The National Heart Failure Audit: An overview of the audit process
The National Heart Failure Audit focuses on inpatient care and aims to: Identify the percentage of people admitted to hospital with heart failure who have quality of care recorded. Describe current clinical practices in heart failure diagnosis, care and treatment and to explain variation in practice using data on patient characteristics and healthcare provider identity as per CHD NSF and NICE recommendations Describe the following patient outcomes: length of stay, in-hospital mortality and late mortality (up to one year post discharge).
The following document provides information on getting started and how to use the audit information to support local improvement. Participation in the National Heart Failure Audit requires five steps: 1. Registering with the audit 2. Installing software to submit the data 3. The audit process a. Identifying patients b. Inputting data c. The Heart Failure Helpdesk 4. Accessing results 5. Using audit results
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1. How do I register with the audit?
All national heart disease audit data is submitted to The Information Centre Central Cardiac Audit Database. To participate in the audit you will need to register with the Central Cardiac Audit Database (CCAD) helpdesk. To register, please send an email to the helpdesk (helpdesk@ccad.org.uk) with ‘national heart failure audit’ in the reference. You will need to provide the helpdesk with the following information for each user who requires access to the heart failure application: user name, title, job etc name of the clinical lead for the audit user email addresses and telephone number state that you require access to the heart failure database.
The helpdesk will then issue a user ID. Each hospital will have a nominated high-level user, normally a lead clinician for heart failure. Requests to CCAD to register new users are only accepted from this person. Hospitals are responsible for authenticating all their own users and for informing CCAD when users leave or no longer need access to CCAD.
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2. How is data submitted to the central cardiac audit database?
Heart failure data is submitted to the national database from a local client computer using Lotus Notes software. This is easy to install and already installed in all hospitals as the software is used to support various heart disease projects including the Myocardial Infarction National Audit Project (MINAP) On registration, the CCAD helpdesk will send you a CD containing application and installation instructions. Detailed information on installing the software and the heart failure databases can be found in the documents listed below and can be accessed via The IC Heart failure web page: http://www.ic.nhs.uk/our-services/improving-patient-care/national-clinicalaudit-support-programme-ncasp/heart-disease/heart-failure/getting-started Volume 1: Installation Guide Information on installing Lotus Notes, connecting to CCAD servers, security and system requirements Volume 2: CCAD Portal Guide Information on using the CCAD Welcome Portal Volume 3: Lotus Notes Guide Guidance on using Lotus Notes Volume 4: Heart Failure Database Guide Guidance on the database CCAD security document Heart Failure Dataset V1.3a
The CCAD helpdesk will provide technical support throughout the whole process: helpdesk@ccad.org.uk or 0845 300 6016, selecting option 2. Once your organisation has successfully registered and installed the software you can start using the database to submit data to the National Heart Failure Audit.
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3. The audit process
The following sections focus on the audit process and includes sections on : 3.1 Identifying patients Inputting data Accessing results Using results to improve patient care
How are patients identified?
The aim of the audit is to measure the quality of care for all inpatients discharged with a primary diagnosis of heart failure using the following codes: I50.0 Congestive heart failure I50.1 Left ventricular failure I50.9 Heart failure, unspecified I11.0 Hypertensive heart disease with (congestive) heart failure I42.0 Dilated cardiomyopathy I25.5 Ischaemic cardiomyopathy I42.9 Cardiomyopathy, unspecified.
The process of identifying patients varies between hospitals and depends on local resources, care pathways and the designated roles responsible for collecting data. The table below provides examples of how some of our current users have approached the audit:
Hospital A The heart failure nurse is the clinical lead for the heart failure audit within the hospital. Patient notes are identified in three ways: 1) by patient referral to the heart failure specialist nurse 2) by the cardiology ward clerk 3) by the hospital coding team Information is collated by the heart failure nurse using the heart failure proforma (available via the heart failure database following registration). Data is inputted either by the heart failure specialist nurse or by admin support.
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Hospital B The heart failure nurse identifies patients through referral to the heart failure service and will input data after each clinical session. In addition, the coding department highlights cases on a monthly basis which the heart failure nurse enters on a monthly basis. Missed cases have helped the heart failure specialist nurse to identify patients who would have benefited from referral to the heart failure specialist service and improve the referral process.
