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									               SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST

Meeting             Trust Board                            Date         6 November 2008

Subject             Clinical Audit and Effectiveness       Enclosure    N
                    Report


Nature of item      For information        
                    For approval
                    For decision


Decision
required (if any)


General             Report Author          Marian Benjamin and Ruth Brown - Clinical Audit
Information                                and Effectiveness Specialists

                    Lead Director          Steve Mather - Medical Director



Received or         Meeting
approved by         Date


Resource            Revenue
Implications        Capital
                    Workforce
                    Use of Estate
                    Funding Source

Freedom of          Confidential (Y/N)     No
Information         (if yes, give
                    reasons)
                    Final/draft format     Final

                    Ownership              Trust

                    Intended for release   Yes
                    to the public

Decision Made
                        South Warwickshire General Hospitals NHS Trust

                       Report to Trust Board – Thursday 6 November 2008

                              Clinical Audit and Effectiveness Report

Executive Summary
This report outlines the work undertaken by the department for Quarter 2 - July to September 2008.

National Audits
The Trust is currently involved in several national audits:
      Occupational Health management of NHS staff with lower back pain and with depression audit.
      National Sentinel Audit for Stroke
      The Patient Outcomes in Surgery (POIS) audit
      Myocardial Infarction National Audit Project (MINAP).
      Inflammatory Bowel Disease Audit (2nd round)
      NCEPOD Deaths in Acute Hospitals study

Project Activity
For this quarter 13 new projects were registered with the Department. Six projects were completed.
The report also identifies actions undertaken as a response to the audits.

Dr Foster Real Time Monitoring Tool
This tool provides the Trust with data which has been standardised for age, sex and deprivation which
is also case mix adjusted. This enables the Trust to monitor its performance against 4 outcome
measures: mortality, LOS, day case rate and readmissions. There is an alert system that shows good
(green flag) and poor (red flag) performance. The Clinical Audit and Effectiveness Specialist monitors
the system on a monthly basis. Flags are reported to the appropriate audit and operational
governance groups. If a red flag appears more than twice in a row then a clinician is nominated by the
group to investigate and report their findings and actions taken back to the group. The report outlines
progress to date.

For the purpose of this report we have shown data relating to the last six months -April – September
2008

Green Flags
     62 diagnoses or procedures that green flagged one or more times
          o 4 for mortality
          o 24 for LOS
          o 21 for Day Case Rate
          o 13 for readmissions
Red Flags
     23 diagnoses or procedures that red flagged one or more times
          o 6 for mortality
          o 8 for LOS
          o 3 for Day Case Rate
          o 6 for readmissions

The actions taken as a response to the red flags are shown in the report.

Marian Benjamin and Ruth Brown - Clinical Audit and Effectiveness Specialists
              SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST

               Clinical Audit & Effectiveness Department Quarterly Report

July – September 2008

This report outlines fundamental work undertaken in the Department during the second
quarter of 2008 – 09.

National Audits

The Trust is currently involved in several national audits:

       Occupational Health management of NHS staff with lower back pain and with
        depression; this is co-ordinated by The Royal College of Physicians. Data collection
        is now complete. Questionnaires have been sent out to patients (staff). The final
        report is awaited.
       The 6th round of the National Sentinel Audit for Stroke. This is also co-ordinated by
        the Royal College of Physicians. The organisational report was released in July 2008
        followed by an Organisational Public Report in September. Data collection for the
        clinical audit is now underway.
       Patient Outcomes in Surgery (POIS) audit (for elective hip and knee replacement)
        began in September 2008 and will run until March 2010. This is co-ordinated by the
        Royal College of Surgeons. It has been added to the Trust Annual Audit Plan (see
        Appendix 1)
       Myocardial Infarction National Audit Project (MINAP). The department has provided
        continuous support for this since it began in 2000. The call to needle time (CTN) is
        one of the Healthcare Commission’s targets. The department has also been involved
        in regular thrombolysis meetings which address problems in door to needle (DTN)
        and CTN times. The numbers of eligible patients for these targets has reduced now
        that confirmed myocardial infarction patients are transferred to UHCW for primary
        percutaneous coronary intervention (PPCI).
       Data collection for the Royal College of Physicians UK Inflammatory Bowel Disease
        Audit (2nd round) commenced in September. This re-audit is clinical and
        organisational. December 31st is the deadline for completion.
       Clinical and anaesthetic questionnaires are presently being completed by consultants
        for the NCEPOD Deaths in Acute Hospitals study.
       NCEPOD will be carrying out a study to examine the care of elderly patients
        undergoing elective and emergency surgery. Data collection will start in the autumn
        with questionnaires being sent out in January 2009.

