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Dr Don Berwick President & CEO, IHI Prof Bernard Crump NHS Institute for Innovation & Improvement Dr Ross Wilson Chair, Strategic Advisory Board International Forum. Local Improvement Clinic.

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local improvement clinic
Dr Don Berwick

President & CEO, IHI

Prof Bernard Crump

NHS Institute for Innovation & Improvement

Dr Ross Wilson

Chair, Strategic Advisory Board International Forum

Local Improvement Clinic

To Improve the Prescription of Osteoporosis Treatment in Post-Menopausal with a Hip or Vertebral Fracture

Kate Cotter, Jennifer Dempsey, Cheryl Baldwin

Central Coast Health

mission statement
Mission Statement
  • To Improve the prescription of osteoporosis treatment in post-menopausal with a hip or vertebral fracture
  • Triple therapy osteoporosis treatment
    • includes Calcium, Vitamin D and a Bisphosphonate.
  • Improve prescription from 25% to 100% for all appropriate women in 3 months
  • Longer term goal to reduce further osteoporotic fractures
team members role
Team members & role
  • Project team members with fundamental knowledge and who worked on the project:
    • Kate Cotter: Ortho-geriatric registrar
    • Jennifer Dempsey: CNC Medicine
    • Cheryl Baldwin: CNC Ortho-geriatric
    • Consultation with pharmacy department, orthopaedic clinical teams
evidence for there being a problem worth solving
Evidence for there being a problem worth solving

Post-Menopausal Osteoporotic Fractures Are:

  • Common
  • Proven therapies to reduce further fractures
  • BUT
  • Evidence-based guidelines are poorly implemented
a common problem australia
A Common Problem - Australia


  • In 2001 2 million people were estimated to be affected by osteoporosis, three-quarters of whom were women.
  • 20,000 hip fractures per year, and this is estimated to increase by 40% each decade.
  • Every 8.1 minutes someone in Australia is admitted to hospital with an osteoporotic fracture and this will increase to every 3.7 minutes by 2021 if nothing is done.
evidence for there being a problem worth solving1
Evidence for there being a problem worth solving

Proven therapies to reduce further fractures

  • Supplementation with Calcium and Vitamin D has been shown to reduce hip fractures by 43%
  • National Osteoporosis Foundation Guidelines state that providing adequate daily Calcium and vitamin D is a safe and inexpensive ways to help reduce fracture risk
flow chart of process
Flow Chart of Process


to Rehab

in emergency department
In Emergency Department
  • Routine serum calcium measurement in all patients presenting to Emergency Department with a low impact fracture
orthopaedic ward
Orthopaedic Ward
  • Orthogeriatric orientation provided to all RMO’s at start of new term
    • Every patient with a low impact fracture has osteoporosis
    • Encourage charting of “Triple Therapy”
      • Caltrate 1200mg daily
      • Ergocalciferol 1,000 units daily
      • Alendronate 70mg weekly (to commence on discharge)
    • If on a bisphosphonate at admission it must be charted on drug chart as “recommence on discharge”
    • Importance of putting date of X-ray on discharge summary (required for special authority script)
orthopaedic ward1
Orthopaedic Ward
  • Increase awareness at staffing level
    • Participation in osteoporosis week
    • Poster in orthopaedic ward, orthopaedic outpatient clinic and emergency department
    • Incorporating osteoporosis treatment into existing nursing pathway for fractured NOF
orthopaedic ward2
Orthopaedic Ward
  • Increasing awareness at patient level
    • Orthogeriatric team providing verbal and written information to patient about osteoporosis and its treatment
at discharge
At Discharge
  • Copy of dictated letter from Orthogeriatric Registrar listing diagnosis of osteoporosis and recommended treatment sent electronically to GP
fracture clinic
Fracture Clinic

Attention: All Fracture Clinic Staff

Patient with minimal trauma fracture?

The Bone Protection Project has been implemented to ensure ALL patients presenting with a minimal trauma fracture are correctly managed and investigated for underlying osteoporosis.


Please give the patient a G.P. referral letter.

Use stamp provided to record letter given to patient.

run chart

Percentage on Treatment at Discharge

run chart1

Percentage of those NOT on treatment, who had treatment commenced

showing restraint


Nigel Dounton

Doris Kinnaird

Sam Alfred

Adrian Jackson

Central Northern Adelaide Health Service

mission statement1
Mission Statement
  • The Aim is to Reduce by 60% Within

Six Months the Use of Emergency Department Initiated Physical/Mechanical Restraint for Behaviourally Disturbed Patients.

team members
Team Members
  • Nigel Dounton – Mental Health Nurse ED Queen Elizabeth Hospital
  • Doris Kinnaird - Mental Health Nurse ED Lyell McEwin Hospital
  • Sam Alfred – Consultant ED Royal Adelaide Hospital
  • Adrian Jackson - Mental Health Nurse ED Royal Adelaide Hospital
  • Central Northern Adelaide Health Service
guiding committee
Guiding Committee
  • Dr Darryl Watson - General Manager Early Intervention and Acute Services Mental Health
  • Dr James Hundertmark - Director Acute Service Mental Health QEH (CHAIR)
  • Dr Geoff Hughes - Director Emergency Department Royal Adelaide Hospital
  • Neville Phillips - Nursing Director Early Intervention and Acute Services Mental Health
  • Suzanne Heath - Manager Service Development Mental Health Directorate
  • Adrian Jackson - Project Officer, Early Intervention and Acute Services Mental Health
  • Lynne James - Senior Program Planning Officer Acute Services Mental Health Directorate

