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High SMR- What Happens Next?. Brian Cook. Critical Care Outcomes in 2007- Scottish Unit SMR’s. High SMR- SICSAG Definition. > 2SD difference from Scottish SMR Unit lower 95% CI > Scottish upper 95% CI Consistent definition in all SICSAG reports

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Critical care outcomes in 2007 scottish unit smr s l.jpg
Critical Care Outcomes in 2007- Scottish Unit SMR’s


High smr sicsag definition l.jpg
High SMR- SICSAG Definition

  • > 2SD difference from Scottish SMR

    • Unit lower 95% CI > Scottish upper 95% CI

  • Consistent definition in all SICSAG reports

  • ICNARC > 3SD difference in 4 consecutive quarters

  • > 2SD “may be” different

  • > 3SD “is” different


  • High smr sicsag definition5 l.jpg
    High SMR- SICSAG Definition

    > 2SD “may be” different

    > 3SD “is” different


    High smr communication from sicsag l.jpg
    High SMR- Communication from SICSAG

    • As soon as known- unit audit lead letter

    • 1 week later- MD and Chief Exec letter

      • 2008 completed 9th May

  • 10 days before publication full SICSAG report to: Unit leads, Hospital, Health Board Chief Execs, MD’s, CMO.

  • Friday before publication- Statistical Publication Notice placed on ISD website

  • Publication- Tuesday paper and web (29/7/08)



  • Responses to high smr unit and hospital l.jpg
    Responses to High SMR- Unit and Hospital

    • Data??

    • Are we different?

      • Case mix

  • How have we performed over the years?

  • Care might be sub-standard?

  • Internal review

    • Critical Care +/- Other Specialties

  • Other Audits and Governance Evidence

  • External Review


  • Slide9 l.jpg
    Data??

    • SICSAG will reanalyse data

      • But we need focused questions!

  • Data Quality?

    • APACHE II, Diagnoses

    • Case note review v WardWatcher

  • Data Completion?

    • APACHE II NB GCS accurate and complete


  • Slide10 l.jpg
    Data??

    • Random case-note sample

      • 58% APACHE II score wrong

      • 47% underscored

    • Data completion

      • 93 missing GCS or presedation GCS

      • 67 filled in for re-analysis

    • SMR decreased 1.18 to 1.04

    • Lower 95% CI overlaps Scottish upper



    Internal review l.jpg
    Internal Review

    • Involve other specialties?

      • Any particular patient group look a problem?

    • Consultant from another local ICU?

    • Governance structures

      • M+M reports?

      • Incident reports?

      • Risk Register?

      • Quality Improvement Programmes?


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    Internal Review

    • Case Note Review

      • Target low mortality prediction deaths

      • 35 neuro patients who died with MP <25%

      • ICU

      • Referring specialty- useful perspective and advice


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    External Audits

    • SASM

      • ACON’s?

      • 11 reported

      • 2 ACON’s graded “there were areas of concern that may have contributed to this patient’s death”

      • Both referred to incidents during transfer to WGH


    External review l.jpg
    External Review

    • Who? ICS

    • Service

      • Facilities

      • Staff

      • Procedures and Guidelines

      • Referral and Admission Population and Policies

      • Referring Specialties

      • Management

    • Case Note Review



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    Afterwards

    • Positive Experience?

    • Report

      • Division Governance Committee

      • Medical Directors

      • Chief Executives

      • Press Office

    • Action Plan

      • Data quality is an issue


    How can we prevent data causing problems l.jpg
    How can we prevent data causing problems?

    • Local data quality assurance

      • Clerical support for data entry

      • Clinical staff interest and involvement

      • Don’t assume it is just happening

    • SICSAG

      • Quality Assurance Manager- Moranne

      • Data validation

      • Monthly feedback

      • An early warning system?





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    High SMR Summary

    • SICSAG will warn you as early as possible

    • SICSAG will help where possible

    • Explain why you are different

    • Others may be interested

    • You may gain from the experience

    • DATA!!