Hospital C Hospital C uses existing IT systems (either in-house or via third party IT suppliers) to provide direct data links to the National Heart Failure Database. If your hospital has approached the audit in a different way please let us know so that we can share your approach with other users on h-f@ic.nhs.uk. 3.2 Inputting data Who collects and inputs the data? User roles vary between hospitals but the main roles tend to be Heart Failure specialist nurses, clinical audit leads and MINAP leads. How much data do I need to submit? All participating sites are collecting the mandatory/core fields. These reflect the key NSF and NICE audit requirements (Appendix 1) The number of core fields has increased from 21 to 36 core fields1. These are broken down as follows: Type of database record Patient registration Number User input of core fields 8 These are demographic fields that will enable links to the admission and readmission records within the database. It will also enable The IC to link clinical data with data from other sources (e.g. ONS mortality data). This will enable us to: look at variation between groups of patients (e.g. age, sex, geographic area) measure patient outcomes 26 Refers to clinical data and processes and relates to diagnosis, treatment and follow-up
Admission
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There are 36 core fields but some fields, such as hospital identifier, are repeated across each of the database records (e.g. patient registration, admission, and readmission). Repeated items are automatically populated and do not need to be double entered.
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Readmission 26
Unscheduled 4 event
Life status
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The database uses demographic data to recognise existing patients within the database and the need to create a readmission record. This is a replica of the admission record and refers to clinical data and processes and relates to diagnosis, treatment and follow-up. Not applicable at this stage. These fields are only core if you create this type of record. They were created in anticipation of the audit extending into an outpatient setting. Not applicable at this stage. These fields will be populated with data from other sources, e.g. ONS mortality data at a later stage (please see above).
Additional fields In addition to the core data fields, some hospitals are also using the database to collect additional data used for local use only. Examples of how the database and information is used include care management, local audit and monitoring access to specialist services. How is the data inputted? All data is submitted electronically by hospital into a protected central database via a secure website. Data may be entered into the central cardiac audit database in three ways: Direct data entry via the database Completion of paper proforma (accessed via the database) followed by entry via the database Uploading of electronic data (in CSV file format) into the database from existing local IT systems and third party commercial databases such as TOMCAT, PATS and DATACAM.
If you experience any difficulties please contact the CCAD helpdesk on helpdesk@ccad.org.uk or 0845 300 6016, selecting option 2. How much time does it take to input information for each record? The time taken to manually input the core data fields ranges from 5 to 20 minutes and depends on a number of factors including: Complexity of the case. Whether an audit record already exists for a patent. For example, if the episode of care is readmission for heart failure, the Patient Registration record containing demographics will already be complete. The quality of clinical notes.
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3.3
The Heart Failure Helpdesk If you have any non-technical questions about the heart failure audit that are not covered in this document or by our FAQ section on the website (http://www.ic.nhs.uk/our-services/improving-patient-care/thenational-clinical-audit-support-programme-ncasp/heart-disease/heartfailure/frequently-asked-questions-faqs) please contact The heart failure helpdesk (contact details). For all technical queries please continue to contact the CCAD helpdesk on helpdesk@ccad.org.uk or 0845 300 6016, selecting option 2.
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Accessing audit results Once you have submitted your data you will be able to access results in a number of ways: Local Reports Online updates on the number of patients registered with the audit at a local and national level Online comparisons of clinical data against local and national data The ability to download Unit data for local analysis.
National Reports The audit is ongoing and annual national reports are scheduled for April 2008, 2009 and 2010. These reports will be made publicly available in electronic format and will include the following information: A list of participating hospitals A comparison of the level of audit activity between and within hospitals A comparison of clinical practice between and within hospitals Evidence of any inequity of access by age, gender, ethnicity and social deprivation Association of any of the above factors with the patient outcomes such as admission and readmission rates, length of stay, in hospital and post discharge mortality.
