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Reducing cardiac arrests in the Acute Admissions Unit : A Quality Improvement Journey. Dan Beckett Consultant in Acute Medicine Forth Valley Royal Hospital SPSP Fellow. Situation. Combined surgical and medical admissions unit 46 beds (but elastic walls...)

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reducing cardiac arrests in the acute admissions unit a quality improvement journey

Reducing cardiac arrests in the Acute Admissions Unit :A Quality Improvement Journey

Dan Beckett

Consultant in Acute Medicine

Forth Valley Royal Hospital

SPSP Fellow

situation
Situation

Combined surgical and medical admissions unit

46 beds (but elastic walls...)

Admits 1500 patients per calendar month

In July 2011 moved from Stirling Royal Infirmary to Forth Valley Royal Hospital

background
Background

Stirling Royal Infirmary, 2010

assessment
Assessment

AAU morbidity and mortality meetings established in 2010

Failure to rescue

Recognition

Response

Resuscitation attempts undertaken on patients with terminal illness

Limited learning from adverse outcome

recommendation
Recommendation

Aim statement developed

FMEA (Failure Modes Effects Analysis) undertaken

Driver diagram developed

Structured response to the deteriorating patient

Improved end of life care

Improved learning from adverse events

Measurement plan agreed

Process, Outcome and Balancing measures

Use of data for improvement vs data for scrutiny

Sharing of data with board, staff, patients and relatives

slide6

Structured response tested

2.8/1000 to 0.8/1000 admissions = 72% reduction

Safety meetings start

Poor patient flow from AAU starts

Move to FVRH

slide7

Structured response tested

Safety meetings start

Poor patient flow from AAU starts

Move to FVRH

use of data to soothe the naysayers
Use of data to soothe the naysayers

‘The reduction in rate of cardiac arrests in AAU has purely been achieved by moving patients out of AAU earlier so they have their cardiac arrests elsewhere...’

‘The reduction in rate of cardiac arrests in AAU is due solely to patients having DNACPR decisions made earlier in their admission’

slide10

Safety initiatives started

Move to ward based team at FVRH

17% DROP IN 30 DAY MORTALITY

SINCE MOVING TO FVRH

=

16 LIVES SAVED PER MONTH

SIGNIFICANT SHIFT IN MORTALITY

slide11
HSMR

HSMR October 2006 – September 2012 (19.5% reduction)

slide12

Safety initiatives started

Move to ward based team at FVRH

slide13

Move to ward based team at FVRH

Safety initiatives started

importance of data and measurement
Importance of data and measurement

Use of data for improvement

Sepsis 6

Compliance with structured response checklists

Use of data for scrutiny

Cardiac arrests

Mortality

Sharing of data

acknowledgements
Acknowledgements

Sharon Oswald

Monica Inglis

Iain Wallace

SPSP

The whole AAU multidisciplinary team!

daniel.beckett@nhs.net

@djbeckett

slide18

Background - Haemophilia

  • A severe inherited X-linked bleeding disorder
  • Untreated males suffer spontaneous bleeding in joints, soft tissues and brain
  • Treatment strategies: ‘on demand’ or ‘prophylaxis’
  • ‘On demand’ patients may suffer 2-6 bleeds per month

-> chronic joint damage

slide19

Background

  • Six Haemophilia Treatment Centres in Scotland [2 west + 4 east]
  • Recombinant coagulation products are managed as part of the risk share scheme: total cost for 2012/13 was £24.5million
  • UK Annual Report 2009-10

Identified geographical variation in

mean annual coagulation product use

per patient with severe haemophilia

slide20

Background

  • A review was commissioned by Board Chief Executives’ in 2011 to assess clinical practice and product usage across the six centres
  • Review highlighted:
    • Subtle variation in clinical practice
    • No standard way to measure clinical outcomes or quality of care
  • Recommendations:
    • Developmental of standardised protocols
    • Development of key performance and clinical outcome indicators
slide21

- develop key performance and clinical outcome indicators

  • produce a clinical audit form to capture dataset in relation to the indicators

Centres worked together to

- produce standard policies and protocols in relation to dosing, stock holding and management

slide22

Performance & Clinical Outcome Indicators

Largely confined to treatment of severe haemophilia

  • Performance indicators
    • % attending for 6-month review
    • Uptake of home treatment & home delivery of product
    • % severe patients receiving ‘standard’ prophylactic coagulation factor treatment
    • % patients receiving an excess amount of coagulation product per Kg in 6m
  • Outcome indicators
    • Patients with spontaneous major bleeds
    • Days missed from school/work because of bleeds
    • Patients on standard prophylaxis remaining bleed free
    • Patients having had joint replacement or arthrodesis
slide23

Systems & processes adopted in clinical practice

Policies and Protocols have been implemented in all centres

Clinical Audit Forms are completed for moderate and severe users of recombinant products 6-monthly from January 2012

Data is recorded in clinics based on information provided by patients

The Data has been recorded on the Clinical Audit System

Allowing comparative clinical audit across the Haemophilia Centres

slide25

% severe patients receiving standard prophylaxis

% patients with a spontaneous major bleed

slide26

% severe patients losing >5 school or work days as result of bleeding

% severe patients free of spontaneous bleeds

improving quality and effectiveness of care
Improving quality and effectiveness of care

