Discharges from NHS Hospitals to Care Homes between 1 March and 31 May 2020
Validated register of hospital discharges to care homes methodology Publication date: 28 October 2020 Revised 21 April 2021
A Management Information release for Scotland Public Health Scotland
This is a Management Information publication
Published management information are non-official statistics which may be in the process of being transitioned into official statistics. They may not comply with the UK Statistics Authority’s Code of Practice with regard to high data quality or high public value but there is a public interest or a specific interest by a specialist user group in accessing these statistics as there are no associated official statistics available. Users should therefore be aware of the aspects of data quality and caveats surrounding these data, all of which are listed in this document.
Find out more about Management Information publications at: https://code.statisticsauthority.gov.uk/national-statisticians-guidance-management-information- and-official-statistics-3/
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Contents
Revisions ...... 4 Introduction ...... 5 Identifying People Discharged to a Care Home ...... 5 Section 1 – Discharges from NHSScotland Hospitals to care homes ...... 6 Overview – creating the register of discharges to care homes ...... 6 Datasets used to identify hospital discharges ...... 10 SMR01/SMR01E – acute & geriatric long stay activity ...... 10 SMR04 – Psychiatric inpatient activity ...... 11 RAPID - Rapid Preliminary Inpatient Data (RAPID) ...... 11 Linking hospital activity datasets together ...... 12 Additional Datasets used to identify care home residents ...... 13 Delayed Discharges ...... 14 Scottish Ambulance Service (SAS) Patient Transport Service (PTS) ...... 14 National Records Scotland (NRS) Deaths ...... 14 CHI Institution Flag ...... 15 Health and Social Care Partnership Temporary Care Home Residents ...... 15 Adding care home flags to hospital dataset ...... 16 Delayed discharges Flag ...... 16 Scottish Ambulance Service patient transfer service data flag ...... 16 Health & Social Care Partnerships temporary care home information flag ...... 16 Summary of care home flags ...... 17 Quality assurance of discharges register ...... 17 Adding records into the dataset ...... 17 Removing records from the dataset ...... 18 Specific data quality issues identified and resolved ...... 18 Conclusions ...... 19 Revisions ...... 19 Defining COVID-19 status of individuals ...... 21 Electronic Communication of Surveillance in Scotland (ECOSS) ...... 21 Linking testing and discharges dataset ...... 21 Section 2 – Impact on care homes ...... 23
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Care home data sources ...... 23 Allocation of care home of discharge ...... 23 Unique Property Reference Number (UPRN)...... 25 Care home service data ...... 25 Relationship between care home size and discharges ...... 27 Section 3 – Additional analysis including Genomic Sequencing ...... 30 How individual discharges were assigned pre-hospital residency ...... 30 Glossary ...... 32 Contact ...... 34 Further Information ...... 34 Rate this publication ...... 34 Appendices ...... 35 Appendix 1 – Comparison of Hospitals in SMR01 and RAPID ...... 35 Hospitals in SMR01 not in RAPID ...... 35 Hospitals in RAPID not in SMR01 ...... 37 Appendix 2 – References ...... 39 Appendix 3 – Publication Metadata ...... 40 Appendix 4 – Early access details ...... 42 Appendix 5 – PHS and Official Statistics ...... 42
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Revisions This report is a revised version of the previous “Hospital Discharges into Care Homes in Scotland” published on 28 October 2020. The following revisions have taken place: • Further quality assurance of the data used in this report, which has resulted in 6 discharges (3 individuals) being removed from the analysis. This is because these discharges were later identified as not being to a care home. All statistics, tables and charts have been updated in the report to reflect this change. This means there are now 5,198 discharges in the underlying data-set, rather than 5,204 previously. This does not impact on the main conclusions from the original report. • The statistical modelling part of section 2 (which analyses the risk of care home outbreaks associated with hospital discharge) has been updated following feedback from users and the Office for Statistics Regulation. We have included additional visuals and commentary relating to the interpretation of the results to provide greater clarity on our findings. • Section 3 has been added. Since the publication of the original report in October 2020, further analysis has been performed to explore specific aspects in detail including: • classification of discharges based on pre-hospital residency (where people lived before they were admitted to hospital); • analysis of the outcomes within 30 days of hospital discharge (all-cause mortality, COVID-19 mortality and COVID-19 infection) of all those who were discharged; • and analysis of those individuals whose last positive test before discharge was positive (including relationship with care home outbreaks). • Collaboration with the Public Health Microbiology Team within Public Health Scotland enabling the clinical data on people whose last positive test before discharge was positive to be combined with viral genomic sequencing data (where available). The genomic data has allowed analysis of the specific samples of those discharged from hospital and the samples from the care home they were discharged-to, to be compared to understand more about patterns of infection transmission and relationships between hospital discharge and care home outbreaks.
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Introduction On 18 August 2020 the Cabinet Secretary for Health and Sport, commissioned Public Health Scotland (PHS) to carry out work to identify and report on people aged 18 and over who were discharged from NHS Hospitals to care homes during the first wave of the COVID-19 Pandemic, from 1 March to 31 May 2020. Both the University of Edinburgh and the University of Glasgow were partners in the production of this report. Identifying People Discharged to a Care Home Identifying those discharged from hospital into care homes requires identification of three groups: 1. Existing care home residents admitted to hospital who are discharged back to the care home where they live 2. People admitted to hospital from their own home/private residence who are discharged to a care home where they are going to live permanently (new admissions to care homes) 3. People admitted from their own home/private residence who are discharged to a care home on a temporary basis (e.g. for rehabilitation, while their own homes are adapted, while waiting for care-at-home to be organised or for intermediate care) (temporary admissions to care homes) In order to identify the people in these three groups, PHS used as many different data sources as possible to produce a register of discharges from hospital to a care home during 1 March to 31 May 2020. The lists of people identified were shared with the appropriate NHS Boards and Health and Social Care Partnerships for checking. Separately, Health and Social Care Partnerships were also asked to supply data intelligence on anyone who moved into care homes from hospital on a temporary basis during this period.
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Section 1 – Discharges from NHSScotland Hospitals to care homes This section explains the methodology in defining the cohort of patients who were discharged to a care home between 1 March and 31 May 2020.
Overview – creating the register of discharges to care homes This work relied upon the development of a comprehensive register of discharges of people aged 18 and over who were discharged to a care home and were; • admitted to hospital prior to 1 March 2020 and discharged by 31 May 2020 or • admitted and discharged from hospital during 1 March and 31 May 2020. There is no one source of data which identifies discharges from hospitals to care homes. The register of discharges from hospital to care homes was developed initially using national datasets, which were linked together using the Community Health Index (CHI) number. The datasets used to create the register of discharges from hospital to a care home and inform the analyses were as follows: • SMR01 – general inpatient and daycase record (the definitive record of general hospital admission and discharge but not finalised for some weeks after discharge) • RAPID – daily rapid and preliminary inpatients and daycases (an immediately available but not finalised version of SMR01, and can be used as a source of information if the SMR01 record is not available) • SMR01E – geriatric long stay records • SMR04 – inpatient psychiatry records (the definitive record of psychiatric hospital admission and discharge but not finalised for some weeks after discharge) • Delayed discharges – hospital inpatients who are clinically ready for discharge from inpatient hospital care and who continue to occupy a hospital bed beyond the ready for discharge date. • Community Health Index (CHI) – demographic data for all patients in Scotland, including the GP recorded address and an institution flag which identifies patients who reside in a care home • Scottish Ambulance Service Patient Transport Service (PTS) – people who have been taken to a care home address • Temporary Placements - Health and Social Care Partnerships were asked to supply data on people who moved into care homes from hospital on a temporary basis during this period, as these cases were thought to be less reliably identified using other methods. • Deaths data – National Records Scotland data on registered deaths, where place of death was a care home. • Discharges identified through local review in NHS Boards
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• Care Inspectorate list of registered care home services • ECOSS – labs data (includes NHSScotland and UK Lighthouse COVID-19 tests)
Figure 1: Outline of linkage to identify discharges to care homes
Due to completeness issues with some SMR01 general inpatient and daycase hospital records towards the end of the time period under review, RAPID records were used wherever possible. However, not all hospitals submit data to RAPID and not all information is mandatory for a RAPID submission. Where a delayed discharge record indicated a patient was discharged to a placement, but there was no matching SMR (SMR01, SMR01E, SMR04) or RAPID record, the delayed discharge record was added to the SMR/RAPID linked dataset and included in the final validated register of hospital discharges to care homes where appropriate. The relevant sections below detail the selections made for each of the data sources and the validation methods. The latest completeness estimates for SMR at the time of analysis are outlined in Table 1.
