, and when performed frequency is inappropriately low despite being on an appropriate ward

90 Recommendations All emergency admissions should receive adequate review (Clinical directors) A clear physiological monitoring plan should be made (Clinical directors) Part of treatment plan should be an explicit statement of parameters that should prompt a request for review (Clinical directors)

91 Adverse events

92 Adverse events, error and preventability

93 Adverse events “ An unintended injury caused by medical management rather than by the disease process and which is sufficiently serious to lead to prolongation of the hospitalisation or to temporary or permanent impairment or disability to the patient at the time of discharge”

94 Adverse events Initially 150 patients were identified as having suffered a potential adverse event On more detailed examination of records, only 51/1275 (4%) of cases fulfilled the NCEPOD defined criteria for inclusion This was NOT a systematic assessment of the true number of adverse events Delays occurred both in the identification and response to adverse events

95 Adverse events

96 Case study 11 An alcohol-dependent patient on diazepam, DF118, chlormethiazole and other analgesics was noted to be agitated and recorded as having an oxygen saturation of 91%. Nursing handover was poor, and medical staff appeared unaware of the situation. No blood gases were obtained. The patient subsequently died of a cardio-respiratory arrest.

97 Recommendations Further work is required by the NPSA to educate and inform clinical staff about the definitions surrounding adverse events There must be standardisation of reporting and audit of that reporting to ensure that accurate data is obtained (National Patient Safety Agency)

98 Summary

99 Overall the quality of care for this sample of patients admitted as emergencies was rated good in 61.6% of cases, despite the sample having been biased toward those patients most likely to stretch the system There was a relationship between the quality of the initial assessment and the overall quality of care Despite the fact that 63.5% of assessments were undertaken by SHOs, 93% of all initial assessments were judged by advisors to be good or adequate There was no detectable difference in the quality of assessments undertaken by clinicians of different seniority In a minority of cases, there was no evidence of timely consultant involvement In 16% of cases which could be assessed, advisors felt that the delay to consultant review was not acceptable

100 Case study 2 An elderly patient was seen on an EAU and the initial assessment made by the surgical SHO led to a differential diagnosis of cholecystitis, peptic ulcer, or small bowel obstruction. A clear management plan was documented. A consultant reviewed the patient within 6 hours and ordered a USS which demonstrated a dilated CBD. A CT scan performed the next day showed small bowel obstruction. The patient was seen again by the consultant who determined that the patient’s condition was deteriorating, and an emergency laparotomy was performed. At operation a necrotic gall bladder and small bowel adhesions were discovered. The patient was admitted postoperatively to ICU returning to the ward two days later. Advisors commended this case for well documented evidence of appropriate team based management.

101 Summary It is important that trainees have sufficient skills to recognise sick patients. Consultants retain overall clinical responsibility of their patients, and they must ensure duties are only delegated to trainees within their level of competence The restriction on junior doctors hours, poses challenges for training and assessment of competence, and for continuity of care There must be appropriate handover systems in place Senior doctors must be available in a timely fashion to ensure an appropriate management plan is formulated Whilst it may be acceptable for consultants to multi-task, job plans must ensure that they are able to attend emergency admissions when clinical priority dictates In order to audit the quality of care it is important that accurate records are maintained which identify the seniority of staff involved and the timing of events


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