National Audit of Dementia Round 4 (2018) Sampling guidance for the Casenote Audit
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
National Audit of Dementia
Round 4 (2018)
Sampling guidance for the Casenote Audit
March 2018
© HQIP 2018
Timeline for data collection
The data collection period will be staggered as shown below. This is the sampling
guidance for the casenote audit. The guidance for individual questions in the
casenote audit will follow when the casenote audit has been finalised.
Organisational Casenote Carer Staff
checklist audit questionnaire questionnaire
March Guidance issued
Data collection Guidance
April
opens 16 April issued
Data collection
opens 21 May
(collecting data Guidance Guidance
May
for discharges issued issued
from April
2018)
Data collection Data collection
June Deadline:15 June
opens 4 June opens 4 June
July
August
Data collection Data collection
Deadline: 21
September closes: 21 closes: 21
September
September September
October
2Contacting the Project Team
For any queries, please contact the project team:
nad@rcpsych.ac.uk
Website:
www.nationalauditofdementia.org.uk
Or you may contact the team individually:
Chloë Hood, Programme Manager chloe.hood@rcpsych.ac.uk
020 3701 2682
Chloë Snowdon, Deputy PM chloe.snowdon@rcpsych.ac.uk
020 3701 2697
Samantha Ofili, Project Worker samantha.ofili@rcpsych.ac.uk
020 3701 2707
Lori Bourke, Project Worker lori.bourke@rcpsych.ac.uk
020 3701 2681
Emily Rayfield, Project Administrator emily.rayfield@rcpsych.ac.uk
020 3701 2688
Please note that when contacting the project team about your
casenotes, do not at any time include any identifiable data about
patients (for example: name, NHS number, address).
3Before you begin:
Please make sure you TEST the online data collection link before data collection opens:
http://rcop.formic.com/webforms/
This brings up Formic Web Forms. Click the Login button in the top left of the page to get to
the login page. You will then need to enter the unique username and password for your
hospital. These will be sent via post to your nominated audit lead.
If you cannot access the Formic Web Forms page, this is probably due to your local IT
settings and you will need to contact your IT department to ask them to approve the link.
Anyone entering data for the organisational checklist or casenote audit, as well as all staff
accessing the staff questionnaire online will need access to this website, so please do arrange
for this as soon as possible.
IDENTIFY the key people you are going to work with. This is a complex audit which should
not be carried out by a single lead. The guidance for each tool gives some suggestions of
colleagues who could help you to collect and co-ordinate the return of the different types of
data required.
Let us know if we can help. We are available to answer queries within office hours, or
you can email us, and we will respond as soon as we can.
We look forward to working with you.
4Completing the casenote audit
Each hospital site is expected to submit an audit of casenotes of patients discharged
with dementia, identified through ICD10 coding (listed at APPENDIX B). One form is to
be submitted online per set of notes audited.
Data collection opens 21st May with a deadline of 21st September 2018.
Each hospital will be asked for:
1) The total number of eligible patients discharged from the hospital in April 2018.
Please note this is a separate form to the casenote audit form and is a
mandatory part of the audit.
2) An audit return of eligible casenotes, for which the minimum sample will be
50, and the maximum 100 patients. This will give larger hospitals the
opportunity to return a larger sample. If your hospital cannot identify 50 patients
discharged in April, you may continue to identify patients discharged in May.
Input will be required from:
• Your local audit lead;
• The lead for dementia or a senior clinician working in this area;
• Staff who normally undertake casenote audit, i.e. audit department or information
services staff, junior doctors, dementia champions or nursing staff.
Data can be submitted online by persons other than the auditors.
Estimated time to complete:
We predict that 2-3 hours will be required to identify the sample and each casenote will
take between 15 minutes and 50 minutes to submit, with the first couple of sets taking
the longest to do, according to feedback from hospitals.
Organising your sample
1) The casenotes identified should be from a single hospital site - and not trust wide.
The number generated should be completed admissions, and not consultant
episodes, as there will be many of these per patient.
52) A list of ICD10 codes used to generate HES data is provided (Appendix B). These
codes indicate a diagnosis of dementia. They may appear in primary coding but
are more likely to be a secondary or subsidiary code. Dementia may also appear
in current history.
All casenotes with any of the codings provided are eligible and should be used to
generate a list. Patients should:
• Have been discharged between 1 April – 30 April 2018 (you may
continue into May if fewer than 50 patients were discharged in April);
• Have a diagnosis of dementia;
• Have been admitted to hospital for 72 or more hours;
• And, where the patient has had more than one admission, please include
only the first admission for this patient in your patient list.
3) Submit the total number of patients identified via the short online form ”Total N
patients identified for casenote audit”. You will be asked to enter the total number
identified from April (and May if enough casenotes could not be identified from
April alone). This data should be submitted online from 21 May onwards. Please
note this is compulsory.
4) Organise your list so that the patients identified are listed in date order that they
were discharged from the hospital.
5) Allocate each casenote a number, from 1 to the total number of casenotes
identified. This is the number you will use when entering “number for patient” on
the data collection form. Please note: This is not the hospital patient number or
NHS number. Please do not enter this information anywhere on the data collection
form.
6) Online entry for each set of notes must be completed and submitted separately.
7) If, after patient number allocation, a set of notes is found to be ineligible for this
audit (e.g. it is later understood that length of stay was less than 72 hours),
exclude this set of notes from data entry. You should then go on to the next set of
notes in the sequence, but do not reallocate the number. E.g. if number 2 is
ineligible, go on to enter data for number 3 (so your inputted casenote patient
numbers will follow as 1, 3, 4 and so on).
