Transcript Scottish Audit of Inter Hospital Transfer of Acutely Ill

Scottish Audit of InterHospital Transfers of
Acutely Ill Adults
Nov 2007 – March 2008
Jean Bruce ~ Audit Coordinator
Robert Colquhoun ~ Audit Assistant, SAS
Mike Fried ~ Clinical Lead
Daren Mochrie ~ IHT Board Manager, SAS
George Smith ~ Database Management
Content
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Context
Introduction
Methodology
Results
Conclusions
Recommendations
Background
Inter Hospital Transport (IHT) of patients is an integral
part of routine healthcare delivery. IHT occurs for the
following reasons:
–
–
–
–
–
Requirement for specialist investigation / imaging
Requirement for specialist management
Lack of critical care facilities in referring hospital
Inadequate number of staffed critical care beds
Repatriation
78,000 IHTs per annum – 2006-07
Introduction
Aims
• Identify the number of acutely ill adult patients who
are being transported between hospitals by Scottish
Ambulance Service front line vehicles
• Assess the process of transportation and quantify
the incidence of adverse events (audit)
• Establish the absolute number of adult IHTs during
audit period (EIS data)
Methodology
• Design
–
–
–
–
Audit ran for 20 weeks (12th Nov 07 to 30th Mar 08)
Initially planned for Critically Ill Adults but:……..
Audit all IHT activity - impractical
Final decision to collect data on “acutely ill adults”
“Patient requires paramedic/technician intervention and recording of
vital signs en route OR where the transfer has a doctor/nurse escort
present.”
– Caldicott Guardians contacted re data protection
– Lothian Ethics committee
Database and Data Entry
• Customised database designed around audit form
– Frequent upgrades as demanded by user
– Subsidiary sections from EIS supplied
• Call date and time
• Station
• Verifies male/female, Date of Birth
– Allowed cross referencing to ensure accuracy of data
• Created associated tables for stations, SAS Divisions,
hospital departments, hospital health board regions
• Additional reports generated to identify
missing/suspect data
Results
• Received 3048 audit forms
• 652 were excluded from results
• No monitoring and no escort
• Children <16 years
• Pick up home address
• Total 2396 included
Type of Transfer
• Emergency
493 (20.5%)
• Urgent
1741 (72.7%)
• Planned
162 (6.8%)
Call Times to SAS
200
180
Total
160
140
120
100
80
60
40
20
0
00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Hour of Day
Emergency
Urgent Planned
Type of Transfer by Day of Week
450
400
350
Total
300
250
200
150
100
50
0
Mon
Tue
Wed
Thu
Fri
Day of Week
Emergency
Urgent
Planned
Sat
Sun
Patient Journey Times (hr:mins)
NHS Health Board
Count
Median
Minimum
Maximum
Ayrshire and Arran
88
00:33
00:11
01:40
Borders
54
00:51
00:15
01:30
Dumfries and Galloway
213
01:35
00:08
05:37
Fife
157
00:24
00:03
01:49
33
00:39
00:16
02:50
Glasgow & Clyde
375
00:25
00:05
02:45
Grampian
438
00:58
00:03
02:50
Highland
479
01:30
00:07
04:10
67
00:30
00:02
02:02
Lothian
379
00:30
00:05
02:30
Orkney
10
01:44
01:29
02:46
Shetland
12
02:33
01:41
03:03
Tayside
81
00:30
00:04
01:33
Western Isles
10
01:57
00:57
03:03
2396
00:44
00:02
05:37
Q1 0:27
Q3 1:18
Forth Valley
Lanarkshire
Scotland Total
Escort Summary
Reg. Nurse
Midwife
ODP
CSW
Aux. Nurse
Student Nurse
Translator
Other
Prison Officers
415
83
15
1
17
9
1
3
1
Consultant
FTSTA
6
ST3 – ST5
ST1 – ST2
GPST
FY1 – FY2
Medical Student
EMRS
Shock Team
69
22
64
2
22
3
13
192
825 (34.4%) of audited IHTs were escorted
Escort Times (hr:mins)
• Median transfer times ~ 2:00
(min 00:05 max 17:33)
• Consultants
2:30
– FTSTA
– ST1-ST2
– Reg. Nurse
3:13
2:17
2:28
• Some escorts 12 - 14 hours if flight back
Transfer Reasons by Health Board
500
450
400
350
Total
300
250
200
150
100
50
0
A&A
Bord
D&G
Fife
Forth V
G&C
Gramp
