Transcript SPSP Fellowship Project Charter

Sustaining Quality
“Expectations will always exceed
capacity. The service must always be
changing, growing and improving…”.
Aneurin Bevan, 1948
Parachute use to prevent death and major trauma related
to gravitational challenge: systematic review of randomised
controlled trials
Gordon C S Smith, Jill P Pell. BMJ 2003;327;1459-1461
• Aim: To determine whether parachutes
are effective in preventing major trauma
related to gravitational challenge.
• Design: Systematic review of randomised
controlled trials
• Results: Our search strategy did not find
any randomised controlled trials of the
parachute.
Parachute use to prevent death and major trauma related
to gravitational challenge: systematic review of randomised
controlled trials
Gordon C S Smith, Jill P Pell. BMJ 2003;327;1459-1461
Conclusion:
As with many interventions intended to prevent ill health,
the effectiveness of parachutes has not been subjected
to rigorous evaluation by using randomised controlled
trials.
Advocates of evidence based medicine have criticised
the adoption of interventions evaluated by using only
observational data.
We think that everyone might benefit if the most radical
protagonists of evidence based medicine organised and
participated in a double blind, randomised, placebo
controlled, crossover trial of the parachute
“Society’s huge investment in technological
innovations that only modestly improve efficacy,
by consuming resources needed for improved delivery of
care, may cost more lives than it saves.”
“Health, economic, and moral arguments make the case
for spending less on technological advances and more
on improving systems for delivering care.”
Fidelity vs Efficacy
$100 Million
$29 Billion
$32 Billion
0.002%
The aspirin example
• In patients who have had a stroke or TIA
aspirin reduces risk by 23%
• 100,000 patients – 23,000 fewer strokes
• 58% of eligible patients receive aspirin =
13,340 fewer strokes
Two options
• Fidelity – increase to 100% of eligible
patients = 9,660 strokes
• Efficacy – requires a proportional
improvement over aspirin of 74%
• Clopidogrel = 10% more efficacy than
aspirin
Outcome Aims
• Mortality: 15% reduction
• Adverse Events: 30% reduction
• Ventilator Associated Pneumonia: 0 or 300 days
between
• Central Line Bloodstream Infection: 0 or 300
days between
• Blood Sugars w/in Range (ITU/HDU): 80% or >
w/in range
• MRSA Bloodstream Infection: 30% reduction
• Crash Calls: 30% reduction
Example Interventions
• Critical Care
– Ventilator acquired pneumonia bundle, central line
• Ward
– Early rescue
– Communication
• Medicines
– Medicines reconciliation
• Theatres
– Surgical pause
– Infection prevention/control
• Leadership
– Safety walkrounds
– Executive leadership board patient safety profile
GRI VAP Prevention Bundle
Sampled one day per week - varied day
Aim >95% Reliability by May 2009
All 4 components of
bundle
100%
30° head up
90%
80%
DG sheet - reformatted,
Prompts added
Script of questions to
ask doctors
70%
60%
responsive to command; had
sedation hold; or described
exclusion
Re-testing at daily goals:
handing script, using
script, change daily
goals sheet
Head-up redundancy
50%
Chlorhexidine used as part of
daily mouth care
Daily Goals Sheet
described weaning target or
described exclusion
40%
AIM - how much by when
30%
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GRI VAP Prevention Bundle Reliability and
VAP rate per 1000 ventilator days
Aim: > 95% reliability by March 2009
25
Script of
questions to ask
Drs
100%
90%
20
15
DG sheet
DG sheet
change;
prompts added
Retesting at DG sheet;
handling sript; change
DG sheet
80%
Ventilator Associated Pneumonia
rate per 1000 ventilator days
70%
60%
Median over first 6 months
50%
10
Last VAP
02/01/2009
5
40%
30%
20%
10%
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nAu 09
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Ventilator Associated Pneumonia
care bundle reliability (%)
0%
AIM
Daily Goals Set and Reviewed > 1 time in the day
Aim #1 >80% by March 2009,
Aim #2 >95% by June 2009
GRI ICU Percentage had Daily Goals Set
and Reviewed > 1 time
100%
90%
80%
100%
70%
80%
60%
60%
50%
40%
40%
30%
20%
20%
10%
UCL
LCL
Process Avg
Days
16
14
12
10
8
6
4
2
0
Daily Goals &
VAP Prevention
bundle start
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GRI ICU Monthly Average Length of Stay (days)
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n03
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Ja 5
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But Does It Work Outside SPSP?
Acute pain management in orthopaedics
GRI Acute Pain Bundle in Elective Orthopaedics
AIM: > 95% Reliability by January 2010 - for the red dot
100%
All 4 components of
bundle implemented
90%
Spread to 5
days per week
80%
Prescribed oral analgesics
70%
Test script of
questions for
recovery nurses to
use 2 days per week
60%
50%
Got Step 2 oral analgesic at
22:00
40%
Test drug recognition with
recovery room nurses
30%
20%
Meet anaesthetists SH, CR,
TMcL, JD – describe tests
with recovery nurses
Meet Julie – ward
manager – set AIMS
10%
Start data collection
Ju
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Oral analgesics written up
regularly not prn
≥ 6 pain recordings on chart
in first 24 hours
Aim:
Acute Pain in Elective Orthopaedics: Primary Hip & Knee Replacement
Process AIM: Bundle reliability > 95% by end of Jan 2010
Outcome AIM: Reduce both classifications of pain by 50%
Acute Pain Bundle reliability
100.0%
Aim
80.0%
Only 45% patients with no
or only mild pain in 1st 24
hours postoperatively
75% patients with no or
only mild pain in 1st 24
hours postoperatively
60.0%
Patients with one or more episode
of moderate or severe pain in first
24 hours (%)
Median for moderate or severe pain
for 1st 6 months
40.0%
Patients with one or more episode
of severe pain in first 24 hours (%)
20.0%
526 patients
337 patients
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No 9
v0
De 9
c0
Ja 9
n1
Fe 0
b1
M 0
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0.0%
Median for severe pain for 1st 6
months
Winter review
• Patient safety walk rounds continued during the winter
period
• Daily monitoring and reporting of 8 hour trolley waits in
the Emergency Departments
• An action tracker has been established to ensure that
the key lessons for improvement are being progressed
• Data:
–
–
–
–
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Breach Analysis of A&E waiting times
Boarder numbers
Delayed Discharges
Elective cancellations
Re-admission rates
The Healthcare Quality Strategy for NHSScotland
• Person-Centred - Mutually beneficial partnerships
between patients, their families, and those delivering
healthcare services which respect individual needs and
values, and which demonstrate compassion, continuity, clear
communication, and shared decision making.
• Clinically Effective - The most appropriate treatments,
interventions, support, and services will be provided at the
right time to everyone who will benefit, and wasteful or
harmful variation will be eradicated.
• Safe - There will be no avoidable injury or harm to patients
from healthcare they receive, and an appropriate clean and
safe environment will be provided for the delivery of
healthcare services at all times.
“We look to Scotland for all
our ideas of civilisation.”
Voltaire
(Francois Marie Arouet, 1694–1778)
[email protected]