Quality Indicator Local Use of Data The clinical audit lead for each contributing site was contacted and asked to answer the following questions (in their own words) about the use of STAG data. In general, how does your hospital utilise the STAG trauma data, i.e. how is the data reviewed, with whom is this shared? How does your hospital utilise the STAG data to inform practice/ influence change/ improvement? Please give an example(s) of when STAG data has been used to influence change/ improvement. Please tell us about Action Plans in your local area to address quality improvement of the care of trauma patients: o Patients highlighted for review by (to date December 2012) STAG quality standards in 2012. o Number of cases reviewed locally. o Number where quality improvements were identified. o Give examples of the types of quality improvements identified and how these will be achieved locally. Any other relevant comments/ summary/ conclusion. Please note due to timescales for submission and feedback of data, sites were asked to comment on all patients highlighted for review whose completed data had been submitted by 10th November 2011 rather than the full year.
NHS Ayrshire & Arran Ayr Hospital data reviewed, with whom is this shared? Data presented at monthly departmental audit meetings and shared with specialties involved if relevant to clinical processes How does your hospital utilise the STAG data to inform practice/ influence change/ improvement? Incorporation of clinical information to guidelines e.g. compound fracture management. Please give an example(s) of when STAG data has been used to influence change/ improvement. Recognising recurrent process issues and need for capital/personnel development e.g. delays to CXR shared, unprotected resus bays. Please tell us about Action Plans in your local area to address quality improvement of the care of trauma patients: Capital development, colocation of radiography facilities in 2012. 35 Number of cases reviewed locally. 33 Number where quality improvements were identified. Give examples of the types of quality improvements identified and how these will be achieved locally. Any other relevant comments/ summary/ conclusion.
Crosshouse Hospital data reviewed, who is this shared with? STAG trauma data is reviewed monthly at departmental audit meeting and shared with Emergency Department Staff How does your hospital utilise the STAG data to inform practice/influence change/improvement? STAG data is used to trigger cases for discussion and identify any improvements required in trauma care and documentation within the Emergency Department Please give an example(s) of when STAG data has been used to influence change/improvement Improvement in documentation in patients with minor and serious head injuries. Attempts to reduce delays to relevant radiological investigations. Increasing use of blood gas analysis in early management of major trauma. Importance of recording of ECG particularly in elderly patients suffering serious injury. Actions planned in your local area to address quality improvement of the care of trauma patients: in 2012: 68 Number of cases reviewed locally: 68 Number where quality improvements were identified: 35 Give example of types of quality improvements identified and how these will be achieved locally Chest xray should have been done earlier staff reminded that there are xray facilities in resus and the xray staff are used to working round ED staff. ABG should have been done staff reminded of the importance of ABG in trauma
ECG should have been done in view of trauma and age It was agreed round the table that more care must be taken with the documentation during the patients pathway through ED, on the whole the care appears appropriate but the documentation of times and procedures as well as referral times and doctor attending times is poor Any other relevant comments/summary/conclusion ED consultant is now reviewing all head injury patients who are transferred to SGH on a monthly basis looking at the reasons for transfer, any delays if so, why? Proforma is now being used more than not after last years issues raised by STAG audit
NHS Fife Victoria Hospital data reviewed, who is this shared with? Any patient with 3 or more missed indicators and/or any patient not seen by a consultant within an hour reviewed by Clinical Audit Lead/Local Coordinator. Weekly report to ED Clinical Safety Lead for consideration of discussion at M+M and/or Clinical Safety meeting and any subsequent issues addressed by Consultant and Charge Nurse. When appropriate, adverse events also discussed with relevant specialities. Monthly report to ED Senior Staff meeting by Local Coordinator. How does your hospital utilise the STAG data to inform practice/ influence change/ improvement? See above. Feedback is also given to nursing staff at departmental nurse meetings. Liaison with SAS Performance manager regarding missed Standby Call indicator. Collected data has been used to assess markers of injury severity to trigger protocol/algorithm investigation pathways to reduce treatment delays. Please give an example(s) of when STAG data has been used to influence change/ improvement. Highlighted need for ATLS training in Orthopaedics Middle Grade Doctors. Surgical High Dependency (SHDU) Referral Pathway established for outofhour polytrauma patients. Triggers for proposed Trauma Team and Pan CT based on analysis of previous collated data under discussion with relevant departments. Joint admission documentation has been superseded by standalone trauma documentation which is in the process of being reintroduced in a new format. Actions planned in your local area to address quality improvement of the care of trauma patients: in 2012: 41 Number of cases reviewed locally: 23 Number where quality improvements were identified: 6
Give example of types of quality improvements identified and how these will be achieved locally SHDU referral pathway (agreed and implemented). Pan CT pathway (under discussion). Criteria for critical care review in ED of polytrauma patients (agreed and implemented).
