Clinical Audit
Clinical audit is a crucial part of the Trust’s strategy to improve health care to service users. The evaluation of clinical performance against standards or through comparative analysis, with the aim of informing the management of services, is an essential component of modern healthcare provision. It forms part of the Trust’s clinical governance arrangements helping to ensure safe and effective clinical practices.
During 2021/22, EEAST participated in 100% of all required national audits which for ambulances are those defined within the Ambulance Clinical Quality Indicator (ACQI) programme, three of which: stroke; cardiac arrest and STEMI were included earlier in this section. It also fully participated in the National epidemiology and Outcome from out-of-Hospital Cardiac Arrest (OHCA) registry study undertaken by the University of Warwick and is included as an audit within the Healthcare Quality Improvement Partnership (HQIP) annual programme.\
The fourth ACQI relates to Sepsis, a description of which is provided below along with EEAST’s performance compared against the national average and upper and lower scores.
Recognition and treatment of sepsis and neutropenic sepsis
Although recognition of sepsis by our staff has a high compliance rate, we were seeking to continue to achieve a sustained high level of recognition and appropriate treatment for sepsis patients, recognising that early recognition, timely interventions and transportation to hospital is a key factor for the patient’s outcome.
The care bundle is made up of four indicators which all have to be met to be compliant:
- Recording of patient observations (breathing rate, level of consciousness and blood pressure)
- Administration of oxygen
- Administration of fluids
- Pre-alert provided to the receiving hospital.
The table below demonstrates our performance for the care bundle against national date published to date (April – November 2021).
| Sepsis Care | National Data (April to November 2021) | |||
|---|---|---|---|---|
| National Average | Highest Score | Lowest Score | EEAST | |
| Sepsis care bundle | 81.6% | 90.5% | 61.7% | 84.5% |
Next steps:
NHSE&I have advised that this ACQI will be removed during 2022/23 due to the high level of performance across all ambulance trusts, however EEAST will include this topic within the plan for early 2023/24 to ensure that the good progress made has not deteriorated.
Local Audits 2021/22
The following information relates to all local clinical audit topics undertaken in 2021/22.
Asthma Re-Audit
A re-audit of compliance with the asthma care bundle (historic National Clinical Performance Indicator) was undertaken in September 2021 to provide an overview of current performance and to establish as to whether an improvement was seen when compared to the previous audit undertaken in December 2019.
| Data inclusion criteria: Asthma recorded as Chief Complaint on the patient care record for patients 18 years and over | |||
| Care Bundle Compliance Target | >85% | ||
| Indicators | December 2019 | September 2021 | Change in compliance |
| A1 Respiratory rate recorded | 100.0% | 100.0% | No change |
| A2 PEFR recorded (before treatment) | 85.7% | 88.8% | +3.2% |
| A3 SpO2 recorded (before treatment) | 98.3% | 100.0% | +1.7% |
| A4 Beta-2 agonist given | 100.0% | 100.0% | No change |
| Overall Care BundleA1+A2+A3+A4 | 78.3% | 88.8% | +9.9% |
Although an improvement was seen overall, it is still apparent that staff are not documenting a peak flow prior to any treatment. It is probable that these patients were not able to provide this due to the severity of their breathing difficulties, however it is important for clinicians to document this on the patient care record to demonstrate that they have considered this as part of their clinical assessment and treatment.
Results have been discussed within the Clinical Best Practice Group and Quality Governance Committee in line with our governance framework and posters and a full copy of the report have been sent to all operational areas.
Next steps:
Re-audit in 2022/23 following feedback to staff and highlight of good practice by the Trust’s clinical leads.
Falls in older people
A re-audit of compliance with the falls in older people care bundle (historic National Clinical Performance Indicator) was undertaken in November 2021 to provide an overview of current performance and to establish as to whether an improvement was seen when compared to the previous audit undertaken in December 2019.
| Data inclusion criteria: 65 years and above who had fallen in the pre-hospital environment and were not conveyed. | |||
| Care Bundle Compliance Target | >85% | ||
| Indicators | December 2019 | September 2021 | Change in compliance |
| E1 Primary observations recorded | 98.3% | 85.3% | -13.0% |
| E2 Recorded assessment of the cause of the fall | 100.0% | 100.0% | No change |
| E3 Recent history of falls documented | 93.3% | 41.3% | -52.0% |
| E4 12 Lead ECG assessment | 60.0% | 51.3% | -8.7% |
| E5 Recorded assessment of mobility | 98.3% | 88.0% | -10.3% |
| E6 Direct referral to an appropriate health professional | 78.3% | 97.7% | +19.4% |
| Overall Care Bundle E1+E2+E3+E4+E5+E6 | 56.7% | 29.7% | -27.0% |
Disappointingly this re-audit showed a huge decrease in compliance with 4/6 of the indicators and a reduction of 27% for the overall care bundle. This also links in with reported patient safety incidents, including serious incidents, relating to deterioration of patients who are left at home where a full assessment was not completed. Following the audit, posters were sent to all operational teams and an aide memoire was produced for staff as part of the lessons learned from associated serious incidents.
Next steps:
Re-audit in 2022/23 following feedback to staff and highlight of good practice by the Trust’s clinical leads.