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Table 1: Completeness estimates for SMR
Board SMR01 SMR01E (GLS) SMR04
Mar-20 Apr-20 May-20 Mar-20 Apr-20 May-20 Mar-20 Apr-20 May-20 National Boards 100% 100% 100% - - - 0% 0% 0% NHS Ayrshire & Arran 100% 100% 100% 100% 100% 100% 100% 100% 100% NHS Borders 100% 100% 100% 100% 100% 100% 100% 100% 100% NHS Dumfries & Galloway 99% 99% 99% - - - 100% 100% 85% NHS Fife 98% 97% 95% 0% 0% 0% 100% 100% 100% NHS Forth Valley 18% 54% 55% 100% 100% 100% 89% 73% 78% NHS Greater Glasgow & Clyde 99% 99% 99% 100% 66% 74% 100% 100% 100% NHS Grampian 99% 98% 98% - - - 99% 96% 99% NHS Highland 99% 99% 99% - - - 98% 93% 83% NHS Lanarkshire 96% 89% 92% 94% 90% 91% 92% 84% 87% NHS Lothian 99% 99% 99% 100% 95% 99% 100% 100% 100% NHS Orkney 100% 100% 100% ------NHS Shetland 96% 93% 91% ------NHS Tayside 100% 100% 100% - - - 100% 100% 100% NHS Western Isles 100% 100% 100% - - - 100% 100% 100% All NHS Boards 95% 96% 96% 92% 80% 86% 99% 95% 96% Source: PHS SMR completeness https://www.isdscotland.org/products-and-Services/Data-Support-and-Monitoring/SMR- Completeness/ For the SMR datasets, the data is collected at individual patient episode level, and a person’s stay in hospital can include more than one episode, therefore each dataset had to be aggregated to create one record for each individual’s unbroken period of time spent in hospital. This is referred to as a continuous inpatient stay (CIS). RAPID is based on hospital stays rather than episodes, so multiple records occur if a patient is transferred to another hospital during the period of treatment. These hospital stays need to be aggregated in a similar way to SMR episodes to create a single CIS. An individual can still have multiple stays in the dataset if the discharge and subsequent admission is not continuous. A patient may change specialty, consultant, significant facility, NHS board and/or hospital during an SMR continuous inpatient stay. As a result, information used to assign a stay to a specific hospital or NHS board has to be taken from specific episodes relating the stay. For RAPID, the information has to be taken from specific stays within the patient’s continuous period of hospitalisation. The rules used to decide which episode was used to capture the information for the full stay in hospital are shown in Table 2.
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Table 2: list of fields used and whether taken from first or last episode in CIS
SMR Field First Last Any Episode Episode Episode Community Health Index (CHI) Surname forename Date of birth Sex Patient Postcode Ethnic group Admission date Admission type Admission/transfer from Discharge date Discharge type Discharge/transfer to Hospital Specialty Significant Facility Intensive Care Unit flag High Dependency Unit flag Management of patient Main Diagnosis Secondary diagnosis 1 Secondary diagnosis 2 Secondary diagnosis 3 Secondary diagnosis 4 Secondary diagnosis 5 NHS Board of residence NHS Board of treatment Source: SMR, RAPID The process of creating the initial extracts, and linking the hospital activity data together, is outlined in the next section.
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Datasets used to identify hospital discharges This section describes each of the datasets used and the method of selection of records for the final SMR/RAPID linked discharges dataset. SMR01/SMR01E – acute & geriatric long stay activity SMR01 is an episode-based patient record relating to all inpatients and day cases discharged from non-obstetric and non-psychiatric specialties. A record is generated when a patient completes an episode of inpatient or day case care. Examples include discharge home from hospital, transfer to another clinician (either at the same or a different hospital), a change of specialty (either under the same or a different clinician), or death. Data collected include patient identifiable and demographic details, episode management details and general clinical information. Currently diagnoses are recorded using the International Classification of Diseases Tenth revision (ICD-10) and operations are recorded using the Office of Population Census and Surveys Classification of Interventions and Procedures version 4 (OPCS- 4). Geriatric Long Stay records – GLS (SMR01_E) are collected as part of SMR01 and relate to all inpatients admitted to and discharged from facilities for Long Term Care of the Elderly. https://www.ndc.scot.nhs.uk/National-Datasets/data.asp?SubID=5 An episode level SMR01 data extract was taken on 14 September 2020, and in order to capture accurately the full Continuous Inpatient Stay (CIS) of each patient discharged during this period, the episode level extract contained all episodes from 1 March 2019 onwards. A Geriatric Long Stay (SMR01_E) extract was also taken, including all episodes from 1 March 2017 onwards, to ensure all relevant long stay episodes within a CIS were included. The two extracts were then merged together, and flags were created to highlight stays in hospital that included some time in an intensive care unit or a high dependency unit. This combined dataset was then sorted by: • link number (an anonymous code to allow data to be linked to other records with the same identifier) • cis marker (attributes the same unique ‘stay’ number to each episode within a CIS) • admission and discharge dates and then aggregated to create a file with one record for each CIS (SMR01/SMR01_E ‘stay’ level file). All discharges with any part of the stay during the period 1 March 2020 to 31 May 2020 were selected and all other stays removed. This combined SMR0/SMR01_E stay level file was then ready to be linked to the remaining data sources.
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SMR04 – Psychiatric inpatient activity The Mental Health Inpatient and Day Case dataset (SMR04) collects episode level data on patients who are receiving care in psychiatric hospitals at both the point of admission and discharge. The dataset contains a wide variety of information such as patient characteristics, mental health diagnosis, length of stay, destination on discharge, if the patient was admitted under Mental Health Legislation and any previous psychiatric care. https://www.ndc.scot.nhs.uk/National-Datasets/data.asp?SubID=7 An episode level SMR04 extract was taken on 14 September 2020 and in order to accurately capture the full Continuous Inpatient Stay (CIS) of each patient discharged during this period, the episode level extract contained all episodes from 1 March 2017 onwards. The episode level data was aggregated by link number, cis marker, admission and discharge dates to create a file with one record for each CIS (‘stay’ level file). Records with missing discharge dates (i.e. not yet completed) were included. Stays were then selected if admission was on or before 31 May and discharge was after 1 March. Admissions before 31 May with no discharge date were also retained. The CIS marker for this file was modified to indicate it is from SMR04, to ensure there was a distinction when the SMR01/SMR01_E and the SMR04 data files were added together.