NHS Forth Valley Forth Valley Royal Hospital data reviewed, who is this shared with? Notes for every patient who died, was an unexpected survivor or who did not fulfil a STAG indicator are reviewed by LMD and LC. Where it is felt there is a potential for improved care the information is shared with the staff who treated the patient, and anonymously all other ED staff. How does your hospital utilise the STAG data to inform practice/ influence change/ improvement? 7 STAG trauma cases discussed at emergency department departmental M&M meetings including 3 cases with spinal fractures. As a result this an ED guidelines for back injuries was introduced, and the teaching on spinal injuries for junior medical staff was revised. There was a cold debrief following a multicasualty road traffic collision, from which 10 patients attending the ED. Please give an example(s) of when STAG data has been used to influence change/ improvement. Teaching of spinal injuries to junior staff reviewed and improved. ED spinal injury guidelines introduced Actions planned in your local area to address quality improvement of the care of trauma patients: in 2012: 49 Number of cases reviewed locally: 49 Number where quality improvements were identified: 10 Give example of types of quality improvements identified and how these will be achieved locally Delay to antibiotics in open fractures highlighted to all ED staff ABG s not documented
Consultant arrival times not documented Awareness improved by communicating with staff
NHS Grampian Aberdeen Royal Infirmary data reviewed, who is this shared with? Reviewed by local coordinator with Emergency Department and radiology at monthly Trauma/Radiology meeting. Presented annually at multidisciplinary trauma meeting. How does your hospital utilise the STAG data to inform practice/ influence change/ improvement? Individual case review with feedback as appropriate to other specialities/organisations. Identification of recurrent issues (for examples see below) Please give an example(s) of when STAG data has been used to influence change/ improvement. Identification of need to improve documentation has led to reintroduction of trauma form which is now started at point of prewarning call from SAS. Delays in acquiring (and reporting) CT scans were identified and highlighted to radiology department through CT users group. Significant improvements have occurred mainly attributable to new location of CT scanner but also to raised awareness and new working relationship. Next step is to introduce use of primary CT report as recommended in Royal College of Radiologists. Actions planned in your local area to address quality improvement of the care of trauma patients: in 2012: 39 Number of cases reviewed locally: 39 Trauma data collection restarted in Aberdeen Royal Infirmary in July 2012 STAG data is being used to inform the development of a hospital based vehicle prehospital trauma response and the reorganisation of inhospital trauma response.
NHS Greater Glasgow & Clyde Glasgow Royal Infirmary data reviewed, who is this shared with? 3 monthly Trauma meeting Shared with Anaesthetics/itu/surgery and orthopaedics How does your hospital utilise the STAG data to inform practice/ influence change/ improvement? Glasgow Royal Infirmary Trauma Group was founded 2 years ago We work to develop the role of the Trauma Team and Trauma based protocols STAG data is presented at the meetings and discussed Please give an example(s) of when STAG data has been used to influence change/ improvement. Mainly to improve our documentation poor target performance when scrutinised appears mainly to be due to poor documentation We have a detailed trauma proforma All Trauma team activations / stand downs and misses are reviewed Actions planned in your local area to address quality improvement of the care of trauma patients: in 2012: Number of cases reviewed locally: Unexpected survivors and deaths are reviewed individually at the meetings Number where quality improvements were identified: Unknown Give example of types of quality improvements identified and how these will be achieved locally Improving access to and presence of senior decision makers Any other relevant comments/ summary/ conclusion Ongoing review of Major Haemorrhage Protocol in progress
Protocol for pre hospital activation of MHP in place
Western Infirmary Glasgow data reviewed, who is this shared with? Following on from the previous year, we continue to hold regular meetings with the local STAG coordinator to discuss cases and highlight issues. This has led to the organisation and integration of a STAG presentation into the monthly Departmental Teaching Programme. All those cases with ISS>15 are presented to both the Senior and Junior Medical and Nursing Staff, with a brief overview and awareness is raised about missed audit data. One STAG trauma case is then discussed in detail by the group, looking at timings and possible areas of improvement. Information and monthly figures are displayed on the notice board. How does your hospital utilise the STAG data to inform practice/ influence change/ improvement? The development of the monthly meetings has allowed a forum for discussion and debriefing of cases, and