Clinical Audit Reporting System (CARS)
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South Central Ambulance Service NHS Trust (SCAS) is part of the NHS and was established in 2006 following the merger of four ambulance trusts in the counties of Berkshire, Buckinghamshire, Hampshire and Oxfordshire. This area covers approximately 4,600 sq miles with a resident population of around four million.
The Challenge
Generating more than 360,000 patient clinical records per annum, SCAS wanted to improve the access to, and the retrieval of, documents across the organisation. This was currently a time consuming and complicated process that could take up to two weeks depending on where the required documents were located. Speeding up this process would be essential to meet the twenty-day period for investigating complaints required by the Healthcare Commission and fulfil the requirements of the NHS Litigation Authority by being able to prove that a full record exists for each individual patient. It also wanted to reduce the high cost of document storage that amounted to more than £10.5k p.a. in Hampshire alone.
SCAS also wanted to improve the way that ambulance staff maintained their skills portfolios used for annual recertifications. It wanted to provide a more efficient way for them to view their own performance for the different procedures and interventions that they have carried out. The Trust also wanted to give clinical audit managers the ability to access all patient related paperwork to ensure that all decisions taken and clinical interventions provided fall within acceptable protocols. Audit managers need to be able to quickly identify any incidents where these protocols have not been followed as soon as they occur to ensure that patient care is delivered to prescribed standards at all times.
The Solution
After proving the concept of an effective Clinical Audit Reporting System (CARS) in an earlier trial in Hampshire, South Central partnered with e-Docs UK to translate the requirements into a cost effective and reliable solution. The development of the system was an interactive process with ongoing reviews to refine the functionality to meet the Trust’s precise requirements.
To roll out the system across The Trust, a single, unified patient clinical record form was developed to standardise the way that information was presented. Document safe post slots were deployed into every A&E department in Hampshire for daily collection and delivery to Hampshire Division HQ. Scanners were installed throughout the other divisions enabling images to be delivered via batch FTP transfers back to the Hampshire Division HQ.
Every form is now scanned and all images are sent to Hampshire division HQ in Winchester where powerful data capture software is used to upload information into CARS. This data repository offers a range of reporting tools that provide important information on clinical performance indicators showing whether all protocols were followed. Any discrepancies are highlighted for further analysis and followed up by clinical supervisors.
CARS also provides the information required for a wide range of national reports and audits carried out by the Department of Health and JRCALC, the committee that produces clinical guidelines for the Ambulance Service. Information on the activities and performance of the ambulance service can also be easily provided to Primary Care Trusts.
CARS is also helping ambulance staff to maintain their skills portfolio. The evidence from patient clinical records that are completed at the end of each shift are scanned into the system enabling staff to quickly and easily monitor the number of different procedures and interventions that they have carried out. They can login to the system to review forms relating to particular case types such as falls, glycaemic emergency, asthma, strokes, etc along with interventions such as cannulations, intubations and defibrillations as well as drugs administered. Images of documents can be displayed or printed without compromising confidentiality or adding to the workload of the clinical department.
In addition, individual paramedics can add personal notes relating to the reasons why protocols were not followed and the contra indications that led the paramedic or technician to apply a different treatment. This gives a realistic picture of performance based on what staff are actually doing rather than what they perceive themselves to be doing – two very different things.
The Trust now has a complete picture of all ambulance crew activity showing how patients are actually being treated along with personal reflections from individual paramedics and technicians.
The second development phase of the project saw the introduction of Clinical Demand Management. CARS provides increased visibility of ‘frequent caller’ patients that make regular requests for an ambulance to attend. Typically, these types of calls are for falls, diabetics, asthmatics, and drink and drug users. CARS highlights such incidences and generates email referrals for these patients to another health or social care organisations to provide the care or equipment the patient needs in order to reduce the amount of calls to the ambulance service.
According to David Sherwood, Head of Clinical Effectiveness, South Central Ambulance Service: “CARS is a ground breaking development that will significantly improve the operational and clinical efficiency of the Trust enabling the provision of a more holistic approach to delivering patient care. It delivers the required level of reporting, gives a greater understanding of the true workload and provides a complete audit trail for every patient treated.”
Taking a more proactive approach to interacting with other agencies has lead to ‘alert lists’ being loaded onto CARS to highlight premises or individuals where special attention is required. This could be to inform the crew that a patient at that address could be on a special care plan, which requires a specific intervention or a direct admission to a specialist unit.
CARS also helps identify ‘hot spots’ where regular accidents or injuries occur. While emergency operations centre’s computer aided dispatch systems can often identify the location of these incidents, they cannot report on or predict accurately the precise nature of the outcome of the emergency. CARS helps ensure that suitably qualified staff are on the vehicle sent to the incident to deliver the fastest possible access to treatment. These ‘hot spots’ might include regular falls in specific locations, accidents at particular roads and assaults or alcohol related collapses relative to the location of a bar or club.
“Improving the way that the ambulance service interacts with other agencies will be a key factor towards ensuring that the most appropriate care is made available to individual patients as well as delivering significant cost savings,” concluded David Sherwood.
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