Transcript Systematic review of deaths at Shrewsbury and Telford Hospital

IMPROVING PRODUCTIVITY BY
FOCUSSING ON QUALITY OF
CARE
- A PROGRAMME OF RESEARCH
AT THE HOSPITAL
Dr Gill Clements
Roger Killen
March 2006
“Patients do not die of their
disease, they die of the
physiologic abnormalities of
their disease”
Sir William Osler
PATIENT ASSESSMENT
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Blood pressure
Heart rate
Respiratory rate (oxygen levels)
Urinary output
Temperature
Conscious level
EARLY WARNING SCORES
• Measure of physiological illness
• Marker of increased mortality risk
• Linked to action
SPECIALIST CRITICAL
OUTREACH TEAMS
• Hospital wide
• Multidisciplinary
• Ensure appropriate intensive care unit
(ICU) admissions
• Provide training and education
NATIONAL CONFIDENTIAL ENQUIRY
into PATIENT OUTCOME and DEATH
(NCEPOD) report 2005
• Inconsistent recognition of physiological
instability
• Inconsistent action
• Inappropriate intensive care unit admissions
• Inequality in early warning score
measurement and outreach team
implementation
COCHRANE REVIEW OF THE
EVIDENCE
• Many hospital deaths potentially
predictable and possibly avoidable
• Clinical deterioration preceded by
changes in physiological measurement
• Changes often misses, misinterpreted,
mismanaged
• Delays in seeking advice, failure to
recognise clinical urgency
SHREWSBURY AND TELFORD
HOSPITAL
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Early warning scores across the 2 sites
Critical outreach teams on both sites
Two busy ICUs
ALERT (acute life threatening events
recognition and treatment) training
courses
• Hospital Standardised Mortality Ratios
(HSMRs) low
• Desire to improve quality of care and
productivity
• Enthusiastic team
• Research opportunity
• Hospital research money
RESEARCH PROGRAMME
Two projects:
• implementing electronic decision support
tools
• development of a more sophisticated patient
risk assessment tool
In partnership:
- Portsmouth and Birmingham Universities
- Portsmouth Hospital
- private limited company - The Learning
Clinic
VitalPAC
• Improve accuracy and timeliness of
observation data collected by nurses
• Automatic creation of early warning
scores (EWS)
• Linked to decision support (bedside and
remote)
• Reduce nurses work burden (remove
paper)
• Wireless handheld computers
• Touch screen guides nurse
through data input
• Calculates EWS
• Protocols embedded
• Personalised reminders and
order of observations
• On line nurse training
PROGRESS SO FAR
• In use on 2 surgical assessment units
• Evaluation of improvement in quality
and productivity
RESULTS
• Accuracy of scores improved from 63%
to 90%
• Time to produce a score reduced from
37 seconds to 24 seconds
• Popular with staff
NEXT STEPS
• Remove paper
• Add in access to blood results
• Remote access for critical outreach
teams
• Role out to medical assessment units
VitalPAC+
• Development of a more sophisticated
risk prediction/early warning score
using data collected as a by product of
clinical care (blood tests)
• Based on original work done in
Portsmouth (Prytherch, Br J surg 2003)
Category
Mortality risk (%)
1
0 to  5
2
>5 to  7.5
3
> 7.5 to  10
4
> 10 to  12.5
5
> 12.5 to  15
6
>15 to  20
7
>20 to  25
8
>25 to  33
9
> 33 to  50
10
> 50 to  100
• Model replicated at Shrewsbury and
Telford Hospital
• Model fits surgical and medical patients
• 90% emergency patients have routine
bloods taken on admission
• Data in hospital systems
Percentage of low risk and
high risk patients at SATH
over 5 years
Risk category
1
Risk category
8, 9 and 10
2000
49
8
2001
45
8
2002
40
8
2003
42
10
2004
44
8
SO WHAT?
• Improvement in the quality of care
• Improvement in productivity
QUALITY IMPROVEMENT
• Systematic implementation of accurate
risk scoring of patients
• Systematic link to appropriate action
• Effective, appropriate use of resources
(doctors, critical outreach nurses, ITU)
• Audit tool
 Reduction in mortality and morbidity
PRODUCTIVITY
IMPROVEMENT
• Stream emergency patients
• Identify “appropriate” admissions –
emergency triage
• Appropriate level of resources to
patients
• Predict LOS
• Predict risk of readmission
Any questions?