MORTALITY OF POWYS CITIZENS. Medical Director. This paper supports:

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1 MORTALITY OF POWYS CITIZENS QUALITY & SAFETY COMMITTEE 05 MAY 2016 AGENDA ITEM 2.2 Report of Medical Director Paper prepared by Safety & Quality Improvement Manager Purpose of Paper Action/Decision required To provide the committee with an overview of the organisations knowledge of the mortality levels of Powys citizens To note and consider any future actions Link to Health and Care Standards Link to Health Board s Annual Plan Acronyms and abbreviations This paper supports: Governance, Leadership and Accountability Theme 2: Safe Care Theme 3: Effective Care Theme 4: Dignified Care Theme 5: Timely Care Theme 6: Individual Care Ensuring the Right Access Striving for Excellence Involving the People of Powys Always with our Staff ABHB Aneurin Bevan University Health Board Mortality of Powys Citizens Page 1 of 19 Quality and Safety

2 MORTALITY OF POWYS CITIZENS Background As an organisation that provides care not only within Powys, but extensively commissions activity outside its borders, the Health Board must examine a number of sources to build a comprehensive picture of the mortality of its population. This report presents information from a number of sources to inform the committee of what is currently known about the mortality of Powys citizens. The report is presented in five sections: Section 1. Overall Mortality of Powys residents Section 2. Crude mortality rates of Powys residents treated in out of county District General Hospitals Section 3. A comparison of crude mortality rates suffered by Powys residents who are admitted on either an elective or emergency basis into the Aneurin Bevan Healthcare system with residents from other parts of the country Section 4. Mortality Rates as Reported in Audits from the National Clinical Audit and Outcomes Review Programme Section 5. A detailed review of inpatient deaths occurring in a six month period in Powys community hospitals 1. Overall Mortality of Powys Residents Data: Calendar year (Source: Public Health Wales) Total number of deaths of Powys residents: 1454 Table 1. Place of Death of Powys residents Place Number Percentage of total Out of County District General Hospital % Private residence in Powys % Residential/Nursing home in Powys % Community Hospital in Powys % Out of County Hospice % Out of County Residential/Nursing home % Powys other (workplaces/roads/rivers/public % places) Other Out of county/overseas categories % Powys community establishments (children s homes, sheltered accommodation, hostels, etc.) % Mortality of Powys Citizens Page 2 of 19 Quality and Safety

3 As can be seen from the table approximately 40% of Powys residents currently die at an out of county location. 2. Mortality of Powys residents treated in out of county District General Hospitals Data: Financial year 2014/15. (Source: Powys Informatics team) Table 2. Crude mortality rates (simply the percentage of those treated who die) for the main providers of commissioned out of county care. Place of treatment Number of Powys Number of Powys Crude mortality citizens treated citizens who died during treatment Shrewsbury and Telford hospitals % Aneurin Bevan Health Board % Abertawe Bro Morgannwg University % Health Board Wye Valley NHS Trust % Hywel Dda Health Board % Other English NHS Trusts % (combined) Other Welsh Health Boards % (combined) Robert Jones & Agnes Hunt % However crude mortality is not always an informative measure. Whilst it can be deduced that the patients who are admitted to Robert Jones & Agnes Hunt are admitted on an elective basis for orthopaedic surgery it might well be that Powys residents are being admitted to the other sites for palliative or emergency care. It can be useful therefore to examine whether there is a difference in mortality rates between elective and emergency admission. The next section seeks to examine this. Mortality of Powys Citizens Page 3 of 19 Quality and Safety