Project Activity

For this quarter 13 new projects were registered with the Department, including:
        4 national projects, 2 NICE guidance, 2 National Service Framework (NSF)
        7 projects already in the Trust Annual Audit Plan and 5 have been added
        Six projects have been completed.



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              SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST

Implemented recommendations as a result of completed audits are identified below:

Number    Project                     Action                          Annual plan
596       Incidence of wound          Continue with current           Yes
          infection after             antibiotic regime
          laparotomy for colorectal
          cancer and relation to
          change in antibiotic
          prophylaxis
683       Audit of management of      Results of audit: presented     Yes
          shoulder dystocia           at Labour Ward Forum,
                                      published in Newsletter,
                                      included in Shoulder
                                      Dystocia Guidelines, used
                                      in Drills/Skills training
688       A&E Physiotherapy           All patients to receive         No
          Service patient             written and verbal
          satisfaction                information. Regular
          questionnaire               communication with A&E
                                      staff regarding slot
                                      utilisation
689       A&E Physiotherapy           Regular communication           No
          Service review              with A&E staff regarding
                                      slot utilisation. Ensure
                                      adequate cover due to
                                      leave etc. Reception staff to
                                      contact DNAs regarding
                                      reason for non attendance
695       Re-audit of instrumental    Continue to use                 No
          deliveries                  documentation proforma.
          documentation               Make proforma available in
                                      theatres. Use proforma for
                                      unsuccessful instrumental
                                      deliveries
696       Dermatology Outpatient      Resurvey all consultant         No
          satisfaction                outpatient clinics for a
          questionnaire               longer period of time


Annual Audit Plan 2008-09
A six month monitoring exercise of the audit plan has taken place. There are 11 audits that
the Department is not involved with so the current status of these is unknown. From the
remainder:

        10 have been completed (final reports awaited)
        21 are underway
        15 have not been registered with the department and therefore assumed not to have
         started

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              SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST


The monitoring exercise is attached in Appendix 1.

NICE Register

During this quarter the following were applicable to the Trust and added to the register:

Guidance      Title                             Lead appointed    Implemented
                                                                  Action plan in
CG 68         Stroke                            Yes
                                                                  development
                                                                  To be discussed at
CG 70         Induction of Labour               Yes
                                                                  Labour Ward Forum
              Continuous subcutaneous
              insulin infusion for the
TA 151                                          Yes               Yes
              treatment of diabetes mellitus
              (review of TA 57)
                                                                  Action plan
CG 63         Diabetes in Pregnancy             Yes
                                                                  developed
              Routine antenatal anti-D                            To be discussed at
TA 156        prophylaxis for women who         Yes               Labour Ward Forum
              are rhesus D negative
              Technical patient safety                            via Critical Care
              solutions for ventilator-                           Delivery Group
PSG 002                                         Yes
              associated pneumonia in
              adults
              Ranibizumab and pegaptanib                          Funding expected
              for the treatment of age-                           November 2008
TA 155                                          Yes
              related macular
              degeneration.
              Familial                                            Action plan to be
CG 71                                           Yes
              hypercholesterolaemia                               developed.
              Oseltamavir, amantadine and
              zanamivir for the prophylaxis
                                                To be submitted
TA 158        of influenza (including a
                                                to MAOGG
              review of NICE technology
              appraisal guidance 67)
              Attention Deficit Hyperactivity   To be submitted
TA 72
              Disorder                          to SAOGG
              Dabigatran etixilate for the
              prevention of venous              To be discussed
TA 157        thromboembolism after hip or      at Thrombosis
              knee replacement surgery in       Committee
              adults




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              SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST

Standards for Better Health and NHSLA activity

Supporting activity for this is shown below:

Blood bank – Monthly traceability figures provided for discussion at Hospital Transfusion
Committee; a requirement of the MHRA.

Medical records – this department continues to work with medical records staff to ensure
compliance with NHSLA and Standards for Better Health.

Falls prevention – A Trust-wide audit of the falls risk assessment process and the use of the
electronic falls prevention devices is scheduled for early October.

Do Not Attempt Resuscitation (DNAR) - A Trust-wide audit is in progress.


