This is the first time the report is being presented. For information only. Medical Director. Clinical Auditor. Improving Quality & Safety

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1 CATEGORY OF PAPER Specific action required: Provides Assurance: Information: Board of Directors Meeting 28/02/19 Report title: Clinical Audit Dashboard January 2019 Purpose of report: To provide assurance on the Trust s performance in the June 2018 Ambulance Clinical Quality Indicator audits. In August the Trust performed above the national average in the following indicators: Cardiac Arrest, ROSC at hospital (All patients) Cardiac Arrest, ROSC at hospital (Utstein group) Cardiac Arrest, Survival to Discharge from hospital (All patients) Cardiac Arrest, Survival to Discharge from hospital (Utstein group) Stroke Care Bundle Stroke mean average call to hospital time In August the Trust did not perform below any of the national averages. In August the there were 4 incidents that failed the Stroke care bundle, placing us 3 Rd Nationally. BMs were missed in all 4 incidents. NHS England only required submission for the Stroke care bundle this month. was the highest perform trust for Cardiac arrest ROSC and survival to Discharge in both the all patient and Utstein groups. Issue previously considered by: Recommended actions: Sponsor / approving director: Report author: This is the first time the report is being presented information only Medical Director Clinical Auditor Governance and assurance Link to Trust Priorities: (please tick) Link to CQC / KLOE: (please tick) Organisational Sustainability Improving Quality & Safety Workforc e & Investors in People Clinical Care & Transport NHS 111 & Clinical Assessment Service Comms & Engagement Caring Responsive Effective Well Led Safe Link to Trust values: (please tick) (Please explain how this paper supports the application of the Trust s values in practice) Pride Strive for excellence Respect Compassion Take responsibility & be accountable Make a difference day in & day out This paper provides assurance regarding performance of the Cardiac Arrest, Stroke and STEMI ACQI audits. Any relevant legal / statutory issues? N/A 1

2 Equality analysis completed If this is not relevant please explain why: Key considerations Yes No Not Relevant There has been no change to policy, function or service. This report is for information only. Details Confirm whether any risks that have been identified have been recognized on a risk register and provide the reference number: To be discussed at the meeting. Please specify any Financial Implications Please explain whether there are any associated efficiency savings or increased productivity opportunities? Are any additional resources required e.g. staff capacity? N/A To be discussed at the meeting for inclusion in the risk register as appropriate Is there any current or expected impact on patient outcomes/experience/quality? Above the national average in patients surviving to discharge. Specify whether appropriate clinical and/or stakeholder engagement has been undertaken: (stakeholders could include staff, other Trust departments, providers, CCGs, patients, carers or the general public) Are there any aspects of this paper which need to be communicated to our stakeholders (internal or external)? (Please tick if yes then please complete all boxes. Please briefly specify the key points for communication and ensure the Comms team are informed via mailto:publicrelations@neas.nhs.uk) N/A Yes No Positive Negative Proactive Reactive Internal External Please enter specified points 2

3 Clinical Audit Dashboard: Summary for January This is the January 2019 Clinical Audit Dashboard which provides updates on both the Trust s performance and on the national comparator performance for the Ambulance Clinical Quality Indicators in August During August the Trust performed above the national average in the following indicators: Code Indicator Description National Ranking R1n+R1r Cardiac Arrest, ROSC at hospital (All patients) 1 st R2n+R2r Cardiac Arrest, ROSC at hospital (Utstein group) 1st R3n+R3s Cardiac Arrest, Survival to Discharge (All patients) 1 st R4n+R4s Cardiac Arrest, Survival to Discharge ( Utstein group ) 1St Stroke care bundle 3 rd K1m Stroke mean average call to hospital time Joint 2 nd 1.2 During August the trust did not perform below the national average in any indicator. 1.3 In accordance with the national AQI submission timetable only the stroke care bundle was submitted. Care bundle element Number of fails BM 4 BP 1 There were 4 patients who had the care bundle failed. 1 patient, attended by Red Cross had BM and BP not recorded. Feedback on failed care bundles will be forwarded to line managers for feedback and action. 3

4 2.0 Clinical Audit Dashboard 4

5 Perfromance 3.0 Comparison of with National Average ROSC at Hospital - All Cardiac Arrest Patients National average ROSC at Hospital - Utstein Group National Avg 3.3 Survival to Discharge - All Cardiac Arrest Patients 1 National average Survival to Discharge - Utstein Group National average 5

6 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 HH:MM Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug Stroke Care Bundle % % National avg 3.6 Stroke - Mean Average Call to Hospital Time 01:40 01:26 01:12 00:57 00:43 00:28 00:14 00:00 National avg 6

7 4.0 ACQI Timings Measures 4.1 Outcomes from Acute STEMI - August 2018 Not available. 4.2 Outcomes from Stroke August Source : Sentinel Stroke National Audit Programme (SSNAP). Name K1n K1m K150 K190 K2n K2m K250 K290 K3n K3m K350 K390 Number of patients either FAST positive, or with provisional diagnosis of stroke, transported by Ambulance Service patients in K1n, mean average time from call to hospital arrival K1n, 50th centile (median) call to hospital arrival patients in K1n, the 90th centile call to hospital arrival Number of stroke patients in SSNAP who had a CT scan K2n, mean average CT scan K2n, median CT scan K2n, the 90th centile CT scan Number of stroke SSNAP who had patients in K3n, mean average patients in K3n, median time from arrival at hospital to patients in K3n, 90th centile time from arrival at hospital to England :11 01:05 01: :48 00:40 03: :58 00:50 01: :08 01:04 01: :51 00:38 03: :56 00:38 01:32 Ranking Joint 2nd 7