RAPID - Rapid Preliminary Inpatient Data (RAPID)
RAPID is a daily submission of people who have been admitted and discharged to hospital. It contains patient identifiable data and is based on the format of SMR01. However, as this data collection was primarily designed for the purpose of monitoring emergency hospital admissions, hospitals with elective only facilities are excluded – see list of hospitals included in Appendix 1 Due to the focus on hospital admission counts, RAPID data is based on hospital stays rather than individual episodes of care, or continuous inpatient stays as per SMR datasets. This means that there can be multiple ‘stay’ records for a single patient if they have been transferred between locations during the course of a continuous period of treatment. Therefore, a RAPID ‘stay’ differs to a SMR based stay (CIS). Due to the timeliness requirement of the data submissions, minimal validation is applied, and discharge related fields are not mandatory for completion in order to ensure admission related data is as up to date as possible. This means that records are not always updated with discharge information and it can appear that some patients are still in hospital, when in fact they have been discharged. https://www.ndc.scot.nhs.uk/National-Datasets/data.asp?SubID=37
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A RAPID stay level data extract was taken on 8 September 2020, with all admissions from 1 January to 7 September 2020 included, as the SMR01 completion for some boards was low from January 2020. The time period for RAPID was extended to ensure there were no further updates to records with discharges in March to May 2020 identified via SMR – i.e. that the SMR record was in fact as yet incomplete. Records with missing CHI were removed, (815 out of 467,396 – 0.2%). In order to match SMR methodology, time of admission and discharge - collected routinely as part of the RAPID dataset - were utilised and admission records for patients with less than 24 hours’ difference between admission were considered a continuation of the previous treatment – i.e. same Continuous Inpatient Stay, and aggregated into one CIS. The hospital stay level data was aggregated by CHI number, cis marker, admission and discharge dates to create a RAPID CIS or ‘stay’ level file. A marker was added to identify the records came from RAPID. The RAPID CIS file was then filtered to include only those records where admission is on or before 31 May and discharge was after 1 March; records with missing discharge date were also included.
Linking hospital activity datasets together The SMR01/SMR01_E and SMR04 extracts were merged together and at this point, any records with a missing CHI were removed (379). The next step was to add the RAPID data, to try to ensure coverage where SMR01 records were not complete for the time period in question, without duplicating stays from RAPID and SMR (although RAPID is an acute inpatient data collection, some mental health records are submitted). A number of checks were made on the data, to ensure duplicate RAPID records were removed. For each scenario, the RAPID record was removed, as the SMR data has been through extensive validation, unlike RAPID, so is therefore more reliable. For each duplicate records were removed if the: • admission and discharge identical (exact match) • EITHER date of admission or date of discharge differ but discharge or admission match (partial date match) • date of admission and date of discharge were within the dates of the previous record (e.g. incomplete CIS record on one dataset) • date of admission or discharge overlapped the discharge or admission of the duplicate record (overlapping records)
In total, 88% of the RAPID records were subsequently removed due to duplication of one of the forms described above. The following selections were then applied to the dataset before the care home records were identified.
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• Restrict the file to records with a discharge date between 1 March and 31 May 2020 • Remove records with a length of stay of zero • Remove records where patient died in hospital
Table 3 shows the total number of records in the original SMR/RAPID linked discharges file used for matching the care home flags, and creating the final validated register of hospital discharges to care homes. Note, the information is based on discharges, rather than individual patients, so a patient admitted and discharged multiple times during the time period in question will have multiple records in the dataset.
Table 3: Number of discharges per data source; Scotland; Discharges between 1 March to 31 May 2020
Data Source1 Number of Percent discharges SMR01 85,720 87.8% RAPID 8,569 8.8% SMR04 3,295 3.4% Total 97,584 100.0% Source: SMR01, SMR01E, RAPID, SMR04 1. At a later stage 44 delayed discharges records were also added.
Additional Datasets used to identify care home residents Although the SMR/RAPID datasets have an admission from and discharge to code, to indicate whether a patient has been admitted from or is discharged to a care home, there are known quality issues with these fields. Therefore, a number of datasets were utilised, in order to help identify all patients potentially discharged to a care home. The table below outlines these potential data sources, and the methodology used to link these to the SMR/RAPID linked discharges dataset is outlined in the sections below.
Table 4: list of data sources considered to identify care homes
Data source Information Identifier1 SMR01,SMR_01E, SMR04, RAPID Admitted from Care Home Coded variable 20,25 SMR01,SMR_01E, SMR04, RAPID Discharged to Care Home Coded variable 20,25 Delayed Discharge Destination Placement Patient Transport Service (PTS) Transported to Care Home Postcode match & manual address review National Records of Scotland (NRS) Death in Care Home Institution and Location Code CHI Institution Flag Denotes Care Home Coded as 93 or 98 (with date) Health and Social Care Partnership Temporary placement Chi/DoB, date and location of placement 1. Please see individual data source sections for details of identifiers
After conversations with boards (see quality assurance section for full details) the SMR/RAPID based flag ‘admission from code 20 or 25’ - indicating admission from an institution or care home
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- was not used as a viable flag for identifying discharges to care homes on its own. i.e. in order for records to be retained in the discharges to care homes register, an indicator other than ‘admitted to’ either code 20 or 25 had to be present.
Delayed Discharges A delayed discharge occurs when a patient, clinically ready for discharge, cannot leave hospital because the other necessary care, support or accommodation for them is not readily accessible and/or funding is not available, for example to purchase a care home place. Delayed discharge information is submitted directly to PHS from health boards. This submission is separate to SMR and RAPID data submissions and so there may potentially be inconsistencies between dates recorded in each dataset. There are no validation checks carried out to compare delayed discharge data with SMR or RAPID data when it is received. An extract was taken from the delayed discharge dataset including all discharges following a period of delay to a placement. This includes discharges to care homes, nursing homes and other settings such as Intermediate Care, however under current recording practices it is not possible to provide a breakdown of the different types of placement. Discharges between 1 March and 31 May 2020 were included. The methodology used to match the delayed discharges data onto the main SMR/RAPID linked discharges dataset is outlined in the ‘Adding care home flags to the hospital dataset’ section below.
Scottish Ambulance Service (SAS) Patient Transport Service (PTS) The Patient Transport Service (PTS) provides ambulances to patients who need support to reach their healthcare appointment, or for their admission to and discharge from hospital, due to their medical/clinical needs. An extract was received from SAS containing PTS Journeys between 1 March and 31 May 2020. These were PTS discharges (scheduled care) from hospital to any of the locations in the Care Inspectorate list. This file was initially searched using postcode then manually reviewed to check the address matches.
National Records Scotland (NRS) Deaths A data extract containing all NRS death records with a date of death between 1 March and 30 June 2020 was created on 8 September 2020, and included institution code and place of death. Two separate flags were added to the NRS deaths extract - a care home flag was added by identifying relevant care home institution codes, and records with a cause of death code indicating death related to COVID-19 (either U07.1 COVID-19 confirmed by laboratory testing or U07.2 COVID-19, suspected, laboratory confirmation is inconclusive or not available) in any of the
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underlying cause of death fields were also flagged. The resulting COVID deaths figure was checked against the NRS published figures for accuracy. This meant that all deaths, as well as COVID-19 specific deaths and any subsequent deaths in care homes could be identified once the file was matched onto the SMR/RAPID linked discharges dataset.
CHI Institution Flag The CHI register holds detailed information on individuals including the address as held by the patient’s registered GP Practice. Using this information, an ‘Institution Flag’ is applied by NHS Scotland Practitioner Services Division and signals residential and nursing home residency, where institution flag is either 93 or 98; PHS receive a monthly update of the CHI file. As the information is received monthly and relies on GP registration, there can be a delay between an individual moving into a care home and their CHI record having the institution flag applied. If the CHI institution flag says that someone lives in a care home, then this is usually correct, however it is incomplete1. A CHI extract for individuals with an institution flag of 93 or 98 at 31 March 2020, was created by the CHI Linkage team in PHS. A second extract, with historical CHI information also at 31 March 2020 was also used to ensure no records were missed.