Dr Foster

This tool provides the Trust with data which has been standardised for age, sex and
deprivation which is also case mix adjusted. This enables the Trust to monitor its
performance against 4 outcome measures: mortality, LOS, day case rate and readmissions.
There is an alert system that shows good (green flag) and poor (red flag) performance. The
Clinical Audit and Effectiveness Specialist monitors the system on a monthly basis. New red
flags are notified to the relevant Audit and Operational Governance Group and a preliminary
report sent to the relevant clinician; green flags are circulated. If a red flag appears more than
twice in a row then the relevant clinician is nominated by the group to investigate and report
their findings and report back to the group. The report outlines progress to date for data
relating to the last six months.

The following charts show a six month breakdown of Dr Foster activity April – September
2008. In May there was a back log in data processing as data were standardised against a
new year, therefore there were no new flags for May.

Green Flags
In the period from April – September 2008 there were:
        62 diagnoses or procedures that green flagged one or more times
            4 for mortality
            24 for LOS
            21 for Day Case Rate
            13 for readmissions




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       SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST



MORTALITY                                            DATE REPORTED
Diagnoses                                            April June  July     August Sept
                                                     DATA PERIOD


                                                     Nov
                                                           Jan-   Feb-    Mar-   Apr-
                                                     07-
                                                           Mar    April   May    June
                                                     Jan


Pneumonia                                                                 X      X
Procedures
Cardiac pacemaker system introduced through
                                                                  X
vein
Other blood transfusion                              X
Other drainage of peritoneal cavity                        X



LENGTH OF STAY                                       DATE REPORTED
Diagnoses                                            April June  July     August Sept
                                                     DATA PERIOD

                                                     Nov
                                                           Jan-   Feb-    Mar-   Apr-
                                                     07-
                                                           Mar    April   May    June
                                                     Jan

Acute cerebrovascular disease                        X     X      X       X      X
Acute myocardial infarction                          X
Biliary tract disease                                X                    X      X
Cancer of bladder                                          X
Cancer of breast                                     X            X       X      X
Congestive heart failure, non hypertensive           X            X
Fracture of neck of femur (hip)                      X     X      X       X      X
Noninfectious gastroenteritis                        X
Non specific chest pain                                                   X      X
Other liver diseases                                                      X
                                                     X

Pleurisy, pneumothorax, pulmonary collapse           X
Pneumonia                                            X     X              X
Senility and organic mental disorders                X     X      X
Septicaemia                                                               X      X
Short gestation, low birth weight and fetal growth
retardation                                                X      X       X

Procedures
Abdominal excision of uterus                               X      X       X

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               SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST

       LENGTH OF STAY                                 DATE REPORTED
       Diagnoses                                      April June  July               August Sept
                                                      DATA PERIOD

                                                      Nov
                                                              Jan-       Feb-        Mar-    Apr-
                                                      07-
                                                              Mar        April       May     June
                                                      Jan

       Delivery                                       X
       Diagnostic endoscopic procedures on upper GI
                                                      X
       tract
       Excision of breast                             X       X          X
       Femur replacement                                                             X       X
       Hip replacement                                X       X          X           X       X
       Knee replacement                               X       X          X           X       X
       Laparoscopic cholecystectomy                   X                              X       X
       Reduction of fracture of bone                  X                              X       X


DAY CASE RATE                                         DATE REPORTED
                                                      April       June       July        August     Sept
Procedures
                                                      DATA PERIOD


                                                      Nov 07- Jan-           Feb-
                                                                                         Mar-May Apr-June
                                                      Jan     Mar            April


Arthroscopy                                           X           X          X           X          X
Bunion operations                                     X           X          X           X          X
Carpal tunnel decompression                           X           X          X           X
Circumcision                                          X           X          X           X
Dilation and curettage/hysteroscopy                                          X           X          X
Excision of breast lump                               X                                             X
Excision of cervix uteri                              X           X          X           X          X
Excision of Dupuytren's contracture                   X
Excision of ganglion                                              X                      X
Extraction of cataract with/without implant           X           X          X           X          X
Extraction of tooth                                   X           X          X           X          X
Inguinal hernia                                       X           X          X           X          X
Laparoscopy                                           X           X          X           X          X
Myringotomy with/without grommets                                 X          X

Other destruction of haemorrhoid                      X                      X           X          X

Puncture of joint                                     X           X          X           X          X

Reduction of nasal fracture                                                              X


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                SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST

 DAY CASE RATE                                             DATE REPORTED
                                                           April    June     July      August   Sept
 Procedures
                                                           DATA PERIOD


                                                           Nov 07- Jan-      Feb-
                                                                                       Mar-May Apr-June
                                                           Jan     Mar       April


 Removal of metalware                                      X        X        X         X        X

 Repair of umbilical hernia                                X        X                  X

 Transurethral resection of bladder tumour                 X        X                  X        X

