Enhanced Recovery: Measurement for Improvement Monthly Data Submission Guidance. Version 1.0

Transcription

1 Enhanced Recovery: Measurement for Improvement Monthly Data Submission Guidance Version 1.0

2 Document Control Version Version 1.0 Date Issued January 2014 Document To provide guidance for the monthly collection of Enhanced purpose Recovery data. Author Further Information Whole System Patient Flow Improvement Programme Enhanced Recovery monthly data collection Guidance Notes Page 2

3 Contents Context... 4 Purpose... 4 Aim... 4 Approach... 4 Enhanced Recovery After Surgery Data collection cohorts... 5 Definition of Cohorts... 5 Data collection - Summary information... 7 Operational Definitions... 8 Submitting data Data submission methods Timescales Feedback Contacts Additional guidance for using the excel template Appendix 1: Measures for Improvement - Enhanced Recovery Appendix 2: Monthly Data Submission Example Appendix 3: Timetable for data submissions Enhanced Recovery monthly data collection Guidance Notes Page 3

4 Context In 2010, the Quality Strategy (Scottish Government, 2010) was published defining the strategic vision of the future health service in Scotland. Three broad overarching themes of safe, effective and patient centred care were put forward as central to the vision. The strategy stated that the most appropriate treatments, interventions will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated. The principles of Enhanced Recovery fit with the overall vision of the Whole System Patient Flow Improvement Programme of, right care, right time, right place, right team every time. The Programme will use an improvement approach to focus on reducing variation and achieving reliable implementation and spread of enhanced recovery across specialties across NHS Scotland. Purpose The use of real time clinical data is critical in developing an understanding of how systems are currently delivering services and the level of variation that exists. The national team will work in partnership with local NHS Boards to ensure the effective introduction of the measurement strategy and thereafter engage NHS Boards with the outcomes of this data collection and analysis. Collating a national dataset of information for improvement allows NHS Boards to understand where the opportunities for improvement exist (through highlighting of variation) and identifies areas of best practice, which enables signposting. The aim of this document is to support you locally with implementing measurement for improvement. How Enhanced Recovery implementation is measured is challenging at present as detailed data specific to Enhanced Recovery is not easily identifiable at a local or national level from the current Patient Administration Systems (PAS). This agreed group of clinical measures will support the evaluation of the current position in relation to enhanced recovery implementation and thereafter allow monitoring of the progress of reliable implementation and spread. Aim Reliable implementation and spread of enhanced recovery principles across specialties. Approach The use of real time clinical data is critical in supporting engagement with key stakeholders and as previously stated no clearly defined and agreed measurement for improvement strategy is in place. This is a priority for the work stream. Collating a national dataset of information for improvement allows NHS Boards to understand where the opportunities for improvement exist and identifies areas of best practice. Through the development of real time local data bases, services will be able to continuously monitor and improve services, providing evidenced based care and measuring the impact of these changes. Through the national and local teams within boards working collaboratively, we will build the will and create the conditions for reliable implementation and spread of Enhanced Recovery. As this is a new dataset it has the opportunity to develop over time. As part of the data development, we value your judgement and comments. A list of the Enhanced Recovery measures for improvement can be found in Appendix 1. Enhanced Recovery monthly data collection Guidance Notes Page 4

5 Enhanced Recovery After Surgery Data collection cohorts The Enhanced Recovery monthly data collection gathers information on patients accessing the following surgical services: Orthopaedics - Knee replacement - Hip replacement Colorectal - Colectomy - Excision of Rectum Gynaecology - Hysterectomy Urology - Bladder Resection Breast - Mastectomy & Excision of lesion of breast Definition of Cohorts Data is to be collected for all patients with an elective surgery that includes the following procedures: Colorectal Services - Colectomy H04 H05 H06 H07 H08 H09 H10 H11 H29 Total excision of colon and rectum (Clean-Contaminated) Total excision of colon (Clean-Contaminated) Extended excision of right hemicolon (Clean-Contaminated). Includes: Excision of right colon and other segment of ileum or colon and surrounding tissue Other excision of right hemicolon (Clean-Contaminated). Includes: Limited excision of caecum and terminal ileum caecum Excision of transverse colon (Clean-Contaminated) Excision of left hemicolon (Clean-Contaminated) Excision of sigmoid colon (Clean-Contaminated) Other excision of colon (Clean-Contaminated). Includes: Excision of colon where segment removed is not stated Subtotal excision of colon and rectum (Clean-Contaminated) - Excision of Rectum H33 Excision of rectum Gynaecology Services - Hysterectomy Q07 Abdominal excision of uterus Q08 Vaginal excision of uterus Urology Services - Bladder Resection M34 Total excision of bladder M35 Partial excision of bladder Enhanced Recovery monthly data collection Guidance Notes Page 5