particular learning points are highlighted. This multidisciplinary approach allows input from numerous groups for potential solutions. Please give an example(s) of when STAG data has been used to influence change/ improvement. This has led to Time to Antibiotics being highlighted as an area for improvement. It also allowed the pitfalls of Handover to be discussed, and we are now looking at developing specific tools to facilitate handover of these complicated patients. Difficulties with intra hospital transfers has also been discussed Actions planned in your local area to address quality improvement of the care of trauma patients: in 2012: 119 Number of cases reviewed locally: 117 Number where quality improvements were identified: 22 Give example of types of quality improvements identified and how these will be achieved locally
We are in the process of developing a handover process and tool for staff to use, to ensure that complicated patients receive all necessary procedures and specialist input. We are also looking at Checklists to improve the transfer process of patients within, and outwith the department. Any other relevant comments/ summary/ conclusion The development of the teaching sessions allows a rapid feedback session to the staff and has resulted in often insightful and meaningful discussion about system errors and failings. The department, in the last few months, has moved towards 24 hour presence of Consultant staff within the department during the working week. We wait to see if this has an effect on our STAG quality indicators.
Victoria Infirmary, Glasgow data reviewed, who is this shared with? Monthly Feedback from STAG Analyst Quality Indicator Feedback Early Quality Indicator Feedback for patients with an ISS >15 are reviewed at monthly meeting s with the LAC & Local Medical Director LAC identifies Unexpected Deaths/Survivors for A&E Consultants to discuss at Senior Trainees Meeting and departmental M&M meetings. LAC identifies patients with an ISS > 15 prospectively and sends copy of Early Quality Indicator Feedback to STAG Consultant. How does your hospital utilise the STAG data to inform practice/ influence change/ improvement? STAG Consultant feedback to colleagues. Please give an example(s) of when STAG data has been used to influence change/ improvement. Actions planned in your local area to address quality improvement of the care of trauma patients: in 2012: 11 Number of cases reviewed locally: 11 Give example of types of quality improvements identified and how these will be achieved locally Any other relevant comments/ summary/ conclusion
Southern General Hospital data reviewed, who is this shared with? Monthly Feedback from STAG Analyst Quality Standard Summary Sent to Local medical Director Early Quality Indicator Feedback for patients with an ISS >15 are reviewed at monthly meeting s with the LAC & Local Medical Director LAC identifies Unexpected Deaths/Survivors for A&E Consultants to discuss at Senior Trainees Meeting and departmental M&M meetings. LAC identifies patients with an ISS > 15 prospectively and sends copy of Early Quality Indicator Feedback to STAG Consultant. How does your hospital utilise the STAG data to inform practice/ influence change/ improvement? STAG Consultant feedback to colleagues. Please give an example(s) of when STAG data has been used to influence change/ improvement. The use of the SEWS chart for patients in Resus who are admitted to ITU/HDU are now recorded as Not applicable on the Early Quality Indicator feedback as 3600 use there own Resus Chart. LAC has discussed with the Lead Senior Charge Nurse SGH regular feedback to nursing staff. To feedback how many patients have an ISS > 15 each month. How many patients were transferred to INS/SIU with an update of patient s outcome. Actions planned in your local area to address quality improvement of the care of trauma patients in 2012: 11 Number of cases reviewed locally: 11 Any other relevant comments/ summary/ conclusion
LAC has discussed with the Lead Senior Charge Nurse regular feedback to nursing staff. I will feedback how many patients have an ISS > 15 each month. How many patients were transferred to INS/SIU with an update of patient s outcome.
Royal Alexandra Hospital / Inverclyde Royal Hospital (data from these hospitals is reviewed by one clinical team therefore a joint response was provided) data reviewed, who is this shared with? Cases reviewed regularly by ED Consultant. In particular unexpected deaths but all major trauma. How does your hospital utilise the STAG data to inform practice/ influence change/ improvement? Any key points fed back to ED and other inpatient specialties. Please give an example(s) of when STAG data has been used to influence change/ improvement. Actions planned in your local area to address quality improvement of the care of trauma patients: in 2012: Number of cases reviewed locally: All major trauma and deaths. Number where quality improvements were identified: Give example of types of quality improvements identified and how these will be achieved locally Any other relevant comments/ summary/ conclusion Continues to provide information on trauma cases which can be identified and reviewed to ensure best practise.