 Varicose vein stripping or ligation                       X


  READMISSIONS (28 days)                                   DATE REPORTED
                                                           April  June   July         August    Sept
  Diagnoses
                                                           DATA PERIOD


                                                                             May
                                                           Feb 07- April 07-          June 07- July 07-
                                                                             07-April
                                                           Jan 08 Mar 08              May 08 June 08
                                                                             08


  Cancer of bronchus, lung                                                                      X
  Complications of surgical procedures or medical care                                          X
  Genitourinary symptoms and ill-defined conditions                                   X         X
  Leukaemias                                               X                          X         X
  Liveborn                                                          X        X        X         X
  Non Hodgkin’s lymphoma                                   X
  Pneumonia                                                                           X
  Skin and subcutaneous tissue infections                                                       X
  Procedures
  Delivery                                                                            X         X
  Other blood transfusion                                  X
  Diagnostic endoscopic examination of bladder                                        X         X
  Diagnostic endoscopic examination of lower respiratory                              X         X
  tract
  Other blood transfusion                                                                       X

Red Flags
In the period from April – September 2008 there were:
23 diagnoses or procedures that red flagged one or more times
6 for mortality
8 for LOS
3 for Day Case Rate
6 for readmissions
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                SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST

MORTALITY                                             Date Reported
Diagnoses                                             April        June   July    August   Sept
                                                      Data Period
                                                      Nov 07-Jan Jan -    Feb -   Mar -    April -
                                                      08           Mar    April   May      June
Alcohol-related mental disorders
Clinical coding error.                                            
ACTION: Coders informed and corrected
Other upper respiratory disease
                                                                                          
Preliminary report with consultant.
Secondary malignancies - re-alert
                                                                                          
Undergoing re-investigation
Senility and organic mental disorders - re-alert
Investigation found:
a) Doctors using’ old age’ as cause of death.
ACTION: Guidance now on Induction CD                                      
b) Coding from death certificate
ACTION: Coders aiming to code from 100% of
patients’ medical records
Septicaemia (except in labour) – re-alert
Investigation found coding was being performed from
death certificate.                                                               
ACTION: Coders aiming to code from 100% of
patients’ medical records
Syncope
                                                                                           
Undergoing investigation


Procedures
NONE




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                 SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST


LENGTH of STAY                                     Date Reported
Diagnoses                                          April           June       July    August   Sept
                                                   Data Period
                                                   Nov 07-Jan 08   Jan -Mar   Feb -   Mar -    April -
                                                                              April   May      June
Abdominal pain – re-alert
Investigation found
a) poor quality discharge summaries resulting in
inaccurate coding
b) inconsistent weekend discharges                                                           
ACTION results presented to surgical
department
c) coding error
ACTION coders informed and corrected
Cancer of colon – re-alert
Investigation found
a) poor quality discharge summaries resulting in
inaccurate coding
b) inconsistent weekend discharges
                                                                                              
ACTION introduction of discharge protocol
c) proportion of wound infections
ACTION audit
d) coding errors
ACTION coders informed and corrected
Cancer of rectum and anus
                                                                                               
Preliminary report to SAOGG 01/10/08
Non-Hodgkin’s lymphoma
                                                                                               
Preliminary report with consultant
Normal pregnancy and/or delivery – re-alert
                nd
As with first, 2 investigation found
a) proportion of mothers needing longer stay as
breast feeding                                                                             
b) PAS inputting inaccurate
ACTION improve inputting c) coding errors.
ACTION coders informed and corrected
Regional enteritis and ulcerative colitis
                                                                                    
Preliminary report with consultant

Procedures
Continuous infusion of therapeutic substance
Coding process changed                             
Other intravenous injection
Coding process changed                             




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                 SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST


DAY CASE RATE
Procedures                                                     DATE REPORTED

                                                               April     June   July    Aug    Sept
                                                               DATA PERIOD

                                                               Nov 07-   Jan-   Feb-    Mar-   Apr-
                                                               Jan       Mar    April   May    June

Laparascopic cholecystectomy
Response from consultant – unhappy to do as day cases
                                                                                             
without protocols and patient selection in place.
NO ACTION
Submucous resection (septum or turbinate of nose)
Response from consultant – day surgery done in afternoon
                                                                                           
patients need overnight stay.
NO ACTION
Tonsillectomy
Response from consultant – day surgery done in afternoon
                                                                                           
patients need overnight stay.
NO ACTION


READMISSIONS
Diagnoses                                                      DATE REPORTED

                                                               April     June   July    Aug    Sept
                                                               DATA PERIOD

