Transcript www.scottishmedicines.org.uk

Local Quality Improvement
Initiatives
Dr Sian Finlay
Dumfries and Galloway Royal
Infirmary
2 Initiatives in our AMU
• Medicines Reconciliation
• SNAP-CAP
“A little white one, doc”
Taking a good drug history essential
• Drugs may have contributed to acute illness.
• If you don’t know what patient is on, you may omit vital meds.
• If you don’t know if they are actually taking their meds, you may give
them a drug they are intolerant of.
• If you don’t know what they are currently taking, you can’t adjust
meds in response to acute illness.
Medicines Reconciliation
• Need to obtain drug information from at least 2 sources
 Patient
 Carer
 GP letter
 Own meds
 Emergency Care Summary
 Home list
 Nursing home kardex
 Very recent discharge letter
Allergy Recording
• Also audited allergy recording
• Required the allergy and one
source of information about
allergy to be documented
Data Collection
• Data collected by me on a daily basis
• Casenotes from new admissions reviewed after morning ward round
• Representative sample rather than trying to collect data on every
patient
• Usually about 12 patients per day
• Results fed back at the weekly journal club meetings (attended by
most of the junior doctors) and displayed graphically on the AMU
W
ee
k
W 1
ee
k
W 3
ee
k
W 6
ee
W k8
ee
k
W 10
ee
k
W 12
ee
k
W 14
ee
k
W 16
ee
k
W 18
ee
k
W 20
ee
W
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e e W 22
ks e e
26 k 2
an 4
d
W 27
ee
k
W 29
ee
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ks e e
34 k 3
an 3
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W 35
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W 38
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W 40
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W 4
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ks 44
46
W 47
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50
% of patients
% of patients with 2 or more sources
120
100
40
Target
=95%
80
60
2 or more codes
20
0
Results – Allergy Recording
Allergy Recording since Aug 2009
100
90
80
60
Recorded with source
50
40
Recorded but no source
Not recorded
30
20
10
k
8
W
ee
k
10
W
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ks ek
14 12
an
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1
W 5
ee
k
16
W
ee
k
18
W
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ks ek
23 20
an
d
2
W 4
ee
k
26
W
ee
k
28
W
ee
k
30
W
ee
W
ee k 3
ks 2
35
-3
W 6
ee
k
38
0
W
ee
% of patients
70
Accuracy of Prescribing
• Process now well-embedded and understood
• But is it improving quality? We still found errors….
• Or had we trained people to improve only what was being recorded?
• Plan: Pharmacists collect data on number of prescriptions containing
errors/requiring pharmacist intervention
•
•
•
•
Early results : 46% needed intervention!
This may still represent an improvement from before med rec
Does it mean we embedded the process but not the quality?
Started feedback on quality
% of charts requiring pharmacist intervention
% of Charts with error
50
45
40
% of charts
35
30
25
20
15
10
5
0
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
Plans
• Will continue rolling audit of number of sources used
• Change weekly feedback to emphasise accuracy rather than
number of codes
• Pharmacists will periodically record individual doctor data
• Have started displaying accuracy results on the AMU weekly
SNAP-CAP
• DGRI joined SNAP-CAP in June 2009
• Audit folders kept on the AMU
• Everyone encouraged to complete forms for newly admitted CAP
patients
• Reality is that I complete the vast majority of the forms
CURB65 Recording
% with CURB65 recorded
120
Target
= 95%
100
% of patients
80
60
40
20
0
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
% who had antibiotics within 4 hours
% who had antibiotics within first 4 hours
120
100
Target
=95%
% of patients
80
60
40
20
0
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
% with O2 sats maintained in target range
% with O2 sats in target range
120
95%
target
100
% of patients
80
60
40
20
0
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
% of severe CAP getting iv antibiotics
% of severe CAP who got iv antibiotics
120
100
Target
95%
% of patients
80
60
40
Small
numbers!
20
0
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Problems
• Small numbers – who should
collect data?
• Skewing of data since collected
mainly by one individual
• Difficult to collect data on patients
discharged from A&E
?is this less important
Plans
•
Generate ‘buy-in’ by starting feedback on SNAP-CAP data:
 Displaying monthly results on the AMU
 Periodically including results in feedback at journal club meetings
 Provide feedback to A&E
•
Try to involve A&E more (folder recently given to them)
Summary of local experience
• Acute Medicine can play a key role in quality improvement initiatives
• Difficult to avoid making audit dependent on individuals
• Rolling audit of performance with public feedback of results
promotes awareness, generates interest, and improves quality