4 3. Mortality of Powys residents admitted to Aneurin Bevan Health Board as either elective or emergency admissions Data: Financial year 2014/15 (Source: Aneurin Bevan Health Board) Table 3. Mortality rates for Elective Admissions to Aneurin Bevan Health Board Number of elective admissions to ABHB of Powys residents 250 Number of deaths during elective admissions of Powys 1 residents Crude mortality rate for Powys residents who were elective 0.4% admissions Number of elective admissions to ABHB of residents from all 4869 other regions Number of deaths during elective admissions of residents 30 from all other regions Crude mortality rate for residents from all other regions who 0.6% were elective admissions Table 4. Mortality rates for Emergency Admissions Aneurin Bevan Health Board Number of emergency admissions to ABHB of Powys residents 1715 Number of deaths during emergency admissions of Powys 144 residents Crude mortality rate for Powys residents who were 8.4% emergency admissions Number of emergency admissions to ABHB of residents from all other regions Number of deaths during emergency admissions of residents 2929 from all other regions Crude mortality rate for residents from all other regions who 8.6% were emergency admissions Two conclusions can be drawn from this work. The first is that, as might be expected, the level of patient mortality is significantly higher in cases where the admission was an emergency. The second is that there is no significant difference between Powys residents and those admitted from other parts of the country in the mortality rates suffered during either emergency or elective admissions. Data anomaly note: It should be noted that whilst there is perfect agreement in the reported number of deaths of Powys residents in Aneurin Bevan Health Board, Powys Health Board and Aneurin Bevan Mortality of Powys Citizens Page 4 of 19 Quality and Safety

5 Health Board report different numbers of episodes of care. Examination of this disagreement was conducted by the Powys Information Team and concluded that Aneurin Bevan had excluded elective zero day and overnight admissions and emergency admissions with overnight stays where the patient survived, from their figures. However the comparison undertaken by Aneurin Bevan Health Board between Powys residents and other area residents was done on a like for like basis and so is still internally valid. 4. Mortality Rates as Reported in Audits from the National Clinical Audit and Outcomes Review Programme The audits of the National Clinical Audits and Outcome Review Programme focus largely on the processes of clinical care. They are mainly designed to assess whether each step of a care pathway is delivered in the manner that the evidence base suggests is the safest and most clinically effective. Some of the audits in the programme do however contain outcome measures. Arguably one of the most important of which is whether the patient lives or dies. This report abstracts the mortality data from recently published National Clinical Audits. Where possible, data is presented on a hospital by hospital basis, however some audits are conducted as part of multi-region networks. The quality of the audit depends entirely on the participation of the organisations providing the service. It is disappointing that some national audits are still not fully supported by the organisations concerned. In recent months Welsh Government has encouraged all Health Boards to fully participate in the National Clinical Audit Programme and to transparently publish their National Clinical Audit results and action plans on their organisational web pages. Compliance with this request will be monitored by Welsh Government during 2016/17. Mortality of Powys Citizens Page 5 of 19 Quality and Safety

6 National Audit of Head and Neck Cancers (2014) (Due to low numbers at individual hospitals audit figures are given by regional networks) Table 5. Observed versus expected deaths Area Number of cases Expected Deaths Observed Deaths Larynx North Wales South Wales West Midlands Oral Cavity North Wales South Wales West Midlands Oropharynx North Wales South Wales West Midlands No areas were considered outliers in this study as observed deaths were within statistical control limits of expected mortality for these conditions. Mortality of Powys Citizens Page 6 of 19 Quality and Safety

7 National Bowel Cancer Audit (2014) Table 6. Crude mortality post surgical intervention Area Number of patients treated % of cases done as an emergency (%) % of cases with metastases at time of operation (%) Risk adjusted 90 day crude mortality (%) Risk adjusted 2 year crude mortality (%) WALES average Bronglais Cardiff Nevill Hall Prince Charles Princess of Wales Royal Glamorgan Royal Gwent Swansea Hospitals Prince Philip Withybush Glan Clwyd Gwynedd Wrexham SaTH Wye Valley Top 3 UK organisations Royal Marsden Maidstone Salisbury Bottom 3 UK organisations Kettering Tameside Nevill Hall Mortality of Powys Citizens Page 7 of 19 Quality and Safety

8 The National Oesophago-gastric cancer audit (2015) Table 7. Outcomes after curative Surgery by Health Board (note: outcomes for Health Boards performing less than 10 operations per year not reported) Health Board Number of patients 30 day % mortality Risk adjusted 60 day % mortality Risk adjusted Betsi Cadwaladr University Health Board Hywel Dda University Health Board Abertawe Bro Morgannwg University Health Board Cardiff and Vale University Health Board Best in class (high volume) operators Newcastle upon Tyne Hospitals FNHST Nottingham University Hospital NHS Trust Plymouth Hospitals NHS Trust Mortality of Powys Citizens Page 8 of 19 Quality and Safety

