Address by Leo Varadkar T.D. Minister for Health at the 2nd Annual NCEC Symposium
Check against delivery
I’m very pleased to be here with you in Dublin Castle. You’re all extremely welcome and thank you for coming.
This is an important Symposium for patients and the health services. Today I am endorsing and launching three new National Clinical Guidelines which have been delivered through the national clinical effectiveness agenda led by my Department.
All of these guidelines are key, high-impact clinical areas for patient safety and quality. They relate to sepsis, maternity early warning scores and clinical handover.
Clinical effectiveness is fundamental to reducing risk and improving the performance of our health system. At its simplest, clinical effectiveness is about striving to ensure that healthcare practice is based on the best available data and evidence of effectiveness.
Healthcare that is supported by the best available evidence helps to assure providers that they are delivering safe, high-quality reliable care.
I fully support this clinical effectiveness agenda. It’s vital that Ireland has a suite of quality assured National Clinical Guidelines and National Clinical Audit in place. These are of an international standard of excellence to underpin patient safety and quality in our health system.
I want to acknowledge the work of the National Clinical Effectiveness Committee, and its leadership, in advancing the Irish clinical effectiveness agenda under the chairmanship of Professor Hilary Humphreys. This committee is a multi-stakeholder group including representatives from patients, clinicians, patient safety experts, educators, senior managers the public and private health sectors, and the regulators. The work of the National Clinical Effectiveness Committee follows in the footsteps of NICE and SIGN in the UK, by progressing quality-assured National Clinical Guidelines to ensure that evidence-based practice is embedded in our health system.
I want to extend a particular welcome this morning to Professor Mark Baker from NICE. I acknowledge the contributions of NICE to our work here and look forward to building collaboration between NICE and the National Clinical Effectiveness Committee in the future.
It’s important that we remind ourselves of where the recommendations that led to these guidelines have come from. They arise from the HIQA report into the tragic death of Savita Halappanavar in Galway in 2012.
The need is further highlighted by the investigation into maternity services, undertaken by the Chief Medical Officer in 2014. A critical priority in patient safety is that we take the lessons of these unfortunate events and use it to ensure that we do everything to prevent their reoccurrence.
The development, publication and mandating of these national guidelines for national implementation marks a critical milestone in applying this kind of learning. It could not happen without the steadfast commitment and leadership of the guideline leads – Professor Michael Turner, Dr John Fitzsimons, Dr Fidelma Fitzpatrick, Dr Vida Hamilton, Dr Colm Henry and Ms Eilish Croke working with the National Clinical Effectiveness Committee and the Clinical Effectiveness Unit in my Department. I also want to acknowledge the support of the Quality Improvement Division and Clinical Programme Division of the HSE.
I want to talk a little bit about sepsis. Sepsis is a clinical syndrome defined by the presence of infection, and a systemic inflammatory response. To give you a sense of the importance of early recognition of sepsis – it is the tenth leading cause of death worldwide.
The management of severe sepsis and septic shock are considered a time-dependent medical emergency. Mortality increases by 7.6% for every hour of delay in patient treatment.
Almost 9,000 patients in our hospitals last year had a diagnosis of sepsis accounting for over 220,000 bed days. Those patients admitted to an intensive care environment had a mortality rate of almost 29%. In addition their general length of stay was significantly increased up to 26 days which is five times longer than the average, non-sepsis in-patient stay.
A benchmark with other serious conditions shows that sepsis accounts for 300 cases per 100,000 people per annum. This compares with 208 cases of myocardial infarction and 223 cases of stroke per 100,000. Each episode of sepsis is estimated to cost a healthcare institution around €25,000.
This, therefore, is a critical guideline which provides recommendations and practical guidance on the recognition and management of sepsis to improve patient care, minimise patient morbidity and mortality and to help contain healthcare costs. The reduction in practice variation by using a bundle of care, such as Sepsis 6 as included in the recommendations in the Irish guidelines, has been shown to reduce mortality and lead to a reduction in ICU costs of 35%.
Communication (Clinical Handover) in Maternity Services
The second guideline I will refer to is the National Clinical Guideline Communication Clinical Handover in Maternity Services. Clinical handover is the transfer of professional responsibility and accountability for some or all aspects of care for a patient.
Handover is not just a potential point of error, but one which can be optimised to enhance patient safety, actually providing an informal multi-disciplinary team point within the patient’s journey.