Health and Social Care Partnership Temporary Care Home Residents Data was requested from Health and Social Care Partnerships (HSCPs) on individuals who had moved from inpatient hospital settings into care homes on a temporary basis during the period of interest. Data were received from 28 of the 31 HSCPs (90% return). All data received were reviewed and checked, excluding those not meeting the criteria for inclusion in the main SMR/RAPID linked dataset. Manual matching of data to SMR/RAPID dataset was performed using CHI or Date of Birth where CHI was not provided. If date of care home entry and date of hospital discharge were within 48 hours, the date was adjusted to reflect the date of discharge in the SMR/RAPID linked discharge file. This resulted in information on 832 discharges into temporary placements, 683 of whom (82.1%) were already identified using the approaches outlined above to identify those discharged to care homes. Of the 149 remaining cases, 47 discharges were added where an SMR or RAPID record could be identified, and 102 could not be located. There are 730 discharges into care homes on a temporary basis included in the final validated register of hospital discharges to care homes.
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Adding care home flags to hospital dataset Once all the files were prepared, the final linkages were performed to identify all discharges to care homes. Firstly, the SMR/RAPID ‘discharge transfer to’ field was used to identify all records in the SMR/RAPID linked discharges file with a discharge/transfer to code of either 20 - Place of Residence - Institution - no additional detail added or 25 - Care Home. Once the SMR/RAPID discharge/transfer to care home flag was created, the CHI institution code and NRS deaths care home identifiers were linked using CHI.
Delayed discharges Flag
The delayed discharges extract was linked to the SMR/RAPID dataset primarily using CHI and discharge date. The majority of records matched exactly using these variables, however the following methods were also used to link records; • Matched using CHI and discharge date allowing for plus or minus 1 days difference • Matched using CHI and admission date and using discharge date from delayed discharges dataset where missing on SMR/RAPID record • Some records were added to the dataset as extra discharges where there was no matching SMR/RAPID record. These were likely to have not already be included in the dataset due to SMR completeness issues and/or locations not being recorded on RAPID dataset.
Scottish Ambulance Service patient transfer service data flag The Patient Transfer Service (PTS) data extract was then linked onto the SMR/RAPID linked discharges dataset by matching CHI and patient journey date/discharge date. A total of 2,644 of the 2,994 PTS records (88%) matched exactly on CHI & discharge date. Of the remaining unmatched records, 73 of these journeys had CHI missing so were removed. Of those remaining, the difference between the hospital record discharge date and PTS date was investigated, and 40 PTS journeys were found to be within 1 day of discharge date, so were added. For a small number of admissions (36) the PTS did not match due to missing discharge dates, so the PTS date was used as the discharge date to complete the record. In total 2,720 PTS journeys were matched on to the SMR/RAPID linked discharges file.
Health & Social Care Partnerships temporary care home information flag The final care home indicator, using the HSCP temporary care home residents’ data, was then added, using the information from the HSCP matching described in the previous section to flag the 47 SMR/RAPID discharges not otherwise flagged as discharged to a care home.
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Summary of care home flags Following this processing, all the possible care home flags had been added to the discharges file. All records with at least one of the 8 care home flags present were selected for validation and further analysis. The final linked file of discharges to care homes (or suspected discharges to care homes) contained a total of 5,946 discharges. Note this also includes those flagged via SMR/RAPID admission from code 20/25, which was subsequently removed as an indicator. The number of records allocated a care home flag by each of the data sources is shown in Table 5. This data represented the provisional register of hospital discharges to care homes, and NHS board specific extracts were created and sent on to relevant NHS boards for review and validation before the final register was created.
Table 5: Number of discharges flagged per care home indicator - before validation
Care Home Flag Number of Percent Discharges SMR/RAPID flag (Discharge to=20/25) 3,857 64.9% CHI Flag 3,241 54.5% NRS Flag 1,066 17.9% Delayed Discharge Flag 1,591 26.8% PTS Flag 2,629 44.2% SMR/RAPID flag (Admission from=20/25) 854 14.4%
Quality assurance of discharges register As previously noted, it was agreed after initial discussions with NHS boards that the ‘admission from’ field on its own would not be used to identify a discharge to a care home. Therefore, any discharge with only the ‘admission from’ code 20 or 25 care home indicator and no other care home flag was removed from the register of hospital discharges to care homes. Principles were then defined for dealing with all other feedback from boards, involving adding or removing records to the discharges to care homes register. Adding records into the dataset 1. We must be able to identify which national record aligns to the information given (SMR01, SMR01E, SMR04 or Delayed Discharge) - some records have no current SMR or RAPID submission accessible to the team at Public Health Scotland and thus lack the necessary clinical data to allow their inclusion. i.e. we will not be able to add new records not yet submitted via any of the national datasets, only those already on the datasets but not flagged as care home.
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2. We have amended the dates on SMR records where NHS Boards specifically indicated the individual had a different discharge date. We are anticipating a revised SMR submission will be made by Boards (if not already), We are aware that this issue affects some specific NHS Boards and Hospitals, particularly around submissions via SMR01E. Removing records from the dataset Single flag queries - where an individual was identified as being a care home discharge on the basis of a single flag we reviewed the underlying data and made the following decisions: • NRS flag - if patient confirmed as discharged alive to non-care home address and only flag was death in care home - record excluded • CHI Institution Flag - if patient confirmed as discharged to non-care home address and only flag was from CHI (either historic CHI or CHI flag) - record excluded • SMR/RAPID discharge to=20/25 - if patient confirmed as discharged to non-care home setting (typically sheltered housing) - record excluded • Delayed discharge flag - if patient confirmed as discharged to non-care home setting and only flag was delayed discharge - record excluded as likely placement was to another setting • PTS flag - records reviewed individually - these were CHI matched and had location of discharge - if record did not indicate discharge to care home (e.g. hospice, adjacent property) - record excluded. Some specific queries were followed-up with individual NHS Boards. • Multiple flag queries - where an individual was identified as being a care home discharge on the basis of multiple flags we reviewed the data collectively and discussed each case to reach consensus, taking account of the information supplied by NHS Board about why the record was deemed not to be a care home discharge. Some were certain based on clinical case note review, others based their judgement on current address on TRAK (electronic patient management system), which has limitations. Information supplied by Health and Social Care Partnerships about temporary placements and PTS journey data were particularly useful here and often aligned with CHI.
Specific data quality issues identified and resolved A common error was within the CHI Institution Flag, where younger adults who have accessed specialist substance misuse residential support were identified as residing in a care home. Their data appeared not to be contemporaneous as there was no subsequent change of address data in the system. We have removed any cases where we have no other supportive flags that the Institution Flag is the individual's current address (e.g. PTS journey on discharge, SMR postcode etc.) - this intelligence will be fed-back to the national CHI team. The CHI institution flag is designed only to identify care homes, but there is variation across Practitioner Services Division about how this is applied and some areas identified that Sheltered Housing complexes had been incorrectly flagged. This information will also be shared with the CHI
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team and recommendations made around alignment of the flag application with the Care Inspectorate list of registered services, as a gold standard dataset of care home services in Scotland.
Conclusions This topic has prompted an unprecedented level of clinical review of multiple data sources at both local and national level, highlighting the complexity of recording who is discharged to a care home setting. Due to the bespoke nature of this project in terms of the clinical question asked, we have amended our data for analysis in accordance with feedback received. Where we have accepted feedback received that disagrees with information in the current national SMR data, we anticipate that the boards will resubmit the SMR data with correct information (e.g. removing incorrect code 25s, adding code 25s and amending dates) to ensure the national data for this period aligns. A total of 716 discharges were removed, and 91 were added as a result of the quality assurance exercise. There were also a small number of records where admission or discharge date was amended. A further 99 were removed due to the admission transfer from being the only flag present. Revisions Post publication date of 28 October 2020, further quality assurance of the data found 6 discharges (relating to 3 individuals) wrongly identified as being discharged to a care home. These records were removed and the analysis re-run and updated. Tables 6-8 below have been updated to reflect the revised register. Tables 6 to 8 below describe the data within the final validated register of hospital discharges to care homes:
Table 6: Final number of discharges per primary data source
Data Source Number of Percent discharges SMR01 4,635 89.2% SMR04 337 6.5% RAPID 184 3.5% Delayed Discharges 42 0.8% Total 5,198 100.0% Source: Validated register of hospital discharges to care homes
The table 7 below details the number of discharges flagged per indicator – a discharge can have more than one indicator present so can appear in more than one row.