9 Trauma Audit and Research Network (2015) Unfortunately no meaningful information could be gained from this audit due to poor participation by Welsh Health Boards and bordering English trusts in last year s data collection exercise Table 8. % of trauma cases submitted by organisation for auditing Organisation Year: 2013 Year: 2014 Year: 2015 Abertawe Bro 91.5% 86% 53% Morgannwg University Health Board Aneurin Bevan Health Board 4% No data submitted No data submitted Cardiff & Vale 86% 83% 57.5% Health Board Cwm Taf Health No data 57.7% 58.5% Board submitted Hywel Dda 17% 15% 33% Health Board Betsi 36% 47% 25% Cadwaladr Health Board Shrewsbury 31% 45% 54% and Telford Hospitals NHS Trust Wye Valley NHS Trust 49% 79% 29% Mortality of Powys Citizens Page 9 of 19 Quality and Safety

10 National Lung Cancer Audit (2014) Note: The audit does not give mortality data at an individual hospital basis but instead gives regional survival data. Mortality of Powys Citizens Page 10 of 19 Quality and Safety

11 Table 9. It does however give some process measures for individual hospitals Site Number of cases % discussed at MDT % patient receiving CT before bronchoscopy % patient seen by specialist nurse % patients with histological diagnosis % patients being actively treated % patients receiving surgery % patients receiving radiotherapy YGC WM YG BGH PPH With PoW Sing Morr NPT UHL RGlH PCH NHH RGwH Herfd SaTH England Key YGC Ysbyty Glan Clywd WM Wrexham Maelor YG Ysbyty Gwynedd BGH Bronglais General Hospital PPH Prince Philip Hospital With. Withybush Hospital PoW Princess of Wales Hospital Sing. Singleton Hospital Morr. Morriston Hospital NPT Neath Port Talbot UHL University Hospital Llandough RGlH Royal Glamorgan Hospital PCH Prince Charles Hospital NHH Nevill Hall Hospital RGwH Royal Gwent Hospital Herfd Hereford County Hospital SaTH Shrewsbury and Telford Hospitals Mortality of Powys Citizens Page 11 of 19 Quality and Safety

12 SSNAP: Sentinel Stroke National Audit Programme (April-June 2015) Note: Due to a technical issue with the audit data capture web page it is not possible to extract mortality data from the audit. SSNAP is an ongoing quality database rather than a traditional clinical audit with a fixed end date and the table below shows data for the period 1 April 2015 to 30 June Table 10. All qualifying hospitals in England and Wales have been invited to participate in this rolling audit database. Hospitals are judged on 8 categories of care receiving a Grade A if they achieve this standard for >80% of patients, B (70-80%) C (60-69%) D (40-59%) and E <40% All Welsh hospitals are shown with data from the three top English hospitals provided as a comparison. Mortality of Powys Citizens Page 12 of 19 Quality and Safety

13 MINAP: The Myocardial Ischaemia National Audit Programme (2014) Table 11. The audit gives mortality rates for the first 30 days postheart attack Site Number of cases % of patients who die within 30 days of heart attack % of patients for whom PCI was performed % of cases submitted to the audit Morriston University Hospital Wales Bronglais Hereford Glan Clwyd Glangwili Llandough Nevill Hall Prince Charles Prince Philip Princess of Wales Telford (Princess Royal) Royal Glamorgan Royal Gwent Royal Shrewsbury Glangwili¹ Withybush Wrexham Maelor Ysbyty Gwynedd Historic cases reported under the previous name of West Wales General Hospital Mortality of Powys Citizens Page 13 of 19 Quality and Safety

14 National Hip Fracture Database (NHFD) 2014 The NHFD uses validated third party data on death from the Office of National Statistics to report on deaths that occur within 30 days of surgery for fractured neck of femur. Hip fracture is a significant predictor of near future mortality with one third of people suffering a fracture dying within 12 months of the event. Deaths within 30 days however are often down to factors that can be avoided if best practice is followed. All 180 units providing acute hip fracture care in England, Wales and Northern Ireland were included in this audit. A funnel plot of crude and adjusted mortality was then constructed. The average crude mortality rate within 30 days was calculated to be 7.5%. Seven hospitals were identified as having a mortality rate more than two standard deviations higher than the average. These are: Medway Maritime Hospital Bristol Royal Infirmary North Middlesex Hospital Royal Cornwall Hospital Mortality of Powys Citizens Page 14 of 19 Quality and Safety