High
Lanark
Loth
Ork
Shet
Tay
Health Board
Specialist care
Specialist investigation
Lack of beds
Repatriation
Lack of nurses
NK / Other
W Isles
Transfers by Health Board
SAS front line trolley v CCT6
CCT 6 Trolley during audit
Ventilated but
NOT on CCT6
81
16
ventilated
3 equip
failures
(1.79%)
7 equip
failures
(8.6%)
151
ventilated
CCT 6
Trolley
207
Other Units
40 non
ventilated
SHOCK
TEAM
(1)
26 non
ventilated
Critical Department Transfers
(ITU, CCU, HDU)
• 540 transfers into departments
• 411 transfers out of departments
• 248 ventilated patients
Critical Department Transfers
% Transfers into Receiving Department
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
CCU
HDU
ITU
Other
Referring Department
CCU
HDU
ITU
Other
Does not included A&E to A&E(n=9), A&E to Cath Lab (n=1)
Ventilated Patient Journey Time
NHS Health Board
Count
Median
Minimum
Maximum
Ayrshire and Arran
7
00:30
00:25
01:15
Borders
1
00:46
00:46
00:46
10
01:24
00:55
02:10
Fife
9
00:18
00:04
00:44
Forth Valley
3
00:39
00:36
00:40
137
00:20
00:05
02:45
Grampian
20
01:15
00:07
01:40
Highland
11
01:00
00:25
02:05
Lanarkshire
21
00:30
00:15
01:20
Lothian
20
00:25
00:13
01:17
Shetland
1
02:55
02:55
02:55
Tayside
4
00:57
00:24
01:10
Western Isles
4
02:00
01:55
02:45
248
00:28
00:04
02:55
Q1 0:17
Q3 0:50
Dumfries and Galloway
Glasgow & Clyde
Scotland Total
Escort Summary ~ Ventilated Patients
Reg. Nurse
41
Student Nurse 1
ODP
8
EMRS
Shock Team
5
162
Consultants
46
FTSTA
2
SPR5
2
ST3 – ST5
13
ST1 – ST2
20
FY1 – FY2
6
Medical student 1
248 ventilated patient transfers
(10.3% of audited IHTs)
Escort Comments ~ return journey
• “not authorised to get a taxi back. Carrying
equipment on a bus extremely difficult. Ridiculous
expecting staff to go on a shuttle bus as well as carry
equipment. Took one hour to get back from Western to
Royal” RIE to WGH - patient not ventilated
• “abandoned in Govan at 1 am on a Friday night.
SPR, nurse and equipment delayed in returning as
crew sent to another job” WIG to SG
Escort Return Modes ~ ventilated transfers
not including Shock Team or EMRS
Return Mode
NHS Health Board
SAS
Ayrshire and Arran
SAS and
Taxi
Taxi
3
Borders
1
Dumfries and Galloway
7
Fife
9
Forth Valley
3
Glasgow & Clyde
2
2
Grampian
18
1
1
Highland
1
3
1
Lanarkshire
3
1
Lothian
11
7
Tayside
4
Totals
Police
61
1
16
1
2
1
Clinical and Adverse Events
• Unsecured equipment in escorted patients (excluding
Shock Team and EMRS) = 113/620 (18.2%)
• Clinical events requiring Rx = 84/2396 (3.5%)
– cardiac arrhythmias, hypo/hypertension, desaturation
• Adverse events 29/2396 (1.2%)
• Adverse events in escorted patients 22/825 (2.7%)
– Saturation monitor, infusion pump and 4 ventilator failures
– ET tube displacement (n=1)
Shock Team
• Shock team transfers 192 – within audit criteria
–
–
–
–
–
Specialist care 92
Lack of beds 88
Repatriation
4
Specialist Inv
3
Lack of nurses 3
Emergency Medical Retrieval Service
(EMRS)
• EMRS 13 – within audit criteria
– Specialist Care
– Specialist Inv
11
2
Shock & EMRS Away Time
NHS Health Board
Count
Median
Minimum
Maximum
Ayrshire and Arran
4
05:17
02:30
06:00
Dumfries and Galloway
2
07:26
07:00
07:52
162
02:50
00:45
07:20
Highland
14
03:08
01:47
05:45
Lanarkshire
17
03:40
02:10
08:03
Shetland
1
09:20
09:20
09:20
Western Isles
5
08:00
07:00
10:05
205
03:22
00:45
10:05
Q1 2:20
Q3 4:00
Glasgow & Clyde
Scotland Total
Time calculated from “leaving base” to “arriving back to base”
Ventilated Patient transfer by Health Board
Receiving Health Board
From Health
Board
A&A
A&A
Borders
D&G
Fife
Forth V
1
G&C
Gramp
High
Lanark
5
Borders
D&G
3
2
Fife
1
5
130
Grampian
Highland
6
Lanark
1
total
7
1
1
1
1
10
9
3
3
2
137
16
4
20
2
3
11
13
Lothian
2
Cumbria
1
3
2
Tayside
3
Forth V
G&C
Lothian
8
2
Tayside
21
17
1
20
3
1
4
W Isles
4
4
Shetland
1
1
Totals
6
0
2
7
0