High Order Flowchart

Presentation to Emergency Department

Admission into ED

Behaviour Escalates

Treatment with Settling of Behaviour

Discharge, Transfer or Admission


Entering ED



SAAS can Request Restraint Team Standby on Arrival

If Not Behaviourally Disturbed – Possible Waiting Room/Cubicle

Patient’s Behaviour Escalates


Clerk for A9 and Old Files


If Behaviourally Disturbed – Safe Room/Resus

Nursing/Medical Staff Arrive/Present


If Affected by Drug Alcohol – Longer Waiting Time to Detox


Intervention Minimal Effect, Behaviour Escalates

Security Called



Monitoring Process – Observations for Restrained Patient

AssessmentProcess To Determine Best Treatment

If Restraint – 33# Call

If De-escalation is Not Effective

Medication Given

And/or Seclusion Room And/or Shackles

Behaviour De-escalates

Security Arrives

If De-escalation is Effective


De-escalation Can Occur at Any Point


Medical Assessment Completed if Necessary


Decision to Admit, Discharge etc

Discharge from ED

Destination Can Delay discharge From ED

More Formal Psychiatric Assessment

Med & Psych May Disagree Who is Responsible for Patient



cause and effect diagram1
Cause and Effect Diagram

Patient Factors

Perceived Neglect





Psych illness


Medical illness


Escalation Requiring Restraint


Seclusion room location

Psych assessment

Medical assessment

High stimulus

Pre contact wait


Interventional Delays

intervention plan protocol etc
Intervention - plan, protocol etc
  • Weeks 1 – 3 (Intervention A)
    • Identify patients who are becoming agitated but are not yet violent or requiring restraint. (Early warning signs of agitation discussed with and printed out for staff)
    • Offer fluids, sandwich etc and communicate with patient re issues of immediate concern.
    • Outline normal processes involved in ED assessment to patient
    • Place patient label in one of the study book located at Triage and Area A & B.
  • Weeks 4 – 7 (Intervention B)
    • Early administration of Lorazepam 1mg, generally initiated by nursing staff. If necessary repeat dosing with input from medical staff.
    • Place patient label in one of the study books as previously described.
data sheet with results in the three key areas
Data sheet with results in the three key areas
  • The initiation of intervention was recorded in a ‘study book’ placed at three locations in the ED. The patients ‘identifying label’ was stuck in the book and a brief note recorded next to their name.
  • Data on urgent restraint callouts was collected by the security firm responsible, and compiled by the Royal Adelaide Hospital Safety and Quality Unit.
  • Results in three key areas are:
    • There were no additional costs above those of usual treatment as medication costs and consumables are already budgeted for.
    • The consumer representative on the steering council was unavailable. There were no complaints voiced by patients in the ED. Staff were universally supportive at weekly review sessions.
    • No adverse events related to the interventions were identified during review of case notes for enrolled patients
restraint as overall of patient numbers before during study period
Restraint as Overall % of Patient Numbers Before & During Study Period

Intervention 1

Intervention 2


strategies for sustaining improvement
Strategies for Sustaining Improvement
  • Formalise the ED/Mental Health protocol for the assessment of the agitated patient to include both of the study interventions
    • Regular staff feedback on the process has already been instituted on a weekly basis and will continue until entrenched
    • The RAH drug committee has been approached to ratify nurse initiation of the Lorazepam protocol
    • An ongoing review process screening for complications has been put in place
strategies for spreading
Strategies for Spreading
  • Support has been secured from Mental Health and Emergency Medicine hierarchies to adopt the same approach on an area wide basis
  • Team members from various institutions will be instrumental in implementing the process within their own institutions
  • The next meeting of the steering committee is scheduled for November.

Mission Statement

At Level 11 of Tan Tock Seng Hospital, the peripheral iv cannula phlebitis rate will be reduced by 50% in 3 months


Team Members & Roles

1. SNC Margaret Soon

2. NO Wong Siao Pin

3. SN Goh Mei ChernStaff from unit

4. AN Widarni

5. NE Prema BalanTeaching of staff

6. NE Pua Lay Hoon

7. Dr Benjamin TanDr covering L11


Evidence for there

being a problem worth solving

Point Prevalence Phlebitis rate done on May 31 2002 is 26.3%.

  • International average = 15%
  • Institutional average = 11.8%
  • National average = 8.3%

Repeated point prevalence rate in the unit on 28 Nov 2002 is 25%

intervention s plan protocol etc
Intervention(s) - plan, protocol etc
  • Compile, communicate & educate

a. antibiotics information chartSpeed of administration & proper dilution

b. Drugs not for IV administration

c. Flushing of line according to recommendations

d. Proper restraint of restless patients

2. Audit compliance to recommendations & phlebitis rate

strategies for sustaining holding the gains
Strategies for Sustaining(holding the gains)
  • Involve all grades of HCWs within the department
  • Ownership of the problem/issue
  • Random point prevalence audit for comparison

Strategies for Spreading

  • Repeat hospital wide point prevalence study (20 Jan 04)
  • Target at the next area with problems in peripheral phlebitis