This guideline describes the elements that are essential for timely, accurate, complete, unambiguous and focused communication of information at handover. In addition to shift and team handover the scope of this guideline includes handover from laboratory and radiology services to clinical teams.
Risks associated with clinical handover include delay in critical referrals, delay in treatments leading to increased risk of infection and exacerbation of illness which in turn may lead to poor patient outcomes, death or prolonged hospital stays.
This guideline provides recommendations for the use of a structured communication tool, called ISBAR, to promote standardisation of communication, thereby reducing risk for patients.
ISBAR stands for Introduction, Situation, Background, Assessment, Recommendation. It was originally used by the US Navy and then adapted for healthcare use in Australia. ISBAR is already in use in the Irish healthcare system for communication patient deterioration.
I want to draw particular attention to the guideline recommendation for the use of ISBAR3. ISBAR3 is an adaptation of the original ISBAR tool. It is a new communication tool developed by the guideline group for shift and inter-departmental handover.
I commend this innovative work. It exemplifies the on-going contribution of our Irish healthcare clinicians to the international community and I have no doubt that other countries will wish to adopt this communication tool in the future.
Irish Maternity Early Warning System
The third guideline being launched today is the Irish Maternity Early Warning System, also known as IMEWS. Critical illness is an uncommon but potentially devastating complication of pregnancy. It is important to remain vigilant and this guideline recommends a physiological track and trigger system. This is a bedside tool developed for use in maternity care to assist in identifying women with developing, established or deteriorating critical illness.
This system prompts frontline clinical staff to request a medical review at specific trigger points, using a structured communication tool while following a definitive escalation plan.
IMEWS standardises the assessment of the severity of a patients’ illness in maternity care. This enables a timelier and more appropriate response by using a common language across maternity services nationally. This national approach places Ireland at the forefront in terms of early warning systems for maternity care. A programme of evaluative research of this early warning system would positively contribute to furthering the international evidence base on the subject.
With the launch of these guidelines the Irish healthcare system will now have standard early warning systems, which include triggers for sepsis, for both adult and maternity patients, and which are mandated for implementation in all acute adult and maternity hospital services. The development of a paediatric early warning system is at an advanced stage. Under the leadership of Dr John Fitzsimons this will be tested in Our Lady’s Hospital Crumlin, Temple St., Portiuncula Hospital and Limerick Regional Hospital over the next number of months.
The National Clinical Guidelines will, however, only be effective if we support and monitor their implementation.
A structured approach to implementation of guidelines has been shown to improve patients’ health outcomes, reduce variation in practice and improve the quality of clinical decisions.
There is good evidence that we are making progress. I want to use the example of the first National Clinical Guideline – the national early warning score for non-pregnant adults published in 2013. You are all aware of the benefit in detecting deterioration in a patient and early intervention. I know that the excellent work to develop this national early warning score is due to Professor Garry Courtney and Ms Eilish Croke of the Acute Medicine Programme.
The single national standard early warning score for adults is now in place in 98% of all acute hospital settings, thanks to oversight by the HSE and HIQA. This is a tremendous achievement on a national level which stands up to international scrutiny.
I am personally involved to ensure that guidelines of this standard are implemented in full across the health system. It shows what can be achieved by aligning Clinical Programmes, the HSE Service Plan, monitoring by HIQA, and public performance reporting. I will be engaging further with HIQA and the clinical indemnity scheme.
I want to ensure that our indemnity arrangements and monitoring of standards are creating incentives to systemise high quality guidance across the health care system.
That is the power and potential of the clinical effectiveness programme. It creates an incentive to do the right thing, involving clinicians, patients, service providers, regulators, insurers, indemnity providers and others. This is real reform around the needs of patients using high quality evidence in practice, and leading to improved patient outcomes.
Innovation and Technology
Much of what I have addressed so far is about methods to ensure the delivery of practice based on evidence. We also need to consider the eHealth agenda and information technology. These have the potential to add value, and provide the right processes to scale up the benefits from clinical effectiveness approaches to evidence based healthcare.
I am pleased that a programme of work to explore the potential of technology for early warning scores and clinical handover at the clinical interface is about to begin, led by my Department, with the support of HIQA. The development of an App to make the guidelines more accessible to clinicians is at an advanced stage. These initiatives will provide benefits at the bedside, and will have additional benefits by creating opportunities for increased collaboration with the technology industry and health.