                                                               Nov 07-   Jan-   Feb-    Mar-   Apr-
                                                               Jan       Mar    April   May    June

Cancer of ovary
Response from CNS – patients not suitable for procedures as
a day case. Ascites needs staged procedure over period of      
time.
NO ACTION
Liveborn
Investigation found readmissions by midwives, GPs and
through A&E. Consultant impression admission was due to a
                                                               
lack of available midwife support. New mothers will continue
to bring perceived unwell babies to A&E.
NO ACTION
Liver disease alcohol related
Preliminary report with consultant                                                         
NO ACTION
Syncope
Investigation found one patient had multiple readmissions                      
NO ACTION
Procedures
Other drainage of peritoneal cavity
                                                                               
Preliminary report sent to MAOGG

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                 SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST

READMISSIONS
Diagnoses                                               DATE REPORTED

                                                        April     June   July    Aug    Sept
                                                        DATA PERIOD

                                                        Nov 07-   Jan-   Feb-    Mar-   Apr-
                                                        Jan       Mar    April   May    June

Therapeutic epidural injection
Investigation found patients has been readmitted with
                                                                        
problems unrelated to procedure
NO ACTION



Additional work undertaken by the Department

Cause of death register – a database has been developed to enable the Trust to:
     Determine the number of deaths that occur in the Trust
     Ascertain the cause of death
     Promptly notify GPs of deaths occurring in hospital

Carbonated death register forms are completed as the same time as the death certificate.
These forms are being back dated to the 1st April and transferred to the database by the
Governance Department who are administrating it. The top copy is sent to the GP.

Trust documentation

The following documents have been revised this quarter by the Department:
       Junior Doctors Handbook – also available on the intranet
       Antimicrobial Prescribing Guidelines – also available on the intranet
       Anticoagulant Chart and Referral Form
       Nursing process

And the following new documents are in development:
      Medical Assessment Unit Doctors Clerking Proforma (this will be audited
       subsequently)
      Venous thromboembolism (VTE) risk assessment and guideline for adult surgical
       patients
      Venous thromboembolism (VTE) risk assessment and guideline for adult medical
       patients

Ruth Brown
Marian Benjamin
Clinical Audit and Effectiveness Department




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                                SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST



Appendix 1
Annual Plan 2008 – 09

Clinical
Effectivenes
                                                                                                             Status of   Comments as at
s            Body          Division     Specialty     Audit title            Date          Clinical Lead
                                                                                                             audit       1 October 2008
Department
involved?
Yes          Cancer Plan   Medicine     Haematology   Intrathecal            Annual        Dr Peter Hawker   Underway    Data collection
                                                      chemotherapy                                                       complete for
                                                                                                                         2007 patients
Yes         CMO (NICE Medicine          Medical       Audit of               2 - 3 x per   Dr Peter Rose     Due         1st phase
            Guidance due                              thromboprophylaxis     year                                        introduced
            2009)                                     in medical patients                                                August 2008
                                                                                                                         (risk assessment
                                                                                                                         and guideline)
Yes         CNST           Surgery      Obs & Gynae   Audits of guidelines   due Sept      Mr Dave D'Souza Underway      Shoulder
                                                                             2009                                        dystocia
                                                                                                                         completed
Yes         Dr Foster      Medicine /   All           Review of conditions ongoing         Dr Peter Hawker   Underway    Several
                           Surgery                    where performance                                                  completed "red
                                                      is worse than the                                                  flag" reports.
                                                      average

Yes         Global Rating Surgery       Endoscopy     Audits of endoscopy ongoing          Mr Martin Osborne Underway    Reported at
            Scale                                                                                                        Endoscopy
                                                                                                                         Business
                                                                                                                         Meetings (report
                                                                                                                         due October
                                                                                                                         2008)
Yes         HCC            Medicine     Cardiology    Heart Failure Audit Jan 2008 - Dr P Verma              Pilot
                                                                                                             completed




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                         SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST



Clinical
Effectivenes
                                                                                            Status of   Comments as at
s            Body   Division     Specialty      Audit title      Date       Clinical Lead
                                                                                            audit       1 October 2008
Department
involved?
Yes         HCC     Surgery      Orthopaedics   # Hips           Jan 2008 - Marie Ritson    Underway Continuous
                                                                                                     data
                                                                                                     submission