6 Breast Services - Mastectomy & Excision of lesion of Breast B27 B28 B29 B30 Total excision of breast Other excision of breast Reconstruction of breast Prosthesis for breast Orthopaedics - Knee replacement W401 Primary total prosthetic replacement of knee joint using cement W408 Total prosthetic replacement of knee joint using cement - Other specified W409 Total prosthetic replacement of knee joint using cement - Unspecified W411 Primary total prosthetic replacement of knee joint not using cement W418 Total prosthetic replacement of knee joint not using cement - Other specified W419 Total prosthetic replacement of knee joint not using cement - Unspecified W421 Primary total prosthetic replacement of knee joint NEC W428 Other total prosthetic replacement of knee joint - Other specified W429 Other total prosthetic replacement of knee joint - Unspecified - Hip replacement W371 Primary total prosthetic replacement of hip joint using cement W378 Total prosthetic replacement of hip joint using cement - Other specified W379 Total prosthetic replacement of hip joint using cement - Unspecified W381 Primary total prosthetic replacement of hip joint not using cement W388 Total prosthetic replacement of hip joint not using cement - Other specified W389 Total prosthetic replacement of hip joint not using cement - Unspecified W391 Primary total prosthetic replacement of hip joint NEC W398 Other total prosthetic replacement of hip joint - Other specified W399 Other total prosthetic replacement of hip joint - Unspecified W461 Primary prosthetic replacement of head of femur using cement W468 Prosthetic replacement of head of femur using cement - Other specified W469 Prosthetic replacement of head of femur using cement - Unspecified W471 Primary prosthetic replacement of head of femur not using cement W478 Prosthetic replacement of head of femur not using cement - Other specified W479 Prosthetic replacement of head of femur not using cement - Unspecified W481 Primary prosthetic replacement of head of femur NEC W488 Other prosthetic replacement of head of femur - Other specified W489 Other prosthetic replacement of head of femur - Unspecified Note: Data is collected by NHS Board of Treatment, i.e. include patients resident in other NHS Board areas if they meet the cohort criteria and are being treated in your NHS Board area. Data must be included for every patient who meets the Cohort criteria, even if they are not treated on an Enhanced Recovery pathway. Enhanced Recovery monthly data collection Guidance Notes Page 6

7 Data collection - Summary information The following data items should be completed for each cohort of patients included Hospital name of location where the procedures were carried out. NHS Board name of NHS Board location operates within. Month (MM/YYYY) month in which surgeries were carried out. Surgical Specialty procedure grouping for example: - Orthopaedics Hip replacement - Orthopaedics Knee replacement - Colorectal Colectomy - Colorectal Excision of rectum - Gynaecology Hysterectomy - Urology Bladder resection - Breast - Mastectomy & Excision of lesion of Breast Cohort size Enter the total number of patients within the target cohort, including those who are not on an Enhanced Recovery pathway. Patient Demographics The Enhanced Recovery data collection requires the following personal patient data to be collected for every patient in the target cohort: CHI Number Date of Birth Sex (gender) Data must be included for every patient who meets the cohort criteria, even if they are not treated on an Enhanced Recovery pathway. Enhanced Recovery monthly data collection Guidance Notes Page 7

8 Operational Definitions Data item Format Operational Definition Related to measure: Patient identifiers CHI number 10 digits The Community Health Index (CHI) is a population register, which is used in Scotland for health care purposes. The CHI number uniquely identifies a person on the index Date of Birth DD/MM/YYYY Date of birth of patient. Sex (gender) Consultant Male or Female Text Initial and Surname Gender of patient. Male or Female can be entered. Name of consultant carrying out procedure. Episode Information Pre-admission education text Confirm whether or not a patient has received any education on Enhanced Recovery prior to their admission. ERP1 Options Y N Description Yes, they have received education. No, they have not received education. Carbohydrate drink given preoperatively text Confirm whether or not a patient has received a carbohydrate drink preoperatively. Options Description ERP2 Y N N (local clinical protocol) Yes, they have received a carbohydrate drink preoperatively. No, they have not received a carbohydrate drink preoperatively. No, as per compliance with local clinical protocol. IV fluids stopped by midday on post-operative day 1 text Confirm whether or not a patient had IV fluids stopped by 12 midday on day one post operatively or earlier. post-operative day 1 is defined as: the day after surgery. The day of surgery is post-operative day 0. ERP3 Enhanced Recovery monthly data collection Guidance Notes Page 8