15 Hereford County Hospital St Thomas Hospital Royal Shrewsbury hospital All participating organisations have been advised of the results of the audit. Analysis by the Powys Informatics department however showed that the 30 day mortality of Powys residents treated at Royal Shrewsbury Hospital for fractured neck of femur was, at 5.2%, much lower than the national average. Only 8 Powys residents were treated at Hereford County Hospital for fractured neck of femur during this time period, all of whom survived to 30 days post surgery. 5. A detailed review of inpatient deaths occurring between 1 January 2015 and 30 June 2015 in Powys community hospitals All in-patient hospital deaths that occur in Powys Community Hospitals are reviewed as a matter of course by the local team of clinicians. To obtain a greater overview of Powys in-patient mortality however, the Medical Director ordered a further review of all deaths occurring between 1 January 2015 and 30 June Deaths were assessed as to whether they matched the criteria of one of three categories: Expected Death. For these patients palliative care was the agreed plan of care at the point of death. Some of these patients may have been admitted for end of life care, others may have been determined to be for palliative care after assessment. For all such patients the Integrated Care Priorities (ICP) for the provision of end of life care would have been considered but would not have been offered if the patient was still able to eat and drink up to the point of death. Unanticipated but Unsurprising Death. For these patients active care was still being provided at the point of death. However it would have been previously recognised that the patient had one or more life limiting conditions and their future life expectancy would have been considered to be less than 12 months. For these patients a ceiling of care would have been agreed with them or their relatives. (e.g. not for resuscitation, not for transfer to acute care out of county). Discharge home for end of life care might have been an option that was discussed, but their immediate death was not anticipated. Mortality of Powys Citizens Page 15 of 19 Quality and Safety

16 Unexpected Death. For these patients active care was still being provided at the point of death. There would have been no indication in the notes that the patient was suffering from a life limiting condition. A full recovery was expected and discharge to their normal place of residence would have been the care plan at the time of death. 113 Cases were reviewed and of these 96 were determined to be Expected Deaths with palliative care being the treatment plan at point of death. 42 of these patients had been admitted specifically to receive end of life care. 15 cases were considered to be Unanticipated but Unsurprising Deaths. Though active treatment or discharge planning was still being undertaken at the point of death, all parties were aware that the patient had a limited life expectancy. In 2 cases the patient suddenly died whilst in hospital care. There was no indication that this was linked to any treatment or medication that they had received. Both unexpected deaths and all unanticipated deaths have been submitted to the Medical Director for his personal review. Table 12. Six month inpatient mortality figures Powys Hospitals Hospital Number of Deaths Number admitted with initial goal of palliative care Expected deaths (patients receiving palliative care) Number on ICP at time of death Unanticipated but Unsurprising deaths Unexpected deaths Brecon Bronllys Knighton Llandrindod Llanidloes Machynlleth Newtown Welshpool Ystradgynlais Total Mortality of Powys Citizens Page 16 of 19 Quality and Safety

17 Figure 1. Male/Female ratio of in-patient deaths in Powys hospitals - 1 January 2015 and 30 June 2015 Figure 2. Age at death of in-patients in Powys hospitals 1 January 2015 and 30 June 2015 Mortality of Powys Citizens Page 17 of 19 Quality and Safety

18 Figure 3. Primary Cause of in-patient deaths in Powys hospitals 1 January 2015 and 30 June 2015 Recommendation The Quality and Safety are asked to approve the following recommendations:- 1. Use Commissioning Framework to develop view of mortality for Powys population across secondary care. 2. Work with providers to ensure they take part in national audits to benchmark practice. 3. Work with National Mortality Group to develop primary care review system. Report prepared by: Dr Howard Cooper Safety & Quality Improvement Manager Presented By: Dr Stephen Edwards Medical Director Mortality of Powys Citizens Page 18 of 19 Quality and Safety

19 Mortality of Powys Citizens Page 19 of 19 Quality and Safety