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Table 7: Final number of discharges flagged by care home indicator
Care Home Flag Number of Percent discharges SMR/RAPID flag (Discharge to'=20/25) 3,639 70.0% CHI Flag 2,819 54.2% PTS Flag 2,615 50.3% Delayed Discharge Flag 1,560 30.0% NRS Flag 1,034 19.9% HSCP Flag 730 14.0% Board Additions 91 1.8% Source: Validated register of hospital discharges to care homes
Table 8 highlights the number of discharges with multiple care home flags, with 79.6% of all discharges in the validated register of hospital discharges to care homes flagged as discharged to a care home by more than one source.
Table 8: Final number of discharges by number of flags present on each record
Care Home Flags Number of Percent discharges 1 1,061 20.4% 2 1,758 33.8% 3 1,697 32.6% 4 593 11.4% 5 86 1.7% 6 3 0.1% Total 5,198 100.0% Source: Validated register of hospital discharges to care homes
This dataset constitutes the final validated register of discharges to care homes between 1 March and 31 May 2020, for those aged 18 years and over, with a length of stay of at least one day and who did not die in hospital.
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Defining COVID-19 status of individuals Electronic Communication of Surveillance in Scotland (ECOSS) The ECOSS multi test file contains all COVID-19 tests carried out through NHS Scotland laboratories and Regional Testing Centres (RTCs) as part of the UK Government testing programme (Lighthouse Lab data). This includes tests done at the drive through centres, mobile units, and home testing kits. For test date, the date the specimen was collected is the default date used, where this is not available, the following dates (in order of availability) were used instead - date received, received at lab, date processed. Specimen date was not available for historical UK Government Regional Testing centres data between 15 and 25 April 2020. As a sample date is required to report in ECOSS, these samples were assigned a specimen date of the mid-point within this date range (20th April). This created an artificial spike in tests for this specific date. Data from NHS labs is routinely quality assured by PHS data management team, but these same checks are unable to be run on the UK Lighthouse testing data, so PHS cannot guarantee quality of the dates from these tests. The data is CHI Seeded (CHI seeding involves using personal identifiers for example Date of Birth, Sex, Forename, Surname and Postcode to add a CHI number to a person’s record), and non-matching CHI numbers from NHS labs are manually checked by PHS. The Lighthouse data uses a slightly different methodology for CHI seeding, and are not subject to verification by PHS. Of all tests in the ECOSS dataset with a specimen date up to 31 May 2020 there were 7,323 (1.7%) records removed, due to missing or invalid CHI. A flag was created to differentiate between NHS Scotland Laboratory and Lighthouse sourced results, and a further flag created to identify all positive test results. The test data file was then aggregated to ensure one test result per person per day, with a positive test result prioritised over a negative test result where a person had multiple tests on the same day. NHS Laboratory tests were prioritised over Lighthouse tests where duplication occurred, as the NHS Scotland data had been subjected to further quality assurance once received by PHS. The ECOSS test data was then ready for matching to the validated register of discharges to care homes.
Linking testing and discharges dataset The ECOSS test data was matched to the validated register of discharges to care homes and any ECOSS records with a matching CHI in the validated register of discharges to care homes file were flagged, and ECOSS records with no associated discharge were removed. This allowed the following groups to be identified:
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Table 9: Final number of discharges by test status
Scenario Tests Number of discharges Tested, no discharges 394,456 0 No test, discharged 0 1,395 1 test, 1 discharge 1,167 1,167 Multiple tests, 1 discharge 7,681 1,960 At least 1 test, multiple discharges 1,111 676 Total 404,415 5,198 Source: Validated register of discharges to care homes, ECOSS COVID-19 testing data
Flags were then added to group the records into month of discharge, splitting the month of April into pre and post 22 April, to identify testing procedures pre and post policy change outlining testing requirements on admission to and discharge from hospital. A number of calculations were then performed using specimen (test) date, date of admission and date of discharge in order to identify the number of days between significant events –any testing, admission, discharge - and this enabled the discharges to be categorised into the relevant groups for analysis.
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Section 2 – Impact on care homes This second section focuses on the methodology used to examine laboratory-confirmed care home outbreaks of COVID-19 across Scotland where the first positive test occurred between 1 March and 21 June, and associations between care home characteristics and COVID-19 outbreaks.
Care home data sources The analysis presented in section two required additional data to be collated. The process is summarised in Figure 2. The cohort of individuals discharged from hospital were first allocated to a specific care home at the time of discharge. Care home level data on COVID-19 outbreaks and mortality were collated using information from the Care Inspectorate, ECOSS testing data linked to CHI and National Records of Scotland Deaths information. Each of these will be described in detail in the following sections.
Figure 2: Overview of care home data linkage required for section two analysis
Allocation of care home of discharge In the first section we focused on identifying those discharged to a care home and described all the methods used to define this. To define and describe the data required for section two required identification of the actual care home that people were discharged to and this was assigned using multiple data sources (Figure 3).
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Use of multiple data sources are necessary because full address on admission and at the time of hospital discharge are not fields included in the SMR or RAPID datasets collected nationally. Postcode is the only address field available from these datasets and relates to the postcode of admission. Postcode matching can help in identifying care home addresses, but using this alone introduces error as postcodes are shared across multiple properties1. In addition, as discussed in section one, the cohort of individuals discharged to a care home include those returning to their home, moving into a new care home or moving into a care home on a temporary basis. Therefore, for the second and third group, postcode matching from admission would be misleading. We used CHI and Historic CHI extracts from March 2020 with Institution Codes and had a full extract from CHI in August with Unique Property Reference Number allocations (described in the next section). This enabled review of addresses at multiple time periods to capture changes as individuals move between settings to overcome the delays associated with change of address and change of GP and information within the CHI register. Each care home location was allocated individually based on using the most comprehensive data available and using all data available to the team, including information provided by NHS Boards and Health and Social Care Partnerships. This work was specifically focused on discharges to care homes. Thus, care home was defined based on the Care Inspectorate list of regulated adult care home services. This excludes facilities providing NHS Hospital Based Complex Care, hospices, sheltered housing and other forms of supported accommodation. All care home locations were mapped to their CSNumber (Care Inspectorate identifier) and Unique Property Reference Number. Where a care home location could not be identified (<5%) from these datasets, PHS contacted NHS Boards for more information.
Figure 3: Data sources used to allocate a specific care home location individuals were discharged to
Footnote: HSCP – Health and Social Care Partnership; PTS – Patient Transport Service; CHI – Community Health Index; NRS – National Records of Scotland; SMR – Scottish Morbidity Record
Following this process, a care home location was identified for 5,185 discharges (99.7% of all discharges identified) of 4,793 individuals. Each source contributed the following: PTS (2,600),
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followed by CHI institution flag (1,133), HSCP (730), CHI Address August and SMR Postcode (451), NRS deaths (167) and NHS Boards identified the final 104 locations. The remaining 13 discharges were excluded. Seven were confirmed by Boards as care home discharges, but no location could be provided, and six were discharged to care homes in England so could not be linked to testing data.