Yes         HCC     Medicine /   All            Antibiotic        4 monthly Dr Steve Mather Underway Baseline audit
                    Surgery                     prescribing                                          and re-audit
                                                                                                     completed
Yes         HCC     Surgery      Endoscopy      National Gastro-  Jan 2008 - Dr Bernhard    Underway Data collection
                                                oesophageal audit            Usselmann               period
                                                                                                     extended. New
                                                                                                     diagnoses
                                                                                                     (30th June
                                                                                                     2009) and
                                                                                                     treatments
                                                                                                     (31st
                                                                                                     December
                                                                                                     2009).
Yes         HCC     Medicine     Cardiology     MINAP             continuou Dr Najmi        Underway Annual report
                                                                  s          Qureshi                 2007-08
                                                                                                     available.
                                                                                                     Issued June
                                                                                                     2008.
Yes         HCC     Medicine     Diabetes       National Diabetes Septembe Dr Jyoti Sidhu   Complete Information
                                                Audit (NDA)       r 2008                    d        submitted.
                                                                                                     Report
                                                                                                     expected 2009.




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                          SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST



Clinical
Effectivenes
                                                                                                  Status of   Comments as at
s            Body    Division     Specialty    Audit title         Date         Clinical Lead
                                                                                                  audit       1 October 2008
Department
involved?
Yes         Local    Surgery      Stoma care   Patient Satisfaction continuou   Denise            Complete Final report
                                                                    s           Humphreys         d        awaited
Yes         Local    Surgery      Stoma care   Audit of Quality     continuou   Denise            Complete Final report
                                               Standards            s           Humphreys         d        awaited
Yes         NCEPOD   Medicine /   All          Not known            2008-09     Dr Steve Mather   Underway Deaths in
                     Surgery                                                                               Acute
                                                                                                           Hospitals.
                                                                                                           Consultants
                                                                                                           returning
                                                                                                           questionnaires.
Yes         NHSLA    Surgery      GI Surgery   Audit of            October      Miss K Busby               Due to start
                                               prescription sheets 2008                                    October 2008
Yes         NHSLA    Medicine /   All          Consent             by Sep       Pat Morris        Complete Finding
                     Surgery                                       2008                           d        discussed at
                                                                                                           SAOGG and
                                                                                                           CGC
Yes         NHSLA    Governanc Resuscitation   Audit of cardiac    Annual       Julie Lyons       Underway 2008 data
                     e                         arrests                                                     collection
                                                                                                           underway.

Yes         NHSLA    Medicine /   All          Record keeping      by Sep       Pat Morris        Complete Report on
                     Surgery                                       2008                           d        2007 notes.
                                                                                                           Findings
                                                                                                           discussed at
                                                                                                           SAOGG,
                                                                                                           MAOGG and
                                                                                                           Senior Nurses'




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                           SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST



Clinical
Effectivenes
                                                                                                 Status of   Comments as at
s            Body     Division   Specialty        Audit title         Date       Clinical Lead
                                                                                                 audit       1 October 2008
Department
involved?
                                                                                                             Meeting.
                                                                                                             Awaiting
                                                                                                             revision of
                                                                                                             signature
                                                                                                             policy.
Yes         NHSLA /   Trust-wide Resuscitation    Do not attempt       ongoing   Julie Lyons     Underway
            SfBH                                  resuscitation
                                                  (DNAR)
Yes         NICE      Medicine   Gastroenterology TA 106 Hepatitis C June 2008   Dr Jeremy      Plan to
                                                  - peginterferon alfa           Shearman / Sue start in
                                                  and ribavirin                  Scott          January
                                                                                                 2009

Yes         NICE      Medicine   Haematology      TA 110 Follicular   July 2008 Dr Anton Borg    Plan to
                                                  lymphoma –                                     start in
                                                  rituximab                                      January
                                                                                                 2009

Yes         NICE      Medicine   Haematology      TA 119 Leukaemia July 2008 Dr Anton Borg       Plan to
                                                  (lymphocytic) –                                start in
                                                  fludarabine                                    January
                                                                                                 2009

Yes         NICE      Medicine   Cardiology       TA 094                June 2008 Dr Yasser      Complete Final report
                                                  Cardiovascular                  Haider         d        awaited
                                                  disease - statins
Yes         NICE      Medicine   Cardiology       TA 095 Arrhythmia June 2008 Dr Yasser          Underway Data collection
                                                  - implantantable                Haider                  almost
                                                  cardioverter                                            complete
                                                  defibrillators (ICDs)