8) Continue to skip excluded records and move on to the next consecutively discharged
and numbered patients in the series until you have reached your return total of
50 - 100.
9) Identify casenotes for the inter-rater reliability check (see Appendix A).
10) Please keep a copy of your list of audited patients. You will need this if your hospital
is selected for quality assurance so that you can identify the notes again.
6Appendix A
Inter-rater reliability check
As part of the reporting process for this audit, we are asking sites to collect inter-rater
data to establish reliability.
The process requires two different people to extract and enter the data from the first
five casenotes in order of discharge date onto the data collection forms.
The process for identifying casenotes for audit is described earlier in this document.
Inter-rater reliability check
Identifying the cases to be double audited:
• Follow instructions in “Organising your sample” and select the first five casenotes
eligible to be entered into the data collection system (first five discharges). These
casenotes will be re-audited.
Extracting the data:
• Identify two separate people (‘first’ and ‘repeat’ auditor) who will extract information
from the casenotes and enter data via the online casenote audit data submission
form.
First auditor on their data collection form:
- Ticks “Yes” to “Has this casenote been selected as data reliability check?”
- For the first case, enter “1” in the box which says, “Enter number for this
patient”
- Collect all the information for this patient
- Do not involve the repeat auditor(s)
- Repeat the process for patients 2, 3, 4 and 5.
Repeat auditor on their data collection form:
- Using the same five cases in the same order as the first auditor(s)
- Ticks “Yes” to “Has this casenote been selected as data reliability check?”
- Add “Rel” at the end of the number (so number 1 of the first auditor’s
casenotes, is numbered 1Rel by the repeat auditor)
- Collect all the information for this patient
- Do not involve the first auditor(s)
- Repeat the process for patients 2, 3, 4 and 5, numbering them 2Rel, 3 Rel etc.
N.B. If you have excluded any notes from your list due to wrong coding etc.
so that (for example) your notes are numbers 1, 3, 4, 5, 6, then your second
auditor notes should be numbered the same; 1Rel, 3Rel, 4Rel, 5Rel, 6Rel.
7Appendix B
List of Eligible ICD 10 codes
A81.0 Creutzfeldt-Jakob disease
Subacute spongiform encephalopathy
F00* Dementia in Alzheimer's disease
F00.0* Dementia in Alzheimer's disease with early onset
Alzheimer's disease, type 2
Presenile dementia, Alzheimer's type
Primary degenerative dementia of the Alzheimer's type, presenile onset
F00.1* Dementia in Alzheimer's disease with late onset
Alzheimer's disease, type 1
Primary degenerative dementia of the Alzheimer's type, senile onset
Senile dementia, Alzheimer's type
F00.2* Dementia in Alzheimer's disease, atypical or mixed type
Atypical dementia, Alzheimer's type
F00.9* Dementia in Alzheimer's disease, unspecified
F01 Vascular dementia
F01.0 Vascular dementia of acute onset
F01.1 Multi-infarct dementia
F01.2 Subcortical vascular dementia
F01.3 Mixed cortical and subcortical vascular dementia
F01.8 Other vascular dementia
F01.9 Vascular dementia, unspecified
F02* Dementia in other diseases classified elsewhere
F02.0* Dementia in Pick's disease
F02.1* Dementia in Creutzfeldt-Jakob disease
F02.2* Dementia in Huntington's disease
F02.3* Dementia in Parkinson's disease
8Dementia in:
· paralysis agitans
· parkinsonism
F02.4* Dementia in human immunodeficiency virus [HIV] disease
F02.8* Dementia in other specified diseases classified elsewhere
Dementia in:
· cerebral lipidosis
· epilepsy
· hepatolenticular degeneration
· hypercalcaemia
· hypothyroidism, acquired
· intoxications
· multiple sclerosis
· neurosyphilis
· niacin deficiency [pellagra]
· polyarteritis nodosa
· systemic lupus erythematosus
· trypanosomiasis
· vitamin B 12 deficiency
F03 Unspecified dementia
Presenile:
· dementia NOS
· psychosis NOS
Primary degenerative dementia NOS
Senile:
· dementia:
· NOS
· depressed or paranoid type
· psychosis NOS
F04 Organic amnesic syndrome, not induced by alcohol and other
psychoactive substances
Korsakov's psychosis or syndrome, nonalcoholic
F05.1 Delirium superimposed on dementia
F07.2 Postconcussional syndrome
Postcontusional syndrome (encephalopathy)
Post-traumatic brain syndrome, nonpsychotic
9F10.6 Amnestic disorder, alcohol- or drug-induced
F11.6 Korsakov's psychosis or syndrome, alcohol- or other psychoactive
substance-induced or unspecified
F13.6
F14.6
F15.6
F16.6
F17.6
F18.6
F19.6
G30.0 Alzheimer's disease with early onset
G30.1 Alzheimer's disease with late onset
G30.8 Other Alzheimer's disease
G30.9 Alzheimer's disease, unspecified
G31.0 Circumscribed brain atrophy
Pick's disease
Progressive isolated aphasia
G31.1 Senile degeneration of brain, not elsewhere classified
G31.8 Other specified degenerative diseases of nervous system
Grey-matter degeneration [Alpers]
Lewy body(ies)(dementia)(disease)
Subacute necrotizing encephalopathy [Leigh]
I67.3 Progressive vascular leukoencephalopathy
Binswanger's disease
10National Audit of Dementia
Royal College of Psychiatrists
21 Prescot Street
London
E1 8BB
www.nationalauditofdementia.org.ukYou can also read