Pain management - pilot audit
The main purposes of the pilot audit were;
- to determine how data can be retrieved as the Trust moves over to ePCR fully,
- to identify improvements in the retrieval of data
- to provide a preliminary overview of pain management.
This was the first time that an attempt was made to undertake clinical audit using data extracted from the ‘data lake’ and proved to be a huge learning curve. Although some data was able to be analysed, this was very minimal and combined with the fact that only approximately 50% of records are completed electronically, did not provide enough evidence as to the Trust’s position in the management of pain or administration of pain relief.
Using the learning from the pilot audit, it is very clear that we need to be very specific when requesting data to be extracted by the IMT team. The use of ePCR data is very much in its infancy and discussions are already in place to improve the process and that the most effective way until the improvements are made would be to use the data to identify the records needed for each audit data. However this will mean that data input will be a manual process until these are in place.
Next steps:
Re-audit in 2022/23 using the lessons learned from the pilot audit to ensure full data capture.
Submission of patient care records (PCRs)
A standard audit within the annual clinical audit plan, this reviews as to whether a patient care record can be located for every face-to-face patient contact within the specified audit period (1400-2200; 10 November 2021), how many of the records were completed electronically and for paper records, whether they met the 14-day submission standard as defined within our Patient Care Record Policy. The overall compliance for the audit period (10 November 2021) was 90.1% a decrease of 4.6% when compared to the previous audit (October 2020: 95.8%). Only 228/322 paper records (70.8%) arrived in line with the 14-day standard which although an improvement of 29.3% on the previous audit, causes the Trust ongoing difficulties in locating paperwork in a timely fashion to aid investigations and to respond to external requests for information including those required for HM Coroner purposes. In total, 56.2% of records were completed electronically, an increase of 3.3% when compared to the previous audit (Nov-19: 52.9%). Following discussion at the Clinical Best Practice Group, posters and a copy of the full report which included a breakdown for each sector were distributed to all operational teams.
Next steps:
Re-audit in 2022/23
Administration of Tranexamic Acid - pilot
Tranexamic acid is a medication used to treat or prevent excessive blood loss from conditions such as major trauma and heavy bleeding after having a baby. Although we have been using this medicine for some time, to date, we had not completed an audit on its use. An audit period of three months (01 December 2021 – 28 February 2022) was selected and data from ePCR was used to identify records where tranexamic acid had been administered. The number of records identified totalled 126; 83 of which were major trauma, including head injury and 15 related to obstetrics/gynaecology. A further 28 cases related to other causes such as heavy bleeding after surgery, severe nose bleeds and deliberate self-harm lacerations. With the exception of the documentation of two pain scores, all indicators achieved above the set target.
| Indicator - target 95% | Compliance % |
|---|---|
| Documentation of two sets of observations | 96.8% |
| Documentation of estimated blood loss | 96.0% |
| Documentation of two pain scores | 90.5% |
| Administration of pain relief (where required) | 100.0% |
| Documentation of any other medications indicated eg fluids, oxygen, anti-sickness | 98.4% |
Next steps:
Feedback to staff via posters with a re-audit planned in 2022/23 to determine whether there has been any improvement.
Head Injury - pilot
Due to the ongoing capacity issues caused by the pandemic, records identified as the patient having a head injury as the main cause of their injury within the tranexamic acid audit were only included within this audit which did result in limited data, however the information contained in the table shows that these patients received optimal care for their head injury.
| Indicator - target >95% | Compliance % |
|---|---|
| Documentation of two sets of observations | 100.0% |
| Documentation of consciousness level (AVPU) | 100.0% |
| Documentation of Glasgow Coma Score (GSC) | 100.0% |
| Documentation of pupil assessment | 100.0% |
| Documentation of pupil size | 100.0% |
| Administration of oxygen | 100.0% |
| Documentation of pre-alert to receiving hospital | 100.0% |
Next steps:
Although this audit achieved 100% compliance for allindicators, we have acknowledged that it related to a very small number of patients and will complete a more in-depth audit within 2022/23.
Trauma
Major trauma is any injury that has the potential to cause prolonged disability or death. There are many causes of major trauma, including falls, motor vehicle collisions, stabbing wounds and gunshot wounds.
Due to the extremely complex nature of these cases, it can be difficult to determine very detailed indicators. Medical teams are often asked to attend and assist with treatment as they are able to undertake much more advanced skills and treatment, which can take time to correlate the information they have provided within their paperwork with treatment delivered by our own staff. Therefore within this audit we decided to keep it simple and looked at factors such as the recording of observations, blood loss, type of pain relief and any other medicines that were administered.
As per the head injury audit, records identified as the patient having multiple traumatic injuries within the tranexamic acid audit were only included within this audit and a total of 53 records were identified and EEAST staff were supported by medical teams in 41 of these cases (77.4%).
Other medicines administered included; anti-emetics (anti-sickness), fluids, antibiotics, fentanyl, ketamine and plasma.
| Indicator - target >95% | Compliance % |
|---|---|
| Documentation of two sets of observation | 96.2% |
| Documentation of estimated blood loss | 100.0% |
| Documentation of two pain scores | 90.6% |
| Administration of pain relief (where required) | 94.3% |
Next steps:
A more in depth detailed audit is hoped to be undertaken IN 2022/23 in conjunction with the Trauma Audit & Research Network (TARN) through our clinical lead with responsibility for trauma.
Next Page: Participation in research