                                                                                                                           17
                            SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST



Clinical
Effectivenes
                                                                                                   Status of   Comments as at
s            Body      Division     Specialty       Audit title         Date      Clinical Lead
                                                                                                   audit       1 October 2008
Department
involved?
                                                     [review]
Yes         NICE       Surgery      Paediatrics      CG 054 UTI in     ongoing    Dr Vino Clarke   Complete New guidelines
                                                     children                                      d        agreed
Yes         NICE       Medicine /   Emergency Care / CG 56 Head injury 2008       Mr Matthew       Plan to
                       Surgery      Radiology                                     Dunn             start in
                                                                                                   January
                                                                                                   2009
Yes         NICE       NICE         Surgical        CG 046 Audit of     2008      Dr Peter Rose    Underway 1st phase –
                                                    thromboprophylaxi                                       guideline –
                                                    s in surgical                                           introduced
                                                    patients                                                August 2008
Yes         NICE /     Surgery      Outreach        Audit of the        October   Dr Tim Long               Due to start
            NCEPOD                                  Effectiveness of    2008                                October 2008
                                                    the Outreach
                                                    Team
Yes         NPSA       Medicine     Pharmacy /      Safe use of         ongoing   Dr Peter Rose    Underway New form
                                    Haematology     Anticoagulants                                          (local) and DH
                                                                                                            booklets
                                                                                                            introduced.
                                                                                                            Audit data
                                                                                                            collection not
                                                                                                            commenced.
Yes         NSF -      Medicine     Cardiology      MINAP Data         December Dr Najmi                    Due December
            Coronary                                Quality Audit 2008 2008     Qureshi                     2008
            Heart
            Disease
            (HCC)




                                                                                                                           18
                             SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST



Clinical
Effectivenes
                                                                                                  Status of   Comments as at
s            Body       Division   Specialty       Audit title         Date      Clinical Lead
                                                                                                  audit       1 October 2008
Department
involved?
Yes         NSF -       Medicine   Diabetes        see NDA             Annual    Dr Jyoti Sidhu   Complete Report
            Diabetes                                                                              d        expected 2009
Yes         NSF - Older Medicine   Care of the     Survey of Older     2008      Dr Obaid Khan    Underway
            People                 Elderly         People's
                                                   Perception of
                                                   Healthcare
Yes         NSF / NICE Medicine    Older People    Audit of TIAs       April 2008 Dr Raj Thanvi   Complete Awaiting
                                                                                                  d        presentation
Yes         RCP (HCC) Medicine     Elderly care    Stroke (6th wave)   October   Dr Obaid Khan    Underway Organisational
                                                                       2008                                report
                                                                                                           released.
                                                                                                           Clinical audit
                                                                                                           data collection
                                                                                                           underway.
Yes         RCP (HCC) RCP (HCC) Occupational       National audit of Jan - Dec   Dr Julie         Complete Final report
                                Health             the managements 2008          Popplewell       d        awaited
                                                   of NHS staff with
                                                   lower back pain
                                                   and depression
Yes         RCP BTS     Medicine   Respiratory     COPD audit        March       Dr Jayanta       Complete Data completion
            etc                    Medicine                          2008        Mukherjee        d        by end August
                                                                                                              2008. Report
                                                                                                              date not given
                                                                                                              yet.
Yes         RCP etc     Medicine   Gastroenterology Inflammatory       2008-09 Dr Peter Hawker Underway to be
                                                    Bowel Disease      (date not                        completed by
                                                                       specified)                       end December
                                                                                                        2008



                                                                                                                           19
                              SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST



Clinical
Effectivenes
                                                                                                       Status of   Comments as at
s            Body        Division     Specialty       Audit title          Date      Clinical Lead
                                                                                                       audit       1 October 2008
Department
involved?
Yes         RCP etc      Medicine /   Elderly care /  Falls & Bone         after April Dr Francis Vaz Due          Organisational
                         Surgery      Orthopaedics/A& Health               2008        (Multidisciplinary          Audit due
                                      E                                                )                           November
                                                                                                                   2008
Yes         Royal        Surgery      Orthopaedics    Patient Outcomes Septembe Marie Ritson           Underway
            College of                                in Surgery (POIS) r 2008
            Surgeons                                  audit for elective
                                                      hip and knee
                                                      rplacement

Yes         Trust-wide   Trust-wide Dietetics         Appropriateness of October     Sumithra
                                                      TPN referrals and 2008         Konduru
                                                      insertion of TPN
                                                      lines
Yes         Trust-wide   Trust-wide All               Audit of Falls     Annual      Lorraine Gibson               Due October
                                                                                                                   2008