As Minister for Health, I think that reforms should be focused on the needs of patients, and on changes that empower professionals to develop and improve their services. We trust the professionalism of our staff to constantly improve the safety and quality of the services they deliver.
Regulation, standards, measurement, accountability and governance are all critical to achieving that goal. That’s why I see clinical effectiveness as a tangible reform that brings direct benefit to patients.
Achieving a culture of patient safety requires actions across all areas of our health system. It’s now five years since the Government approved the report of the Commission on Patient Safety, a milestone document in setting the agenda, and building a culture of patient safety. Many of the Commission’s key recommendations have already been implemented.
There have been some significant advances in recent years. We mandated the HIQA National Standards for Safer Better Healthcare, published in 2012. These standards provide all healthcare providers with a blueprint for safe and effective care, which places the patient at the centre of how care is delivered. The HSE and HIQA are now implementing and monitoring against these standards. I expect they will be a significant tool in improving patient safety.
These Standards will ultimately underpin a system of healthcare licensing. It is intended that licensing of healthcare facilities will extend across both public and private healthcare providers, with an initial focus on hospitals and high risk health services in non-hospital settings.
New structures have been created in the HSE and in my Department to advance patient safety and clinical effectiveness. The creation of a Quality Improvement Division within the HSE, and the Clinical Programmes set up between the HSE and the RCPI, have greatly enhanced our governance and capacity for ensuring robust quality and risk frameworks, and developing models of best practice in clinical care.
However, a number of recent reports show that we still face many challenges. These include the HIQA Report into University Hospital Galway, arising from the tragic death of Ms Savita Halappanavar, and the last February Report of the Chief Medical Officer arising from Perinatal Deaths at the HSE Midland Regional Hospital Portlaoise. We must use these reports to ensure that the system can identify, report and learn from adverse events when they occur, and ensure that our health and social care services are truly safe and of the highest quality.
I am very impressed by the work of the National Clinical Programmes. The National Clinical Guidelines and the National Clinical Audit will underpin the work of the models of care for the Clinical Programmes.
To conclude, I appreciate and recognise the work of the National Clinical Effectiveness Committee in bringing these three National Clinical Guidelines to this point. I want to thank everyone involved in advancing the National Clinical Guidelines. The publication by the Department of Health of the first six guidelines of a suite of prioritised and quality assured National Clinical Guidelines for Ireland is a critical step towards the delivery of consistent, safe, evidence based care across the country.
The National Clinical Effectiveness Committee will have a national role in prioritising and quality assuring National Clinical Audit in 2015. It will publish standards for general clinical practice guidance such as care pathways, algorithms and checklists. This approach is bringing a systematic methodology to the implementation of evidence into practice. The extent of national guidance for the health system places Ireland at the forefront of many countries in to achieve evidence-based processes for care delivery and evaluation.
My Department is preparing a statement on a modest number of priorities for the health system in the next number of years. I am particularly anxious to ensure that the priorities for patient safety and quality, in particular clinical effectiveness, are identified as part of that process.
Patient safety is about values. The most important indicator of the quality of patient services is the first-hand experience of patients themselves. That’s what counts to me as Minister. I would, therefore, like to finish with a quote from Ms Linda Dillon, the patient representative who contributed to the development of the Irish sepsis guideline –
‘First and foremost, from a patient’s perspective the early diagnosis of sepsis could become the difference between life and death. Therefore, the pathways that a patient travels within the health system as a whole, and the identification of possible sepsis becomes vitally important for the patient to have the best chance of a good recovery.
Before any of the identifying and treatment begins, it is clear that sepsis needs to be in everyone’s mind as a possibility in all patient groups, not only the patients that present as clearly very ill. This mindset will be a change for many medical professionals. It is, therefore, imperative that all healthcare providers, the Department of Health, the HSE, senior hospital management and all healthcare workers implement the National Clinical Guideline – Sepsis Management. For the loved ones of any patient who has passed away from sepsis to now know that with the National Clinical Guideline – Sepsis Management in place there will be a greater chance of early pick up and therefore recovery will, I am sure, bring great comfort.’
I now formally endorse and launch the three new National Clinical Guidelines – Sepsis, Irish Maternity Early Warning System and Clinical Handover Maternity Services. These guidelines have the potential for high impact on morbidity and mortality improving patient safety and quality. I hope you all have a useful and informative day.