Unique Property Reference Number (UPRN) Unique Property Reference Number (UPRN) is an Office for National Statistics identifier of properties used across Great Britain. Public Health Scotland and the Scottish Centre for Administrative Data Research are leading a national project to assign a UPRN to every address recorded in the Community Health Index (CHI) register2. Due to the known challenges of identifying care home addresses, members the team are collaborating with those working on this national project. A UPRN was matched to all addresses registered in the Community Health Index (CHI) register for individuals alive or who died in 2020, using the Improvement Services automated UPRN- seeding tool (n=5,833,550 records). Around 90% of all CHI records matched automatically to a UPRN. The remaining address records (441,500) were reviewed using postcode and care home name to identify care home addresses and manually assign their UPRN. These preliminary data were made available to the analytical team as an additional resource to lookup CHI records flagged as from care home addresses using UPRN. This tool was used to support identification of discharge location and test location. The Care Inspectorate list of services was matched onto the CHI UPRN file, and 41,237 CHI numbers matched, from 1,008 care homes. This was recognised to be incomplete, but provided additional records to those flagged using the CHI Institution flag. Further work is ongoing to identify other care home service addresses within CHI and improve the allocation of UPRN to care home addresses.
Care home service data The Care Inspectorate Datastore3 was used to obtain a list of active care home services during the period of interest. Care homes are identified using a CSNumber, which is based on their service registration. Other descriptive variables about the care home including: number of registered places (the maximum number of residents allowed); care home subtype (older people; learning disability; mental health problems; physical and sensory impairment; other services including alcohol & drug misuse, blood borne viruses, respite & short breaks); sector (private, voluntary/not for profit, local authority/health board) and Risk Assessment Document score (RAD score) were extracted. The RAD score is used by Care Inspectorate inspectors and managers to inform inspection regimen; homes are categorised into low risk, medium risk and high risk, based on inspections,
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complaints, enforcement cases and updates around service quality.4 The Integration Authority in which the home is located were also extracted (Integration Authorities are joint NHS-local authority bodies responsible for integrated care). The Care Inspectorate supplied an additional variable for use in this work defining whether a service provides registered nursing care to service users.
Identifying COVID-19 tests in care homes To define care home outbreaks, it was necessary to identify tests performed on care home residents and allocate them to individual care homes. There is no national record of all care home residents and thus care home residency had to be derived. We used address matching, fields within ECOSS (specimen location, origin, category and clinical details) and data linkage to CHI extracts from March and August to allocate them to individual services. All positive tests for COVID-19 obtained in NHS Scotland before 30 June were extracted from the Electronic Communication of Surveillance in Scotland (ECOSS) database. This includes tests taken by the NHS and those analysed in the UK Government Lighthouse Laboratories. There were 24,331 tests with a valid CHI number. A minority (194, 0.8%) had no address or postcode and 14% had a postcode, but no first line of address recorded. The following steps were taken to identify tests on care home residents: 1. Review of all tests where specimen origin was recorded = Residential care home 2. Review of all tests where Lighthouse Test location = care home 3. Review of address fields within the file, matching to care home addresses 4. Review of all records where CHI Institution code 93 or 98 were present in March 2020 CHI register 5. Match to August CHI file to identify those living in care homes and the date their address changed Two further steps were taken 1. Postcode check comparing specimen postcode to list of all care home postcodes to ensure no matches missed on initial review 2. Re-review of all specimens in which the Category = PHI Care – Public Health Investigation, Care Home, matched to CHI extracts (note 30% of positive tests have no category associated with them, hence using this as a secondary check rather than a primary source) Tests were eligible for inclusion in the analysis if they were performed between 1 March and 21 June (selected to reflect period of 21 days after last hospital discharge) and were obtained on a resident while in the care home (tests obtained while a resident was in hospital were excluded). There were 3,278 care home residents with one or more positive tests identified, where the test had been done in a care home (some residents were tested more than once). These 3,278 residents lived in 348 of the 1,084 care homes, which were therefore defined as having a laboratory confirmed outbreak. The date of the first positive test in the care home was used to define the start date of each of these 348 laboratory confirmed outbreaks.
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Mortality data Mortality data, for analysis in section 2, was obtained from National Records of Scotland of deaths from 2 March to 21 June 2020. All deaths in care homes were identified using institution codes and these were then mapped to the CSNumber and UPRN of each care home in the Care Inspectorate list of registered services. This used postcode matching and manual allocation, including where care homes shared postcodes or postcodes were incorrect. COVID-19 related mortality was defined by any mention on the death certificate of ICD-10 codes U071 (COVID-19 virus identified on laboratory test) or U072 (Clinical COVID-19 diagnosed on other clinical features), using any of the 10 cause of death fields. This includes confirmed and suspected COVID-19 and is consistent with national reporting of COVID-19 deaths (https://www.gov.scot/publications/coronavirus-covid-19-data-definitions-and-sources/) Data are reported based on date of death, rather than date of death registration. Between 2 March and 21 June, there were 5,768 deaths in 774 care homes, 1,915 (33%) were COVID-19 related deaths.
Relationship between care home size and discharges The relationship between the number of beds in each care home and the total number of discharges they received from hospital during March to May 2020 was examined. We explored whether these two factors were correlated or associated with each other (termed collinear) and whether any relationship between these factors affects their ability to predict an independent outcome, in this case, care home outbreak of COVID-19. This was assessed using a statistical approach called the variance inflation factor (VIF). The VIF describes what percentage the variance is inflated for each coefficient. The result for number of care home beds and number of hospital discharges, was 1.825. This indicates that there is some correlation but not high correlation between the two factors. It is therefore reasonable to examine them in the same statistical model.
Survival modelling methods
A Cox proportional hazards regression model was used to estimate the risk factors for outbreaks of COVID-19 in care homes following hospital discharges in Scotland. These models are used to estimate time to an event, in this case, the first non-hospital positive test for COVID-19 in a care home resident, using tests from 1 March to 21 June 2020. Predictors of interest obtained from the Care Inspectorate include the size of the care home (number of registered places), whether there was provision for nursing care, the homes’ Risk Assessment Document (RAD) Score, subtype and sector. We incorporated the integration authority in which the home is registered as a proxy for the prevalence of COVID-19 in the local
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area. These predictors were assumed to have a stable effect on risk of outbreak over the analysis period. As the occurrence and risk associated with hospital discharges is not stable over time, we further included risk periods from hospital discharges into the model, as a time-dependent covariate. Data on discharges were available from 1 March to 31 May 2020, and used to define periods of ‘at-risk’ for each home. A baseline at-risk period was defined as the 7 to 21 days following a discharge from hospital to care home, and therefore a home could potentially move between the at-risk and not-at-risk periods over time. The 7 to 21 day post-discharge risk period was established by analyses conducted by Public Health Wales5, who included sensitivity analyses exploring a range of plausible exposure windows (lag between 0 and 10 days post discharge, at-risk periods lasting 7, 14 and 21 days). Multiple risk periods in each care home following a discharge are included in the model, and could be non-overlapping or cumulative (See Figure 4). When a home has its first positive non-hospital test, the follow-up time for that home is stopped, while homes which do not experience an outbreak are censored on 21 June 2020. Any outbreaks occurring during an at risk window are therefore recorded as being associated with the discharge event.
Figure 4: Pictorial demonstration of risk periods within a care home. (A) one discharge, no outbreaks, (B) two separate, non-overlapping discharge risk periods, (C) Two discharges, resulting in a cumulative risk period, and (D and E) describe homes experiencing an outbreak, both within and outwith a risk period.
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Assumptions of proportional hazards were tested, and met with non-significant global p-value (p = 0.058) for time trends in the residuals.
Hazard ratios are interpreted as the risk of outbreak, given that the home has survived up to a specific time point, and are interpreted in our model with reference to a baseline category. A hazard ratio of 1 is interpreted as the factor having a null effect on the risk of outbreak, while a ratio of greater than 1 indicates that the predictor is associated with an increased risk of outbreak. Hazard ratios are presented with 95% confidence intervals which are the range in which we are confident that the true value of the hazard ratio lies within. The size of the range is dependent on the number of events which occur within each category, and so low powered analyses will have wider intervals. Hazard ratios were estimated for each predictor variable separately (univariate models), and combined (adjusted). Univariate models measure associations between the event (outbreak) and a singular predictor variable in isolation, whilst the adjusted models allow for confounding factors to be accounted for. All analyses were conducted in R3.6.1, using the Survival library6. Statistical significance was assessed at the 5% level.