NHS Highland Raigmore Hospital data reviewed, who is this shared with? Review of data with Lead Audit Consultant and local coordinator. Shared with colleagues at ED clinical governance meetings, ED clinical educator, and orthopaedic audit meetings. How does your hospital utilise the STAG data to inform practice/ influence change/ improvement? Presenting feedback at clinical governance meetings in the ED and highlighting cases where indicators have not been met. Identifies areas of poor patient journey as well as improvements made in achieving standards. Areas of concern or any issues fed back to speciality. Please give an example(s) of when STAG data has been used to influence change/ improvement. Need for improvement in documentation in resus implementation of a resus trauma form to capture information while the patient is in the ED. Purchase of pelvic binder Actions planned in your local area to address quality improvement of the care of trauma patients: Streamlining patient transfers to CT. Combined Anaesthetic and A&E RSI Training. in 2011: 38 Number of cases reviewed locally: 38 Give example of types of quality improvements identified and how these will be achieved locally Improvement in timing of IV antibiotics for open fractures all cases where delays occurred highlighted to staff.
Identifying when a trauma call out should be made to create new form for capturing ambulance information passed on to ED staff. Recording of ABG s reminding staff to attach ABG printout to notes/ document in notes. Any other relevant comments/ summary/ conclusion Having a clinical educator in the ED is particularly helpful as when issues are identified they can be incorporated into teaching sessions as well as being fed back to staff by the local coordinator. Plan to provide a monthly update to all staff as more timely feedback is an area where improvements can be made.
NHS Lanarkshire Hairmyres Hospital data reviewed, who is this shared with? As you are aware H/M hospital has struggled with the collection of STAG data since the Audit re started and the implementation of TRAKCare. We have had a number of meetings with STAG staff and our consultants (and previous STAG nurse Helen Cameron) with a view to improving data capture. It is likely that one of our senior nurses will take over STAG data collection and we are currently discussing the best way forward regarding accurate data collection. How does your hospital utilise the STAG data to inform practice/ influence change/ improvement? Due to the above difficulties with data collection STAG has not realised it s full potential in the ED at H/M. Our major trauma cases have however been discussed in clinical meetings/ teaching. We hope to have regular STAG presentations for all levels of staff once we are operational with a functioning data collection system. Please give an example(s) of when STAG data has been used to influence change/ improvement. Actions planned in your local area to address quality improvement of the care of trauma patients: in 2012: Number of cases reviewed locally: 5 Number where quality improvements were identified: NIL Give example of types of quality improvements identified and how these will be achieved locally
Any other relevant comments/ summary/ conclusion We know from past experience that STAG is an excellent audit tool and informs are clinical practice. We need to overcome the significant data input and collection problems before we can adequately benefit from STAG. This is a priority for us and is currently being addressed.
Monklands General Hospital data reviewed, who is this shared with? The data is reviewed by the Lead Audit Consultant with assistance of the senior nurses and other members of the multidisciplinary team. The STAG data is discussed at the departmental governance meeting. How does your hospital utilise the STAG data to inform practice/ influence change/ improvement? By highlighting any areas of patient care that could be highlighted for improvement or as models of good practice to senior nurses and consultants to be disseminated within the department. Please give an example(s) of when STAG data has been used to influence change/ improvement. No GCS completed in three patients in 2012, training has been given and improvements have been made. Actions planned in your local area to address quality improvement of the care of trauma patients: in 2012: 7 Number of cases reviewed locally: 7 Give example of types of quality improvements identified and how these will be achieved locally The quality improvements that have been made are mainly to do with identifying missing observations and/or documentation. It has been identified as a training issue through the audit. Any other relevant comments/ summary/ conclusion: The LAC and the Lead Audit Consultant are to meet more regularly to discuss all major traumas and unexpected deaths.