Yes         Warwickshir Surgery       Paediatrics     Audit of             Septembe John Davies        Underway
            e                                         documentation of     r 2008
            Safeguardin                               child protection
            g Children                                issues in medical
            Board                                     records
tba         NICE        Medicine      Dermatology     TA 103 Psoriasis -   tba       tba
                                                      efalizumab and
                                                      etanercept
tba         NICE         Medicine     Rheumatology    TA 104 Psoriatic     tba       tba
                                                      arthritis -




                                                                                                                                 20
                            SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST



Clinical
Effectivenes
                                                                                                   Status of   Comments as at
s            Body      Division   Specialty         Audit title          Date      Clinical Lead
                                                                                                   audit       1 October 2008
Department
involved?
                                                    etanercept and
                                                    infliximab
tba         NICE       Medicine   Cardiology        TA 047 Acute          tba      Dr Najmi
                                                    coronary                       Qureshi
                                                    syndromes -
                                                    glycoprotein IIb/IIIa
                                                    inhibitors (review)
tba         NICE       Surgery    Breast care       TA 112 Breast         tba      Mr Simon        Plan to Unable to
                                                    cancer (early) -               Harries         start inundertake this
                                                    hormonal                                       January audit due to
                                                    treatments                                     2009    other work
                                                                                                           pressures
No          Cancer plan Cancer    Colorectal surgery Colorectal cancer   ongoing   Martin Osborne Underway Data collection
                        plan                                                                               and
                                                                                                           submission
                                                                                                           from colorectal
                                                                                                           surgery dept.
No          Cancer Plan Cancer    Breast surgery    Breast screening     ongoing   Simon Harries
                        Plan                        audit

No          Cancer Plan Cancer    Breast surgery    Symptomatic          ongoing   Simon Harries
                        Plan                        Breast Audit

No          Cancer Plan Cancer    Breast surgery    Atom trial -audit of ongoing   Simon Harries
                        Plan                        outcomes
No          Cancer Plan Cancer    Breast surgery    Sentinel Node        ongoing   Simon Harries
                        Plan                        Audit




                                                                                                                           21
                            SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST



Clinical
Effectivenes
                                                                                                 Status of   Comments as at
s            Body      Division   Specialty        Audit title        Date       Clinical Lead
                                                                                                 audit       1 October 2008
Department
involved?
No          Cancer Plan Cancer    Breast surgery   National           started  Deborah Enser /
                        Plan                       Mastectomy and     Jan 2008 Maureen Walker
                                                   Reconstruction
                                                   Audit

No          ICNARC     Surgery    Critical Care    Intensive Care     continuou Dr Tim Long      Underway Continuous
                                                   National Audit and s                                   data collection.
                                                   Research Centre                                        Update
                                                                                                          presented by
                                                                                                          Dr Tim Long at
                                                                                                          Nultidisciplinar
                                                                                                          y Clinical Audit
                                                                                                          meeting 6th
                                                                                                          June 2008.
No          NICE       Surgery    Urology          IPG 120             ongoing   Mr John         Underway
                                                   Potassium-titanyl-            Strachan
                                                   phosphate (KTP)
                                                   laser vaporisation
                                                   of the prostate for
                                                   benign prostatic
                                                   obstruction

No          NICE       Medicine   Dietetics        Nutrition support in tba      Liz Fancourt
                                                   adults
No          NICE       NICE       Dietetics        CG 032 Nutrition June and Ruth Breese
                                                   support in adults    December
                                                                        2008




                                                                                                                         22
                              SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST



Clinical
Effectivenes
                                                                                                       Status of   Comments as at
s            Body        Division   Specialty         Audit title           Date     Clinical Lead
                                                                                                       audit       1 October 2008
Department
involved?
No          NPSA         NPSA       Dietetics         Compliance with    December Laura Pettifer
                                                      NPSA 19            2008
                                                      (Promoting safer
                                                      measurement and
                                                      administration of
                                                      liquid medicines
                                                      via oral and other
                                                      routes)
No          Pain Audit   Surgery    Critical Care /   PACS               ongoing  Debbie Mundy         Underway
            Collection              Pain Service
            System
            (PACS)
No          Pan Cancer   Pan Cancer Endoscopy         West Midlands         Jan 2008 Dr Jeremy
            Birmingham   Birmingham                   Biliary Drainage               Shearman
            network      network                      Audit
No          Trust and    Trust and Dietetics          Audits of nutrition   October - Ruth Breese /
            Community-   Community                    screening tool        December Modern matrons
            wide         -wide                                              2008
No          Trust-wide   Trust-wide Dietetics         PEG mortality         January   Laura Pettifer
                                                                            2009




Ruth Brown
Marian Benjamin
Clinical Audit and Effectiveness Department




                                                                                                                               23

								
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