Policies and Protocols have driven changes in practice

- formalised processes and ensures a standardised approach across all centres

Clinical Audit reports:

- demonstrate patient outcomes

  • allows centres to review and discuss the most clinically appropriate and effective care for patients
    • Scottish peer review meetings established to discuss ‘exception cases’
  • highlight where targeted work is required to drive improvements in clinical care
just say no
Just say NO!
  • ..............it’s not affordable
  • ..............it’s not possible
  • Difficult in a “free” healthcare system
  • Politically damaging
  • Withdrawal of what is already available is unpopular with patients and doctors.
  • Can’t just say NO!!!
priority setting which one
Priority setting...... Which one?
  • Patient- did we ask?? Most important?!??!
  • Financial- don’t need to ask!!
  • Quality- what questions to ask?
  • Outcomes- Was the question biased?
  • Many more.................... -Croydon list -McKinsey
lothian rilcv process
Lothian RILCV process.
  • Identify area of interest
  • Contact clinicians and seek “buy in”
  • Assessment of health intelligence (HIU and ISD, BQBV dashboard)
  • EVIDENCE REVIEW -efficacy -cost effectiveness -controversy in literature -impact of change
  • ENGAGE STAKEHOLDERS
  • Develop plan
  • Enact and review plan
slide35

Crude Rate of Cataract Interventions by NHS Board of

residence (all) per 1,000 population, 2008/09 - 2010/11

cataract rilcv process
Cataract RILCV process.
  • Identify area of interest- Cataract
  • Contact clinicians and seek “buy in” – Oph & optoms
  • Assessment of health intelligence – 4500 operations, half coded, 35% second eye
  • EVIDENCE REVIEW - impact of threshold - value of 2nd eye surgery
cataract rilcv process1
Cataract RILCV process.
  • Identify area of interest- Cataract
  • Contact clinicians and seek “buy in” – Oph & optoms
  • Assessment of health intelligence – 4500 operations, half coded
  • EVIDENCE REVIEW - impact of threshold - value of 2nd eye surgery
  • ENGAGE STAKEHOLDERS –oph, other boards, RNIB, E&D unit,
  • Develop plan – Set threshold at driving test level plus other “soft” measures run as a shadow audit
  • Enact and review plan – 5% reduction in referrals, 0.4% reduction surgeries
over utilisation
Over-utilisation
  • Quicker to discuss TP than discussion of no treatment
  • Quicker to order a scan than history and exam
  • In breast cancer no benefit to follow up with tumour markers (Rosselli JAMA, GIVIO study JAMA)
  • Many examples of futile care in last weeks and days of life (studies suggest up to one third of cancer care costs)
  • In 2010 the US Patient Protection and Affordable Care Act established a Patient Centred Outcomes Research Institute
improving efficiency and value in cancer care
Improving efficiency and value in cancer care
  • Physician education!!!
  • Identifying interventions of marginal or no clear benefit with high cost- SR’s, meta-A’s, comparative effectiveness research & RCT’s
  • Physician education focussed on tech skills- primary and continuing education needs to incorporate understanding of cost-effectiveness!!!
  • Personalised medicine
  • More rapid adoption of innovation (sentinel & others)
  • Translational and clinically focussed research
  • Comparative effectiveness research and health-services research- how to deliver?
  • Development of outcome data (SCAN report), rapid learning healthcare system
  • Focus on end of life care: account for wishes of patients and families
limitations of evidence
Limitations of evidence
  • RCT’s do not imply clinical significance ONLY statistical significance
  • NCI Canada reported median overall survival benefit of 0.33 months for Erlotinib plus gemcitabine in advanced pancreatic cancer
  • Massive toxicity, FDA, EMA and SMC approved at cost of $500,000 per life year gained (Threshold?? NICE 10%)
  • EUROCAN project- ethical, political and administrative barriers to acquiring and sharing data on outcomes
cancer surgery
Cancer surgery
  • Hunter “an armed savage trying to render by force that which a civilised man would render by strategem”- Main method of cure for solid tumours globally
  • In common cancers surgery alone 50% of direct costs (Warren JNCI 2008)
  • Curative in absence of metastatic disease- little emphasis on defining staging
  • ASCO 2010- ACOSOG Z0011 study showed no benefit of ALND in women with 1-3 positive SNB- Surgical bias!!!
  • Challenge the surgical dogma (XS, trade-off)
where are we with prioritisation
Where are we with prioritisation?
  • RILCV
  • Quality based commissioning
  • Guideline driven care (rationing)
  • We do not have or own the data!
  • Data not geographically/culturally sensitive
  • Data not appropriate to our healthcare system
  • Where are the outcomes for our organisations?? (31/62 vs survival)
some solutions
Some solutions.....
  • Consult widely on the questions and priorities
  • Commission and own the data
  • Share and collaborate on the data
  • Analytical methods that compare and that emphasise clinical benefit
  • Educate physicians with the data (challenge)
  • Use and implement changes
  • Rapidly adopt technological advances
slide47
We need to be able to do more than “just say no”Thank you!Dr Victor Lopes PhD FRCSAssoc Medical Director NHS Lothian