Extending the analyses to allow for types of discharge In Scotland, we are able to link tests conducted within a hospital admission period to the care home receiving the discharge. The analysis was therefore extended to allow for differing levels of risk period to be ascribed to each home: following a discharge where the person had tested negative, had not been tested during admission, or their last test prior to discharge was positive. Figure 5 illustrates overlapping risk periods leading from three discharges: the first is discharged negative, the second is discharged positive, and third is untested during their admission.
Figure 5: Categorised risk periods according to test status at discharge
We assumed that the risk of outbreak associated with a positive test prior to discharge is the highest, followed by those discharged untested, and finally the lowest hazard of outbreak would be following a discharge with a negative test. In Figure 5, the second discharge was for a person who had tested positive, and therefore the risk period is dominated by their full 14 day risk period, and bookended with the lower levels of negative and untested risk periods.
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Section 3 – Additional analysis including Genomic Sequencing
Since the publication of the original report in October 2020, further analysis has been performed to explore specific aspects in detail including: • classification of discharges based on pre-hospital residency (where people lived before they were admitted to hospital); • analysis of the outcomes within 30 days of hospital discharge (all-cause mortality, COVID- 19 mortality and COVID-19 infection) of all those who were discharged; and analysis of those people whose last positive test before discharge was positive (including relationship with care home outbreaks). Collaboration with the Public Health Microbiology Team within Public Health Scotland enabled the clinical data on people whose last positive test before discharge was positive to be combined with viral genomic sequencing data (where available). The genomic data has allowed analysis of the specific samples of those discharged from hospital and the samples from the care home they were discharged-to, to be compared to understand more about patterns of infection transmission and relationships between hospital discharge and care home outbreaks.
How individual discharges were assigned pre-hospital residency Hospital discharges to care homes include those returning to their previous care home after in- hospital care, those moving into a new permanent home, and those moving in to a care home on a temporary basis (for example, for rehabilitation or while waiting for additional care to be provided in their own home). People are therefore not just “discharged to” care homes. There is a flow of people in both directions to and from care homes and hospitals. Of the 5,198 discharges from hospital for 4,804 people, we were able to identify the specific Scottish care home each person was discharged to in all but 13 discharges (11 people), and were therefore able to classify each of these discharges to care homes using the definitions outlined below. Where a person has multiple hospital admissions, this classification is based on their most recent discharge
Returned to previous care home - as defined using SMR postcode match to Care Home postcode, use of admitted/transferred from code 25 (admitted/transferred from care home) in SMR01/04 records and CHI Institution Flag address, with date of address change before date of hospital admission.
New care home placement - defined using CHI Institution Flag address, with date of address change after hospital discharge, retaining those who were placed in a care home in August CHI extract Temporary care home placement - defined using returns from Health and Social Care Partnerships.
Unclear type of discharge - are those identified as discharged to care homes, but whose registered address in CHI is not the same as the care home they were discharged from hospital to. This will include people who died before their registered address in CHI was updated or who
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were discharged to a care home on a temporary basis, as their registered address would not change. Of note a quarter of those in the unclear group died (before 30 June) and it is likely they were new care home admissions whose CHI address was not updated before death.
Care home of discharge not known - Six cases of discharges where NHS Boards could confirm discharge was to care home, but no location could be provided or derived by linkage and seven where person was discharge to a care home in England
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Glossary Community Health The Community Health Index is a register of all patients in NHS Index (CHI) Scotland. Care Home A Care Home as defined by the Care Inspectorate list of Adult Care Home services, available from: https://www.careinspectorate.com/index.php/statistics-and- analysis/data-and-analysis Confidence Interval Confidence intervals (CI) are a measure of the degree of certainty of a result. The upper and lower CI are a range of values that are likely to include the ‘true’ value with a certain degree of confidence (often 95% - i.e 5% chance of error). The wider the CI, the less accurate the result is, and it is influenced by the size of the sample/population you are measuring. Delayed Discharge A delayed discharge is a hospital inpatient (aged 18 and over) who has been judged clinically ready for discharge by the responsible clinician in consultation with all agencies involved in planning that person’s discharge, and who continues to occupy a bed beyond the ready for discharge date, which is the date on which a hospital inpatient is clinically ready to move on to a more appropriate care setting. Discharge A hospital discharge marks the end of an episode of care. Discharges include deaths, transfers to other specialties/significant facilities and hospitals, and discharges home or to other regular place of residence. For this analysis, those with discharge of death were excluded. ECOSS Electronic Communication of Surveillance in Scotland. The ECOSS system captures lab results from diagnostic and reference laboratories for analysis by Health Protection surveillance teams. It's a national tool for monitoring organisms, infections and microbial intoxications that are of clinical or public health importance. Emergency Admission An emergency admission occurs when, for clinical reasons, a patient is admitted to hospital unexpectedly at the earliest possible time. This might be after a visit to a doctor, emergency department or calling an ambulance. Episode An SMR episode is generated when a patient is discharged from hospital but also when a patient is transferred between hospitals, significant facilities, specialties or to the care of a different consultant.
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Geriatric Long Stay Inpatients admitted to and discharged from facilities for Long Term Care of the Elderly. Hazard Ratio The relative risk of an event compared to a reference category. A hazard ratio of more than one means that the risk is increased compared to the reference category. A hazard ratio of less than one means the risk is decreased. Inpatient A patient is termed an inpatient when they occupy a staffed bed in a hospital and either remains overnight (whether intended or not), or is expected to remain overnight but is discharged earlier. An inpatient’s admission can be an emergency, elective or a transfer. Length of Stay This is the total number of days that a patient spends in hospital during a continuous period of time in hospital. Mean Age The mean age is calculated by summing the ages of all discharges from hospital to care homes and dividing by the number of discharges to care homes. Outbreak Defined as a care home where one or more residents tested positive for COVID-19 based on a test taken in the care home. SMR Healthcare data for individual patients is collected as a series of Scottish Morbidity Records (SMR). The record type denotes the general type of healthcare received during an episode and/or the nature or status of the patient. e.g SMR01 – General/Acute, SMR04 – Mental Health. Specialty A specialty is defined as a division of medicine or dentistry covering a specific area of clinical activity.
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Contact Fiona MacKenzie Service Manager
Phone: 07500 854 574 Email: [email protected]
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Further Information Further information and data for this publication are available from the publication page on our website.
