Policy into practice: a personal perspective

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The Audit Commission Report(1) – creating a ‘data collecting’culture in critical careRuth Endacott

Ruth EndacottPhD, MA, RGN,DipN (Lond),Reader in CriticalCare Nursing, LarchCourt, Spreyton,Crediton, DevonEX175 5EA, UK.Tel/Fax: +44 (0)1837 840024;E-mail:endacott@eclipse.co.uk (Requests foroffprints to RE)

Manuscriptaccepted 17/1/00

This new section in Intensive and Critical CareNursing explores some of the implications fornursing in implementing the recommendations ofpolicy documents. The first document reviewed –Critical to Success: the place of efficient and effectivecritical care services within the acute hospital (AuditCommission 1999) – is not actually policy but itsrecommendations are likely to be taken up byTrust Chief Executives in England and Wales,and used to determine local policy.

The Audit Commission are charged withexamining the extent to which publicly fundedservices are using those funds in an efficient andeffective manner (the ‘value for money’ agenda).One of the pieces of work undertaken by theAudit Commission over the past two years is acomprehensive review of critical care services,resulting in the Critical to Success report. One ofthe central messages to come out of this review isthat there has been a growth in both the supplyof, and demand for, critical care services.However, a key theme of the Report is the need tomanage the demand better, and measure it beforeproviding more critical care beds.

The Report makes eight key recommendations(see Table 1), five of which centre on collectingmore data or ‘evidence’ regarding intensive careactivity and outcomes. Many of theserecommendations echo previous publications, forexample the Department of Health (1996)Guidelines for Admission and Discharge and theKing’s Fund report of 1989 which highlighted thelack of evidence surrounding intensive care.High-quality data collection is also a key elementof the clinical governance agenda and the current

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trend for evidence-based practice. A usefuldefinition of ‘evidence’ is provided by Sackett(1996), guru of the evidence-based practicemovement, who suggests that evidence-basedpractice is about ‘integrating clinical expertisewith the best available external clinical evidencefrom systematic research’. Systematic research isnot however, limited to the large cohort studiesundertaken by organizations like the IntensiveCare National Audit and Research Centre(ICNARC). It also includes the systematiccollection of data from patients and relatives, aswell as through qualitative studies exploring theimpact of nursing interventions on our patients.

Creating an appropriateinfrastructureI’m sure as nurses we would support the need for‘evidence’, particularly the experiences ofprevious patients, to support our actions.However, in order to create the ‘data collectingculture’ which is needed to move critical careforward, certain structures and processes need tobe in place within each individual unit and trust:

1. a properly resourced data collector, withappropriate skills, information technology (IT)equipment and information networks toundertake the job efficiently;

2. identification of the data which require aclinical judgment, as distinct from those thatcan be collected by an audit clerk

3. systems to enable feedback of data to staff, akey recommendation of the Royal College of

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Table 1 Key recommendations from the Audit Commission (1999) Report

Improving survival and quality of life

1. Improve the evidence base for critical care medicine by supporting multicentre observational studies and,where it would not be unethical, randomised control trials into key interventions.

2. Join the ICNARC programme, or a similar ‘club’ that allows comparison of outcomes; using this information,review the clinical performance of general critical care units.

3. Find out relatives’ views of their experiences in the unit via systematic satisfaction surveys

Reducing costs through flexibility

4. Improve services for patients on wards who are at risk of deteriorating into a need for critical care:• review trainee doctor and senior ward nurse recognition skills of the early warning signs;• agree ‘danger sign’ guidelines to help ward staff to identify when to call for specialist advice to

prevent deterioration; and• develop an ‘outreach’ service from critical care specialists to support ward staff in managing patients

at risk5. Conduct regular audit to identify the number of unit beds that are occupied by patients who cannot benefit

because they:• are too ill and cannot recover;• could be cared for safely elsewhere – for example, in an HDU not an ICU, or in a ward rather than an

HDU; and• remain in the unit only because ward beds are blocked and unavailable to discharge patients into

6. Set annual nurse staffing budgets at ratios that match the expected mix of intensive and high dependencycare patients in the unit, not at a rigid 1:1 nurse:patient ratio just because the unit is labelled ‘the ICU’. On a dailybasis, deploy nurses to match the actual number and dependency needs of patients in the unit, not at a ratio ofone nurse to one bed irrespective of whether the bed is occupied.