Wishaw General Hospital No information returned
NHS Lothian Royal Infirmary, Edinburgh data reviewed, who is this shared with? Specific cases with ISS 16 or higher are set out in Timelines and reviewed by the Lead Emergency Medicine (EM) Consultant. Cases with a breach of a STAG standard are also reviewed by an appropriate specialist Consultant. A decision is made as to what, if any action is required e.g. formal case review by multidisciplinary team (MDT), discussion with staff who were involved, review of protocol. Specific cases with an ISS 15 or less which are highlighted in the monthly report form STAG central office are reviewed by the lead EM Consultant, and where appropriate discussed further with the relevant medical and nursing staff. Local audits within the Emergency department are supported by the STAG data e.g. Medic One procedures, Chest drain insertion, resuscitation audit STAG data is used to assist with sprint audits done within other departments e.g. Radiology, Scottish Ambulance Service (SAS), speciality M&M meetings. Edinburgh Trauma Care Group comprising specialist Consultants and chaired by EM Consultant, set up to review local trauma care. Meetings involve discussion of STAG audit results (predominately relating to major trauma care), individual case review (if appropriate), departmental sprint audit results (e.g. Radiology), proposals for revised protocols and processes. EM Consultant callout activation criteria. STAG data has been used to ascertain appropriate triggers for establishing a formal outofhours oncall consultant process. How does your hospital utilise the STAG data to inform practice/ influence change/ improvement? As above. Please give an example(s) of when STAG data has been used to influence change/ improvement. The Radiology department has undertaken a review of all cases which breached a national Radiology standard. The data was provided by STAG local coordinator and STAG central office. The findings are being collated into a formal report and presented at hospital meetings. The data relating to Standby calls has been utilised by the Lothian SAS headquarters to inform practice and review protocols Breaches in emergency department standards have been used to raise awareness with medical and nursing staff and to review protocols e.g. IV antibiotics within 1
hour of arrival, triage to resuscitation room (particularly when no standby call was received), use of a pelvic binder. Consultant oncall service being established to meet national standard relating to an EM Consultant attending patient with major trauma within one hour of arrival. Actions planned in your local area to address quality improvement of the care of trauma patients: NB: There is no need to reiterate performance data in this section as it is already included in the report. in 2012: Number of cases reviewed locally: 2012 January December 112 Major trauma cases (ISS 16 or higher) January October (from central office monthly report) around 30 cases who breached a standard Number where quality improvements were identified: Around 6 cases warranted further discussion with either the senior speciality team or the team on duty who provided the care. Give example of types of quality improvements identified and how these will be achieved locally Radiology standards: a significant review has been undertaken by the senior Radiology medical team and the senior EM team to review protocols and processes to ensure that best practice is attained, particularly relating to patients who require an emergency CT scan and quick reporting of findings. The SAS have reviewed cases where no standby call was given to the hospital and instructed crews of revised protocols and identified any training needs which have arisen. Any other relevant comments/ summary/ conclusion The Major Trauma cases in 2013 are being reviewed on a realtime basis locally, and sent to the specialist consultants within a month of the patient attending. There has not been a report from central office since December 2012 (it covered patients who attended up to end of September 2012) and as such any trends in breaches or quality improvements have not yet been identified.
NHS Tayside Ninewells Hospital data reviewed, who is this shared with? In 2011 we attempted to review all cases where any of the standards were not met but we found this to be unrewarding and extremely time consuming. For 2012, having performed review of 50% of cases flagged for review we ultimately elected to limit formal reviews to the unexpected outcomes group for which we had 11 cases to review. A summary of the review is shared with relevant clinical leads in specialties involved in treating trauma patients and the hospital clinical governance office. Please give an example(s) of when STAG data has been used to influence change/ improvement. Ongoing discussions are taking place with Radiology regarding provision of resident CT radiographer which would facilitate earlier CT for head injury patients. Actions planned in your local area to address quality improvement of the care of trauma patients: in 2011: 96 Number of cases reviewed locally: 48 patients were reviewed prior to decision to limit review to unexpected outcomes. Give example of types of quality improvements identified and how these will be achieved locally Time to head CT in the outofhours period remains an ongoing issue (see above). It is hoped that by using the data provided by STAG the Radiology service can be persuaded to reconfigure to a resident CT radiographer service. Any other relevant comments/ summary/ conclusion Whilst we recognise that auditing to standards is clearly appropriate we do not find it helpful to review all cases where a standard was not met rather this leads to disengagement with the process. Review of unexpected outcomes did not reveal any particular systemic failures but did flag up one or two areas for potential improvement e.g. Ensuring that acutely ill medical patients who happen to present with associated injury (in particular orthopaedic injuries) are admitted to an area
equipped and staffed to deliver the appropriate level of care for their medical problems in the first instance.)