9 Options Y N Description Yes, patient s IV fluids were stopped by midday on day one post operatively. No, patient s IV fluids were not stopped by midday on day one post operatively. Mobilised (weight bearing for approx. 2 hour period) by midday on post-operative day 1 text Confirm whether or not a patient was mobilised by 12 midday on day one post-operatively. Mobilisation must be weight bearing and the patient should be out of bed for a continuous period of approx. 2 hours. e.g. from 9:30 to 11:30 a.m. post-operative day 1 is defined as: the day after surgery. The day of surgery is post-operative day 0. ERP4 Options Y N Description Yes, patient was mobilised by 12 midday on day one post-operatively and was out of bed for approx. two hours. No, patient was not mobilised by 12 midday on day one post-operatively. Recommenced Normal Diet by midday on postoperative day 1 text Confirm whether or not a patient recommenced their normal diet (or was given supplement drinks where appropriate) by 12 midday on day one post-operatively. post-operative day 1 is defined as: the day after surgery. The day of surgery is post-operative day 0. ERP5 Options Y N Description Yes, patient recommenced their normal diet (or given supplement drinks where appropriate) by 12 midday on day one postoperatively. No, their normal diet was not recommenced (and supplement drinks were not given) by 12 midday on day one post operatively. Patient catheterised text Confirm whether or not an orthopaedic patient was catheterised during this episode of surgical care. ERP6 Options Y Y (Pre-existing) N Description Yes, patient catheterised. Yes, as was catheterised prior to admission as part of on-going medical condition. No patient not catheterised. Date of admission DD/MM/YYYY The date the patient was admitted for the episode of care that included surgery. ERO1 ERO3 Enhanced Recovery monthly data collection Guidance Notes Page 9

10 Date of Surgery DD/MM/YYYY The date the surgical procedure was carried out. ERO1 ERO2 Date discharge criteria met DD/MM/YYYY The date that the clinical team decided that the patient had met the criteria to allow discharge. ERO4 Date of discharge DD/MM/YYYY The date that the patient was discharged from hospital. ERO2 ERO3 ERO4 ERB1 Readmissions Readmission within 30 days of discharge? text Record whether or not the patient was readmitted as an inpatient to any specialty for an issue related to the surgery, within 30 days of discharge. ERB1 Options Y N Description Yes, the patient was readmitted to hospital for an issue relating to the surgery, within 30 days of discharge. No, the patient was not readmitted for an issue relating to the surgery, within 30 days of discharge. Date of readmission DD/MM/YYYY Date of any readmission as an inpatient to any specialty for an issue related to the surgery, within 30 days of discharge. ERB1 If more than one readmission in the period, enter the date of the first readmission related to the surgery. Comments / Queries text Please use this field to feedback any coding issues you may have with the patient record, to enable the data development process. Enhanced Recovery monthly data collection Guidance Notes Page 10

11 Submitting data Complete patient data should be submitted by each NHS Board for each surgical specialty procedure grouping as applicable. The monthly data submission should be completed by the Health Board of Treatment (HBT). Data submission methods The two options for data submission available to NHS Boards are: 1. an extract from existing NHS Board database for analysis. The NHS Board extract should include all data fields detailed in this Guidance Document. Please contact Kathryn Neill to discuss this further if required. 2. Complete the supplied Excel Workbook template (see Appendix 2) and completed spread sheets. Please submit a separate data sheet for each specialty. These can be compiled in one excel workbook. Please send data to nss.erdata@nhs.net Timescales Data should be returned by the 7 th of the second month after surgery (or first working day thereafter, if the 7 th is at a weekend). (see Appendix 3 for a timetable). If this deadline cannot be met, please notify us as soon as possible. If technical issues are experienced in data entry or submission, please contact Kathryn.Neill@scotland.gsi.gov.uk for clarification. Feedback This is a new dataset that may develop over time. As part of the data development, we value your judgement and comments. Please use the comments/queries field within the excel workbook to feedback coding issues you have on a patient basis. We welcome any feedback you would like to give at any time. Contacts Data collection feedback, issues & data coding queries: Kathryn Neill, Information Advisor Tel: Kathryn.Neill@scotland.gsi.gov.uk Enhanced Recovery Programme queries: Michelle McNulty, Enhanced Recovery Programme Lead Tel: Michelle.McNulty@scotland.gsi.gov.uk Enhanced Recovery monthly data collection Guidance Notes Page 11