Managing a complex network

7. Review the configuration of critical care services across the trust; review the extent to which inappropriatedemand had been reduced and efficiency improved before deciding whether increases in the number of criticalcare unit beds are required.8. Agree a critical care management policy that includes the admission and discharge guidelines to units,ethical guidelines, bed management arrangements and who has the power to make within-hospital transferdecisions, targets for the number of refused admissions that the trust is prepared to accept, training plans andaudit arrangements.

Nursing (RCN) work on dependency scoringsystems (RCN 1995);

4. the acknowledgement that clinical datacollection, collation and interpretation is partof the work of nursing and medical staff, notan additional aspect to be undertaken ‘out ofhours’.

So how can data be used?Data can be used on both a local and nationallevel, as seen in the following examples frompractice:

1. Recent work undertaken by the Intensive CareNational Audit and Research Centre ICNARCon night discharges (Rowan 1999) compareddata from two databases and identified that

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the percentage of patients discharged at night,particularly between midnight and 5 a.m., hadrisen. Using the ICNARC case-mix data, whichenables account to be taken of the severity ofthe patient’s condition, it was also possible toidentify that patients discharged at night were50% more likely to die.

2. On a more local level, patient activity data canbe used to identify, for example, the extent towhich intensive care unit (ICU) patients arebeing managed in high-dependency unit(HDU) beds. Amongst other purposes, thesedata can be used to identify the need foradditional education and support for nursesworking in HDU.

3. The advent of more sophisticated patientactivity systems such as the System of PatientRelated Activities (SOPRA) (ICNARC 2000)

© 2000 Harcourt Publ ishers Ltd

The Audit Commission Report

© 2000 Harcourt

distinguish, for example, between differentlevels of support for relatives and differentlevels of psychological support for the patientand enable these to be ‘scored’ accordingly.This type of development helps to moveforward the nursing agenda around measuringpatient-related activity and move closer toidentifying the nursing dependency of thepatient. SOPRA will be discussed in detail in afuture issue of Intensive and Critical CareNursing.

Taking data out of contextProblems arise when data are taken out ofcontext, as highlighted in the vigorous discussionand debate that has followed publication of theAudit Commission report. For example,according to the Audit Commission, one of thefeatures of ICUs that are ‘expensive’ in terms ofnurse staffing is the use of a ‘non-bedside’ shiftleader. What the Report does not emphasize arethe (many) roles undertaken by the shift leaderand the need for a supernumerary shift leader,for example, when the Unit is staffed with anumber of inexperienced nursing and/or medicalstaff. At the same time, the Report does usefullyidentify some of the diverse contexts in whichcritical care is provided. Perhaps one of the keymessages then for nurses is to ask more questionsabout the ‘evidence’ on which policy decisionsare made. Data from the EURICUS 1 study(Miranda et al. 1998) is regularly used to makerecommendations regarding intensive care (oftento suggest that UK ICUs are over-staffed!!).However, both the researchers (Miranda et al1998, Moreno and Miranda 1998) and others

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(DoH 1996, Barash and Rosenbaum 1998) openlyacknowledge that the study sample was notrepresentative.

One of the benefits of reports such as Critical toSuccess is that they prompt discussion within andbetween the professional groups (nurses, doctors,managers); one purpose of this personalperspective is to stimulate written debate aboutpossible solutions to some of the problems facingcritical care; why not share your thoughts withus?

References

Audit Commission 1999 Critical to Success: the place ofefficient and effective critical care services within theacute hospital. Audit Commission Publications,Abingdon

Barash PG, Rosenbaum SH 1998 Staffing ICUs: the goodnews and the not so good news (editorial). Chest113:569–570

Department of Health 1996 Guidelines on admission toand discharge from Intensive Care and HighDependency Units HMSO, London

ICNARC 2000 System of Patient Related Activities.Intensive Care National Audit and Research Centre,London

King’s Fund 1989 Intensive Care in the United Kingdom.Academia Press Ltd, London

Miranda DR, Ryan DW, Schaufeli WB, Fidler V (eds) 1998Organisation and management of intensive care: aprospective study in 12 European Countries Springer-Verlag, Berlin

Moreno R, Miranda DR 1998 Nursing Staff in IntensiveCare in Europe: the mismatch between planning andpractice. Chest 113:752–758

Rowan K 1999 Improving the evidence base. Unpublishedpaper presented at the Audit Commission Critical CareConference 30 November 1999, London

Royal College of Nursing 1995 Dependency ScoringSystems – Guidelines for Nurses. RCN PublishingCompany, London

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