160
18
8
10
33
3
1
248
Total IHT transfers within audit period
Total IHT transfers within audit
period
19,266
of which
17,877 were adults
All conveyed by A&E vehicles
(average of 894 adults per week)
Edinburgh EMDC ~ top twenty
REFERRING HOSPITAL
count
total time
average time
NEW EDINBURGH ROYAL
KIRKCALDY VICTORIA
ST JOHNS
FALKIRK ROYAL
QUEEN MARGARETS
PERTH ROYAL
WESTERN GENERAL
STIRLING ROYAL
BORDERS GENERAL
ARBROATH INFIRMARY
NINEWELLS
ROYAL EDINBURGH
ST ANDREWS MEMORIAL
GLENROTHES
WHITEHILLS
ASTLEY AINSLEY
LIBERTON HOSPITAL
MONTROSE ROYAL
ROYAL VICTORIA EDIN
HAWICK COTTAGE
944
796
716
459
420
389
349
345
216
190
183
84
70
69
66
57
52
50
49
46
1228:40
839:24
911:22
530:04
447:22
480:40
451:37
559:06
393:46
205:10
309:36
99:31
76:49
67:23
73:47
67:19
60:09
72:04
59:39
46:39
1:18
1:03
1:16
1:09
1:03
1:14
1:17
1:37
1:49
1:04
1:41
1:11
1:05
0:58
1:07
1:10
1:09
1:26
1:13
1:00
Inverness EMDC ~ top twenty
REFERRING HOSPITAL
count
total time
average time
ABERDEEN ROYAL
RAIGMORE
DR GRAYS
PETERHEAD COMMUNITY
BELFORD
FRASERBURGH
ABERDEEN MAT
BALFOUR
CAITHNESS
CHALMERS
WOODEND
GILBERT BAIN
JUBILEE
TOWN AND COUNTY NAIRN
TURRIFFF COTTAGE
WESTERN ISLES
BROADFORD
COUNTY INVERGORDON
PORTREE
ROSS MEMORIAL
483
337
254
250
204
184
151
141
141
130
126
90
89
89
76
71
67
66
66
58
406:46
443:40
568:44
352:11
429:43
310:05
134:19
81:32
266:57
221:27
103:37
83:36
133:43
96:03
131:58
55:37
158:06
78:22
140:23
54:42
0:50
1:18
2:14
1:24
2:06
1:41
0:53
0:34
1:53
1:42
0:49
0:55
1:30
1:04
1:44
0:47
2:21
1:11
2:07
0:56
Paisley EMDC ~ top 20
REFERRING HOSPITAL
WESTERN INFIRMARY
MONKLANDS
VICTORIA INFIRMARY
ROYAL ALEXANDRA
HAIRMYRES
WISHAW GEN
STOBHILL
INVERCLYDE
CROSSHOUSE
AYR
GARTNAVAL
GLASGOW ROYAL
VALE OF LEVEN
SOUTHERN GENERAL
GALLOWAY COM
DUNOON
CAMPBELTOWN
ROTHESAY VICTORIA
LORNE AND ISLES
DUMFRIES & GALLOWAY
count
total time
average time
1089
540
538
531
520
389
388
359
337
316
316
295
267
233
215
207
182
169
144
119
1259:28
652:34
577:20
505:19
619:27
592:07
443:38
534:57
440:34
413:28
432:38
416:48
342:16
366:34
462:44
298:16
459:12
385:33
381:59
299:30
1:09
1:12
1:04
0:57
1:11
1:31
1:08
1:29
1:18
1:18
1:22
1:24
1:16
1:34
2:09
1:26
2:31
2:16
2:39
2:31
IHTs across Scotland ~ top 10
REFERRING HOSPITAL
count
total time
average time
WESTERN INFIRMARY
NEW EDINBURGH ROYAL
KIRKCALDY VICTORIA
ST JOHNS
MONKLANDS
VICTORIA INFIRMARY
ROYAL ALEXANDRA
HAIRMYRES
ABERDEEN ROYAL
FALKIRK ROYAL
1089
944
796
716
540
538
531
520
483
459
1259:28
1228:40
839:24
911:22
652:34
577:20
505:19
619:27
406:46
530:04
1:09
1:18
1:03
1:16
1:12
1:04
0:57
1:11
0:50
1:09
Conclusions from Audit
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Significant IHT activity
Average patient journey time = 57 minutes
Average SAS time = 1:17 (2:54)
Average Escort time = 2:35
Significant impact on A&E service
Adverse events reassuringly infrequent
Conclusions
• Projected total transported by A&E vehicles
– 50,091 total IHTs per annum
– 46,480 adult IHTs per annum
• Total IHT activity SAS annual review
– 83,000 IHTs per annum – 2007-08
Recommendations
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Inform clinicians re use of ambulance service
Use critical care trolley
Establish an IHT service (incl transport paramedic)
Establish transport medicine training
Establish quality criteria for IHTs
Acknowledgements
• SICSAG - Diana Beard, Angela Kellacher
• ALL STAG coordinators – especially Gaynor Howitt,
Debbie Broadhurst for all those queries
• Ms Judith Roulston ~ Shock Team data
• Stephen Hearns, Alasdair Corfield ~ ERMS data
• SAS crews ~ form completion
• Clinical link personnel in individual hospitals
• SGHD, IHT board ~ funding
• Mr George Smith ~ database management
• Mr Robert Colquhoun ~ EIS queries
THANK YOU
[email protected]
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