12 Additional guidance for using the excel template See Appendix 2 for an example of the Excel template. It is important that you do not alter the template or enter data into the shaded cells. When entering the sex of a patient Male or Female can be entered. The following data items are validated to limit the data that can be entered to Y for Yes and N for No: Pre-admission education IV fluids stopped by midday on day one post operatively Mobilised (weight bearing and for approx. 2 hours) by midday on post-operative day 1. Recommenced normal diet by midday on post-operative day 1. Readmission within 30 days of discharge To enter the appropriate code, first select the cell and click on the arrow that appears and select the value from the drop down list. The following data items are validated to limit the data that can be entered to Y, N and one other option Carbohydrate drink given pre-operatively (excluding Orthopaedic and Breast patients) Patient catheterised (Orthopaedic patients only) To enter the appropriate code, first select the cell and click on the arrow that appears and select the value from the drop down list. Data items that are dates should be entered in the following format DD/MM/YYYY: Date of Admission Date of Operation Date Discharge Criteria met Date of Discharge Date of readmission The Excel template includes a range of formulas, to automatically calculate totals at the top of the sheet. Please do not alter the formula or template. Enhanced Recovery monthly data collection Guidance Notes Page 12

13 Appendix 1: Measures for Improvement - Enhanced Recovery Cohort Code ERC1 Measure This is the total number of elective patients for the cohort Process Measures All of the below process measures are aimed to measure compliance with the ERAS pathway elements and will be reported for your cohort Code ERP1 ERP2 Measure Patient given pre admission education about their Enhanced Recovery Pathway. Patient given carbohydrate drinks pre-operatively. ERP3 Patient had IV fluids stopped by midday on post-operative day 1. ERP4 Patient mobilised by midday on post-operative day 1 (mobilisation must be weight-bearing and patients should be out of bed for approx. 2 hours). ERP5 ERP6 Patient recommenced normal diet (or given supplement drinks where appropriate) by midday on post-operative day 1. Patient catheterised. Outcome Measures The below outcome measures will be generated based on the information collected in the submission template Code ERO1 ERO2 ERO3 ERO4 Measure Median days between date admitted and date of surgery. Median post-operative length of stay. Median total length of stay. Median days between meeting discharge criteria and actual discharge Balancing Measure The below balancing measure will be generated from the information collected in the submission template. Code ERB1 Measure Percentage of patients readmitted within 30 days. Enhanced Recovery monthly data collection Guidance Notes Page 13

14 Appendix 2: Monthly Data Submission Template Example Hospital NHS Board Month Surgical Specialty procedure grouping Cohort size (ERC1) 0 Check data ERC1 Check: ERP1 ERP2 ERP3 ERP4 ERP5 ERP6 ERB1 n/a n/a n/a n/a n/a n/a n/a Patient Identifiers Episode Information ERP1 ERP2 ERP3 ERP4 ERP5 ERP6 Readmissions ERB1 Comments / Queries CHI Number Date of Birth 10 digit number DD/MM/YYYY Sex (gender) Consultant Pre-admission Education Male / Female Initial and surname Yes/No Carbohydrate drink given preoperatively IV Fluids stopped by Mobilised by midday on postoperative day 1 operative day midday on post- 1 Yes/ No/ No (as per local clinical protocol) Yes/No Yes/No Yes/No Recommenced Normal Diet by midday on postoperative day 1 Patient catheterised Date of Admission Date of Surgery Date Discharge Criteria met Date of Discharge Readmission within 30 Days of discharge? Date of Readmission Yes/ Yes (preexisting catheter) /No DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY Yes/No DD/MM/YYYY

15 Appendix 3: Timetable for data submissions In order to give sufficient time to check for any readmissions within 30 days, while also obtaining data in as timely a way as possible, please return the month s data by the 7 th (or next working day after if the 7 th is at the weekend) of the second month after the period of data collection. A timetable is shown below for the up to December Month of surgery data collection For surgeries carried out during the period: Deadline for submissions March /03/14 31/03/14 07/05/14 April /04/14 30/04/13 09/06/14 May /05/14 31/05/14 07/07/14 June /06/14 30/06/14 07/08/14 July /07/14 31/07/14 08/09/14 August /08/14 31/08/14 07/10/14 September /09/14 30/09/14 07/11/14 October /10/14 31/10/14 08/12/14 November /11/14 30/11/14 07/01/15 December /12/14 31/12/14 09/02/15 If, at the time of submitting data, 30 days has not passed since the discharge of a patient, please include the patient s record within the dataset and resubmit when the period of 30 days after discharge has been completed.