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Imperial College researchers have developed methods and indicators for highlighting potential variations in healthcare performance and safety using routinely collected health data. Analytical tools based on our methodological research are used by managers and clinicians in over two thirds of NHS hospital trusts, and hospitals throughout the world. The results of our analyses helped detect problems at Mid Staffordshire NHS Foundation Trust and triggered the initial investigation and subsequent public inquiry with wide ranging recommendations based on the recognition of their value and their use in enhancing the safety of healthcare.
Statistical analysis and methodological development carried out by Imperial College London on data from the Bristol Royal Infirmary Inquiry and the Shipman Inquiry have led to new monitoring systems in healthcare. Using routinely collected healthcare information, we have highlighted variations in performance and safety, impacting the NHS through direct interventions and/or policy change. For example: (i) findings and recommendations arising from our research for the Bristol Inquiry were reflected in the final inquiry outputs, which highlighted the importance of routinely collected hospital data to be used to undertake the monitoring of a range of healthcare outcomes, (ii) a range of monitoring recommendations have arisen as a direct result of the research on data from the Shipman Inquiry, (iii) analytical tools based on our methodological research are used by managers and clinicians in over two thirds of NHS hospital trusts, (iv) Imperial's monthly mortality alerts to the Care Quality Commission were major triggers leading to the Healthcare Commission investigation into the Mid Staffordshire NHS Trust.
University of Bristol researchers at the Bristol Heart Institute (BHI) have pioneered the development and clinical take-up of the novel technique of off-pump coronary artery bypass (OPCAB) surgery. Over ten clinical trials and several large cohort analyses have assessed the impact of this technique on elective and high-risk patients. The results have shown that it is as safe as the conventional coronary artery bypass grafting (CABG) technique that uses a cardiopulmonary bypass pump and cardioplegic arrest. Most importantly, however, OPCAB significantly reduces the risk of post-operative complications, and reduces morbidity and mortality. It also uses less hospital resources, reducing time in intensive care and length of hospital stay. In 2011 (the last year for which data are available), 20% of CABG operations in the UK were carried out with the OPCAB technique and it has had significant take-up overseas (for example, 18% of CABG operations in the US and 21% in the EU in 2010). NICE has recommended the safety and efficacy of OPCAB surgery.
Events in the UK NHS have shown the need for a robust understanding of hospital mortality rates.
Surrey's research produced "a unique web-enabled pattern analysis system that is specifically designed to enable clinicians and their teams to view in detail their in-house mortality patterns in the national context" (a).
Launched on a national scale in Ireland in 2013, it has already identified `mortality outliers' and been described as a `game changer' for improving service quality at national level. The tool's impact stems from its ability to translate statistical patterns into a form readily usable by health professionals to improve care quality and sharing best practice.
The management of childhood pleural empyema has been standardised and improved as a direct result of research at the UCL Institute of Child Health (ICH). Pioneering trials demonstrated the clinical equivalence of chest drain insertion with fibrinolytic installation compared to video-assisted thoracoscopic surgery as a primary intervention. Chest X-ray and ultrasound scanning were shown to provide enough information and it was established that chest CT scanning had no role in the routine management of empyema. International guidelines have been modified to reflect this, reducing paediatric exposure to unnecessary general anaesthesia, invasive surgery and ionising radiation. Cost savings are estimated to be £1.5 million/year in the UK alone.
As a result of research undertaken by Professor Mervyn Singer and colleagues at UCL, the oesophageal Doppler haemodynamic monitoring device is now a standard of care in intensive care units and operating theatres. The research underpinned the development of the CardioQ Oesophageal Doppler Monitor that guides optimisation of the circulation in critically ill and perioperative patients. In multiple studies its use has led to significant reductions in postoperative complication rates and length of stay in patients undergoing high-risk surgery. Over 500,000 patients have now benefitted from this technology that, between 2008-13, generated over £33m in sales for its manufacturer, Deltex Medical. The device is recommended in NICE guidance and has been identified by the Department of Health as one of six high impact innovations to be implemented fully across the NHS.
The World Health Organisation's (WHO) Surgical Safety Checklist is the culmination of over 5 years of concerted research effort to better understand, model and intervene in human factors that affect clinical performance and patient safety in operating theatres and surgical care. Imperial researchers were instrumental in the set up and implementation of the WHO `Safe Surgery Saves Lives' working group, launched in 2006, from which the Checklist was a primary outcome. Subsequently, we were co-investigators, and UK-lead, in a global study the implementation of the Checklist in 8 pilot hospitals across 7 continents. The Checklist was demonstrated to significantly improve patient outcomes and was modified and mandated for use in all NHS surgical procedures in England by the National Patient Safety Agency. We have since lead a national study that evaluated the implementation of the Checklist within the NHS and successfully delivered a team training programme aimed at optimising use of the Checklist in our hospitals.
VisensiaTM is a bedside `early warning' system, deployed in many hospitals in the UK and US, which automatically analyses hospital patients' vital signs, produces simple-to-read scores, and alerts healthcare staff to any deterioration in a patient's condition. It resulted from research in this Department, commercialised by Oxford BioSignals Ltd (£1.5m sales to date, and 137 licences sold since 2010). VisensiaTM reduces the number of patients already in hospital who suffer an unexpected cardiac arrest or need an unplanned transfer to intensive care. The US Food and Drug Administration (FDA) approved the system's use after a 1000-patient clinical trial. There were no unexpected fatal cardiac arrests on the wards where the clinical trial took place in the three years after VisensiaTM. was deployed.
This case study describes a significant new index used to monitor death rates in hospitals. The Summary Hospital Mortality Index (SHMI) was developed as a direct result of research carried out at the School of Health and Related Research (ScHARR). This was implemented nationally in October 2011 and the SHMI is now the main mortality indicator used by the NHS. Following publication of the high profile Francis Inquiry on Mid Staffordshire in February 2013, set up to investigate excess mortality in the Trust, the Government has used the SHMI to identify and target 8 further hospitals for investigation.