The development of a clinical audits to assure and improve quality of care was largely response to clinicians to the recognition that there were significant, and unsupportable variations in care of patients with a heart attack, at a time when an evidence base approach to practice - provision of primary PCI - was being introduced (see Figure 1).
Figure 1 presents a number of primary PCIs per million population by Local Area Team in 2012/13.
- About heart attacks
The term ‘heart attack’, while used widely in discussions between clinicians and their patients is too imprecise to define the condition that is the subject of this national clinical audit. The preferred term is Acute Coronary Syndrome (ACS). This covers the symptoms and clinical features that occur when there is an abrupt reduction in the blood supply to a segment of heart muscle. Usually this is a consequence of a slowly progressive build-up of fibro-fatty material (atheroma) within the wall of the coronary artery, occurring over years and often without symptoms, followed by sudden disruption of the internal artery wall. This readily causes blood to clot within the artery – a coronary thrombosis – and leads to a state of myocardial ischaemia, in which the demands of the affected heart muscle for oxygen-rich blood exceed the supply of such blood down the clot-containing artery.
If ischaemia is sufficiently prolonged, death of heart muscle results. This is myocardial infarction and is confirmed when evidence of heart muscle cell death is found on blood testing. Such evidence, of elevated concentrations of cardiac enzymes in circulating blood, may take some hours to appear and, to be most effective, treatment must start before the results of such tests are available. Ischaemia is suggested by characteristic symptoms (for example central chest discomfort, sweating, breathlessness) and abrupt changes in blood pressure, heart rate and heart rhythm (sometimes leading to collapse or sudden death). Ischaemia often can be detected indirectly – as electrical alterations on the electrocardiogram (ECG).
STEMI and nSTEMI
Based upon the ECG, patients with characteristic symptoms are categorised into those with, and those without, ST segment elevation – leading to the final diagnosis, once elevated levels of cardiac enzymes confirm myocardial infarction, of ST-elevation myocardial infarction (STEMI) or non-ST-elevation myocardial infarction (nSTEMI). ST-elevation usually indicates complete blockage of a coronary artery and, in most cases, warrants immediate treatment to re-open the artery. The absence of ST-elevation usually indicates that any coronary thrombosis is only partially occluding the artery.
Although patients with STEMI are at greater early risk, the medium to long-term outcome (in terms of recurrent heart attack or death) is similar, if not worse, for those with nSTEMI – who are generally an older group.
For more information about a heart attack:
- The role of the audit
A Myocardial Infarction (later, ischaemia) National Audit Project (MINAP) was established in 1998. It was founded on the following propositions
- The audit should be a complete record of care rather than a snapshot – all (rather than a sample of) patients being included
- The audit should be prospective – information being collected as soon after treatment as possible,
- Participating hospitals should agree both common definitions of clinically important variables and common standards of good quality care against which to audit their practice
- Standards of care should be chosen that have a proven link to improved outcome– i.e. those aspects of care being audited, whilst capable of being expressed as measures of process or performance, should link directly to better patient outcomes
- The practices of individual hospitals should be aggregated into a national figure – a hospital could audit against agreed standards and compare against the national aggregate
- Sufficient data should be recorded to allow for case-mix adjustment and other techniques for investigating differences in outcomes between hospitals,
- The dataset should be revised periodically to account for the introduction of newer treatments
- The audit should maintain its credibility and validity by being guided and supported by relevant professional bodies and patient groups and be managed by a small project team
- A publicly accessible report should be published annually.
MINAP has been reporting on the process measures i.e whether the appropriate care is provided within the nationally and internationally agreed timelines for number of years.
Over the last three years the MINAP public report has included national unadjusted 30-day mortality rates for both England and Wales, for STEMI and nSTEMI. During the later stages of developing the last year’s report it has become clear that a greater degree of ‘granularity’ and explanation is required with respect to mortality reporting. Therefore, MINAP will be producing a subsidiary “Outcomes Report’ in the spring of 2014.
- Data collection
The current dataset, version 10.3.1, contains 130 fields. The dataset is revised every two years so as to allow both continuing collection of data regarding established practice and information about newly introduced treatments. It is designed in a way so that it can capture the entire patient pathway – from the time the patient calls for professional help to the point of discharge, including patient demographics, medical history and clinical assessment, investigations, treatments, drug therapy prior to admission, during hospital stay and at discharge.
Participating hospitals are requested to enter all patients with suspected myocardial infarction. Approximately 91,000 records are uploaded annually and the database now contains over 1.25 million records, making it the largest database of its kind in the world.
Dataset, data collection form and other supporting documents are available in the Datasets section.
Data are collected by nurses and clinical audit staff (many with support from a local cardiologist) and entered in a dedicated data application (either Lotus Notes or web based). Alternatively hospital personnel may collect data using 3rd party software, which is often linked to their local clinical information system. The project uses a highly secure electronic system of data entry, transmission and analysis developed by the NICOR Technical Team. The audit has been running continuously since 2000 and all hospitals in England, Wales and Northern Ireland that admit patients with ACS contribute data (except Scarborough General Hospital which stopped submitting data in 2011).
- Using audit data
Audit data are used by increasing numbers of groups outside of your hospital which have a legitimate interest in the analysis. These include:
- The QRP (Quality Risk Profiles) - is a tool used for gathering together key information about your organisation to support how the CQC monitor your compliance with essential standards of quality and safety. The QRP enables compliance inspectors to assess where risks lie and may prompt front line regulatory activity, such as further enquiries. For the second year running, MINAP has provided CQC with data to work out QRP for your hospital.
- Data.gov.uk – since 2012 MINAP data has been published on the data.gov.uk website as part of the Government’s Transparency Agenda .
- Public reporting – MINAP has been publishing an annual report since 2003 and the report is available to the public.
- Clinical Commissioning Groups – since establishment of CCGs in April 2013, MINAP has been received many requests for data by commissioning groups.
- Patient Groups – MINAP has developed patient friendly versions of its 2012 Public Report and will continue to improve the way it presents data to the public. Patient groups/representatives have increasingly louder voices for example, in commissioning of services.
- Quality Accounts – all health service providers in England have to submit a report for 30 June each year about the quality of their services in the previous financial year. This report is called a Quality Account. Quality Accounts are required to be submitted to the Secretary of State and published on the NHS Choices website so that they are available to the public. MINAP is included in the DH Quality Accounts.
- Research groups – anonymised MINAP data have been available to external research groups since 2006. This has resulted in numerous publications.
- Monthly Ambulance Quality Indicators – ambulance services report on CTN and CTB on monthly basis using MINAP data.
…and Freedom of Information requests