Impact of a community-acquired pneumonia care bundle in North East England from 2014 to 2017-A quality improvement project.

OBJECTIVES: To explore the impact of implementation of Community-Acquired Pneumonia (CAP) quality care bundle. SETTING: Eight acute hospitals in the North East of England and North Cumbria. PARTICIPANTS: ICD-10 coded CAP aged >18 were identified. A total of 16 201 CAP patients were discharged 2016/2017 (15 707; 2015/2016 and 10 733; 2014/2015). OUTCOME MEASURES: Secondary User Service (SUS) data were collected monthly from April 2014 to 2017. Data were pseudonymised and data flows governed by Data Sharing Agreements. CAP measures were based on British Thoracic Society guidance and agreed following clinician consultation. CAP admissions and individual organisational compliance with and impact of, CAP quality bundle measures was explored. RESULTS: Average length of stay (LOS) was 10.4 days (median 6) 25% >13 days. Crude in-hospital mortality rate was 17.6%, significantly lower (95% CI) than 19.1% in 2015/2016 and 19.3% in 2014/2015. Emergency readmissions within 28 days were 19.7% (19.2%; 2015/2016, 17.9%; 2014/2015). A total of 39.5% of patients received all appropriate care measures. Compliance has improved over time, although not for all hospitals. Most quality measures have higher mortality for those passing measures compared to those failing (P < .05 95% CI). Giving oxygen, had a significantly higher emergency readmission rate, 3.3% higher (95% CI 1.1% to 5.5%). Appropriate antibiotics and recording CURB-65 scores reduced the emergency readmission rates (-2.7% (95% CI -4.5% to -0.8%) -2.6% (95% CI -3.8% to -1.4%), respectively, (P = ns)). CONCLUSION: CAP accounts for significant bed days, mortality and readmissions. Although mortality was lower, LOS and readmission rates were not, despite improvements in compliance after implementation of the care bundle. Care bundle use remained sub-optimal.

From research to practice: results of 7300 mortality retrospective case record reviews in four acute hospitals in the North-East of England.

INTRODUCTION: Monitoring hospital mortality using retrospective case record review (RCRR) is being adopted throughout the National Health Service (NHS) in England with publication of estimates of avoidable mortality beginning in 2017. We describe our experience of reviewing the care records of inpatients who died following admission to hospital in four acute hospital NHS Foundation Trusts in the North-East of England. METHODS: RCRR of 7370 patients who died between January 2012 and December 2015. Cases were reviewed by consultant reviewers with support from other disciplines and graded in terms of quality of care and preventability of deaths. Results were compared with the estimates published in the Preventable Incidents, Survival and Mortality (PRISM) studies, which established the original method. RESULTS: 34 patients (0.5%, 95% CI 0.3% to 0.6%) were judged to have a greater than 50% probability of death being preventable. 1680 patients (22.3%, 95% CI 22.4% to 23.3%) were judged to have room for improvement in clinical, organisational (or both) aspects of care or less than satisfactory care. CONCLUSIONS: Reviews using clinicians within trusts produce lower estimates of preventable deaths than published results using external clinicians. More research is needed to understand the reasons for this, but as the requirement for NHS Trusts to publish estimates of preventable mortality is based on reviews by consultants working for those trusts, lower estimates of preventable mortality can be expected. Room for improvement in the quality of care is more common than preventability of death and so mortality reviews contribute to improvement activity although the outcome of care cannot be changed. RCRR conducted internally is a feasible mechanism for delivering quantitative analysis and in the future can provide qualitative insights relating to inhospital deaths.