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Using Audit Findings to improve patients care The most important part of a clinical audit project is using the findings to improve patient care and outcomes. The Department of Health Core Standards expect Clinical staff in NHS organisations to be involved in prioritising, conducting, reporting and acting on clinical audits. Audit findings can be used in various ways by a wide range of stakeholders to bring about improvements including:
Improving standards of care Access to national comparative data allows clinicians, healthcare professionals and cardiac networks to examine key aspects of the quality of care and impact on patient outcomes and quality of life, and implement change accordingly. NHS commissioners will know the quality of acute services so they can purchase more care from units providing evidence based care and with reduced waiting times and readmissions and with the best outcomes for patients. Audit results are a resource for healthcare professionals in both primary and secondary care to assess whether their hospitals are meeting the standards set by the Department of Health and assessed by the Healthcare Commission.
Patient choice Information can be used to assist patients in making decisions about how, when and where they get treated. Effective commissioning Information can be used to highlight inequities both within an organisation and between different localities. For example, audit findings can highlight postcode lottery in commissioning policy between PCTs. Stakeholders, including NHS commissioners, can match activity rates to the needs of local population to support commissioning decisions.
If you are using audit data to support local improvement please get in touch so that we can share examples of your good practice with others, h-f@ic.nhs.uk
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The role of The Information Centre in supporting local improvement The Information Centre is looking at ways to support local improvement such as: Developing working links with organisations with a cardiac remit such as The Heart Improvement Programme and Cardiac Networks to identify ways in which national clinical audit findings can support local improvement. Identifying organisations that have made good progress in improving data completeness and compile and share cases studies of good practice of local action planning and improvements and share with stakeholders via The IC website and annual reports.
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Appendix 1
Algorithm summarising the key NICE2 heart failure recommendations mapped across to the national heart failure audit core data fields
1) Measuring the quality of care: Diagnosis, treatment and follow up
Suspected heart failure because of history, symptoms and signs Field 3.01 Field 3.04 Field 4.01 Field 4.09 Field 4.12 Field 4.14 Breathlessness Oedema Previous AMI Previous Valve Disease Previous Hypertension Previous Diabetes
Seek to exclude heart failure through: 12-lead ECG And/or natriuretic peptides (BNP or NTproBNP) – where available
Field 9.13 Field 9.21
BNP ECG
Seek to assess systolic (and diastolic) function of the (left) ventricle and detect intracardiac shunts
Field 9.23
LVEF < 40%: principal aetiology To accommodate assessment by other means e.g. angiography
Treatment All patient with heart failure due to LVSD should be considered for treatment with an ACE inhibitor
Field 11.01
Treatment ACE I
Treatment Angiotensin II receptor antagonists may provide an 3 alternative to ACE inhibitors
Field 11.04
Treatment ARB (angiotensin II receptor Antagonists)
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CG5 Chronic heart failure: NICE guideline (http://www.nice.org.uk/guidance/index.jsp?action=download&o=29136)
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Angiotensin II receptor antagonists have been licensed since publication of the Chronic Heart failure guidelines (2003).
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Treatment Beta blockers should be initiated in patients with LVSD after diuretic and ACE inhibitor therapy
Field 11.06
Treatment Beta blocker
Treatment Diuretic therapy is likely to be required to control congestive symptoms and fluid retention
Field 11.09
Treatment Diuretic: loop
Treatment Patients with heart failure due to LVSD who remain moderately to severely symptomatic despite optimal therapy
Field 11.13
Treatment SARA (selective aldosterone antagonist)
Treatment Only patients whose diagnosis is confirmed should be managed in accordance with NICE recommendations.
Field 14.0
Diagnosis (Dx) Heart Failure
Monitoring and follow up
Field 15.0 Field 15.05 Field 15.06 Field 15.07 Field 15.08
Heart Failure Liaison Service Palliative Care Care of the elderly/Medical Cardiology FU GP
2) Measuring patient outcomes and examining variation
Data collected to link clinical data with patient outcomes to examine variation between patient groups Field 1.03 Field 1.06 Field 1.07 Field 1.09 Field 2.00 Field 2.04 Field 15.10 Field 16.01 Field 16.02 Field 17.01 Field 17.02 NHS Number Birth date Gender Postcode Of Usual Address Date of admission Current inpatient Date of discharge Event date Event Life status date Life status
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