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Appendices Appendix 1 – Comparison of Hospitals in SMR01 and RAPID
Hospitals in SMR01 not in RAPID Code Hospital
A101H ARRAN WAR MEMORIAL HOSPITAL
A103H AYRSHIRE CENTRAL HOSPITAL
A110H LADY MARGARET HOSPITAL
A208H BIGGART HOSPITAL
A215H EAST AYRSHIRE COMMUNITY HOSPITAL
A216H GIRVAN COMMUNITY HOSPITAL
A217H WOODLAND VIEW
C306V ARDGOWAN HOSPICE
C413V ACCORD HOSPICE
E006V WASHINGTON HOSPITAL
G412V ROSS HALL HOSPITAL
G414V PRINCE & PRINCESS OF WALES HOSPICE
G502V GLASGOW NUFFIELD HOSPITAL
G583V MARIE CURIE HOSPICE
G584V ROBIN HOUSE, CHILDREN'S HOSPICE ASSOCIATION SCOTLAND
G604V PRINCE AND PRINCESS OF WALES HOSPICE
H239V HOWARD DORIS CENTRE
L305H UDSTON HOSPITAL
L330V CARRICKSTONE HOUSE & DAY HOSPITAL
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N101V ALBYN HOSPITAL
N498V AUCHTERCRAG CARE HOME
S102H BELHAVEN HOSPITAL
S108H EDINGTON COTTAGE HOSPITAL
S113H ROODLANDS GENERAL HOSPITAL
S114H ROYAL VICTORIA HOSPITAL
S121K ST COLUMBA'S HOSPICE
S124V MURRAYFIELD HOSPITAL
S201H ASTLEY AINSLIE HOSPITAL
S203K FAIRMILE MARIE CURIE CENTRE
S209H LIBERTON HOSPITAL
S316H PRINCESS ALEXANDRA EYE PAVILION
S318H MIDLOTHIAN COMMUNITY HOSPITAL
S406C THE EDINBURGH CLINIC
T104V FERNBRAE HOSPITAL
T317V RACHEL HOUSE CHILDREN'S HOSPICE
V103V STRATHCARRON HOSPICE
V105H BO'NESS HOSPITAL
V213V BMI KING'S PARK HOSPITAL
V216H CLACKMANNANSHIRE COMMUNITY HEALTHCARE CENTRE
W102V BETHESDA HOSPICE
Y177C MOUNTAINHALL TREATMENT CENTRE
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Hospitals in RAPID not in SMR01 Code Hospital
B103H THE KNOLL HOSPITAL
B105H HAWICK COMMUNITY HOSPITAL
B114H KELSO HOSPITAL
B118H HAY LODGE HOSPITAL
B129H MELBURN LODGE
B130H HUNTLYBURN HOUSE
C403H DYKEBAR HOSPITAL
F710H RANDOLPH WEMYSS MEMORIAL HOSPITAL
F711H WHYTEMANS BRAE HOSPITAL
F712H STRATHEDEN HOSPITAL
F810H LYNEBANK HOSPITAL
G101Z NHS LOUISA JORDAN (COVID-19)
G111H PARKHEAD HOSPITAL
G302H LEVERNDALE HOSPITAL
G505H GARTNAVEL ROYAL HOSPITAL
G614H ORCHARD VIEW
H223H NEW CRAIGS HOSPITAL
N111H HYPERBARIC CENTRE
T115H STRATHMARTINE HOSPITAL
T317H CARSEVIEW CENTRE
T319H WHITEHILLS HEALTH AND COMMUNITY CARE CENTRE
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T322H KINGSWAY CARE CENTRE
T324H DUDHOPE YOUNG PEOPLES INPATIENT UNIT
Y104H DUMFRIES & GALLOWAY ROYAL INFIRMARY OLD
Y111H GARRICK HOSPITAL
Y126H ACORN HOUSE
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Appendix 2 – References
1. Burton J.K, Marwick C.A, Galloway J, Hall C, Nind T, Reynish E.L, Guthrie B: Identifying care-home residents in routine healthcare datasets: a diagnostic test accuracy study of five methods (P.14,P.23)
2. Addressing people in Scotland - linking CHI and UPRN : Scottish Centre for Administrative Data Research https://www.scadr.ac.uk/our-research/creating-new-datasets/addressing-people-scotland-linking-chi-and-uprn (P24)
3. Care Inspectorate. Datastore 2020. Available from: https://www.careinspectorate.com/index.php/publications- statistics/93-public/datastore (P.24)
4. Care Inspectorate. Risk Assessment 2020. Available from: https://www.careinspectorate.com/images/documents/148/Risk%20Assessment%20%E2%80%93%20Inform ation%20for%20Care%20Service%20Providers.pdf. (p.25)
5. Emmerson C, Adamson JP, Turner D, Gravenor MB, Salmon J, Cottrell S, et al. Risk factors for outbreaks of COVID-19 in care homes following hospital discharge: a national cohort analysis. https://www.medrxiv.org/content/10.1101/2020.08.24.20168955v1 .(p26)
6. R survival Library ://cran.r-project.org/web/packages/survival/index.html (p28)
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Appendix 3 – Publication Metadata
Metadata Indicator Description Publication title Discharges from NHSScotland Hospitals to Care Homes Validated Register Methodology revised 21 Description This publication outlines the methodological approach taken to create the validated register of discharges to care homes, and the statistical methods employed to examine COVID-19 outbreaks in Care homes. Theme Health and Social Care Topic Hospital Discharges and Care Homes Format PDF, Excel Data source(s) SMR01,01E (acute and geriatric long stay), SMR04 (psychiatry), RAPID (preliminary inpatient records), Delayed Discharges, Patient Transport Service (PTS), CHI (institution flag), National Records of Scotland (deaths), Care Inspectorate list of care homes, HSCP list of temporary placements Date that data are acquired September 2020 Release date 28 October 2020 revised 21 April 2021 Frequency One off report Timeframe of data and Discharges between 1 March and 31 May 2020, as at September 2020 timeliness Continuity of data N/A Revisions statement N/A Revisions relevant to this Further quality assurance identified 6 discharges (3 individuals) that were not publication discharged to care homes, these records were removed from the dataset Concepts and definitions Please see the Glossary section within this report and the excel data tables which accompany this publication. There is also a detailed methodology document to accompany this publication. Relevance and key uses of To report on the number of discharges to care homes during the first wave of the statistics the COVID-19 pandemic in Scotland, and the response to changing COVID- 19 testing practices and policy around discharges to care homes. To examine whether discharges from hospital to care homes had any impact on COVID-19 outbreaks in care homes Accuracy Please refer to the data validation section of the methodology report Completeness Please refer to the data validation section of the methodology report Comparability This is a one off publication using unique linkage of multiple datasets, so is not comparable with other published data section 2 statistical methodology similar to Public Health Wales report Accessibility It is the policy of Public Health Scotland to make its web sites and products accessible according to published guidelines. Coherence and clarity Measures to enhance coherence & clarity within this report include: explanatory table/chart notes, minimal use of abbreviations/abbreviations explained in text and notes on background and methodology. Value type and unit of Figures are shown as numbers or percentages measurement Disclosure Disclosure control methods have been applied to the data in order to protect patient confidentiality, therefore some figures may not be additive. The PHS protocol on Statistical Disclosure Protocol is followed.
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Official Statistics Management statistics designation UK Statistics Authority Not been put forward for assessment Assessment Last published not applicable Next published not applicable Date of first publication 28 October 2020; Revised 21 April 2021 Help email Date form completed 19/04/2021
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Appendix 4 – Early access details Pre-Release Access Under terms of the "Pre-Release Access to Official Statistics (Scotland) Order 2008", PHS is obliged to publish information on those receiving Pre-Release Access ("Pre-Release Access" refers to statistics in their final form prior to publication). The standard maximum Pre-Release Access is five working days. Shown below are details of those receiving standard Pre-Release Access.
Standard Pre-Release Access: Scottish Government Mental Health and Social Care Directorate NHS Board Chief Executives NHS Board Communication leads Chief Officers of Integrated Joint Boards formed under the Public Bodies (Joint Working) (Scotland) Act 2014
Early Access for Management Information These statistics will also have been made available to those who needed access to ‘management information’, ie as part of the delivery of health and care: Care Inspectorate
Early Access for Quality Assurance These statistics will also have been made available to those who needed access to help quality assure the publication: NHS Boards Scottish Government Mental Health & Social Care Directorate Appendix 5 – PHS and Official Statistics About Public Health Scotland (PHS) PHS is a knowledge-based and intelligence driven organisation with a critical reliance on data and information to enable it to be an independent voice for the public’s health, leading collaboratively and effectively across the Scottish public health system, accountable at local and national levels, and providing leadership and focus for achieving better health and wellbeing outcomes for the population. Our statistics comply with the Code of Practice for Statistics in terms of trustworthiness, high quality and public value. This also means that we keep data secure at all stages, through collection, processing, analysis and output production, and adhere to the ‘five safes’.
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