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© Trillium Health Centre 2006
Improving Quality & Patient Safety
Evidence Based Order Sets
An effective solution to the complex challenge of improving patient care and safety
© Trillium Health Centre 2006
Order Set Committee
Chris O’Connor, Katharine DeCaire, Zelia Campos, Bruce Tugwood, Pam Johnson, Allan Mills, Vera Jovanovic, Catherine Scaletta
Experimental Design, Data Collection, Analysis
Chris O’Connor MD, Neill KJ Adhikari MD CM MSc, Katharine DeCaire RN MN ACNP, Jan O Friedrich MD DPhil
© Trillium Health Centre 2006
Outline
Current Context: The Need for Order Sets
Order Sets A Clinical Decision Support Tool
Order Sets Improving Care at Trillium
Order Set Advantages
Order Set Challenges
Trillium’s Order Set Innovation
Open Source Order Set Project
© Trillium Health Centre 2006
Current Context:
The Need for Order Sets
© Trillium Health Centre 2006
Modern Case Presentation
67 year old female
Past Medical History:High Blood Pressure, Diabetes
History of Present illness: Presents to Emergency Room with severe pneumonia.
Patient is unable to breathe on her own and is intubated.
She is transferred to the Intensive Care Unit for her medical care
© Trillium Health Centre 2006
Modern Case Treatments
Antibiotic treatment- fast
Activated Protein C
Early goal directed fluid therapy
DVT prophylaxis
Early feeding
Low tidal volume ventilation
Steroids
Pepcid to prevent GI bleeding
Strict glycemic control
Communicate with and support patient family
Proper sedation/pain relief
Correct electrolytes
Elevate the head of the bed
Bowel routine
Mouth care
Ongoing investigations
© Trillium Health Centre 2006
© Trillium Health Centre 2006
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Context:Massive Gap Between the Possible and the Actual
Quality Misuse, under use, overuse on a massive scale:
Crossing the Quality Chasm 2001
SafetyMedical error is common:
Institute Of Medicine Report on Error 2000
Variation in CareVariability in care not explained by patient preferences or different disease patterns:
British Medical Journal 2002; 325: 961-964
© Trillium Health Centre 2006
Context:The Canadian Adverse Events Study
G. Ross Baker et al, CMAJ May 25 2004 170(11)
The adverse event (AE) rate due to health care management was 7.5%
The AE rate of preventable events was 2.8%
The rate of deaths from preventable AEs was 0.66%
This would mean between 9200 and 23750 deaths/yr in Canada
© Trillium Health Centre 2006
Edward Etchells et al, CMAJ April 27, 2004; 170 (9)
84% had at least 1 inpatient gap in care
15% patients with 3 or more gaps in their care,
15% an inpatient adverse event
2 of the 16 pts with adverse events died
longer stays 16.4 v. 8.6 days if a pt had an adverse event
Patients who had an inpatient adverse event had more gaps in their care 2.0 v. 1.3 gaps
Context: Gaps in the Care of Patients Admitted to Hospital
with an Exacerbation of Chronic Obstructive Pulmonary Disease
© Trillium Health Centre 2006
Where do we go from here?
Traditional Methods to Change Clinician BehaviorWritten Materials/guidelinesAudit and FeedbackAcademic DetailingLocal Opinion Leaders
Zero to moderate effectiveness at best
Not scaleable
Limited Scope
Not durable
© Trillium Health Centre 2006
A group of orders with a common functional purpose used by the physician to create orders.
Integrates knowledge into the care delivery process “knowledge where the clinician needs it most”
Organizes clinical knowledge so it is easy to remember, easy to use and has maximum benefit to the patient
Contain evidence-based best practices
Source of education
Can be used in paper or computerized ordering systems
Solution: Order Sets a Clinical Decision Support Tool
© Trillium Health Centre 2006© Trillium Health Centre 2006
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Order Sets: Key Benefits
SafetyReduced transcription errorsReduced errors of omissionReduced errors in medication dosing
QualityImproved compliance with evidence-based best practicesStandardization of care
EfficiencyDecreased time to write and process ordersReduction in physician call-backsReduction in missed orders
Critical enabler for computerized practitioner order entry
© Trillium Health Centre 2006
Order Sets:
Improving Care
© Trillium Health Centre 2006
0
10
20
30
40
50
60
70
80
% Use of Order Sets
Oct-Nov 2003 April-Dec Feb-Mar 2005 Dec-05
Order Set Adoption
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Data Collection
Primary outcome DVT Prophylaxis Rates:Random Chart audit from three time periodsOctober-November 2003April – December 2004February – March 2005
DVT prophylaxis rates in the Department of Medicine
April 2003 to March 2005
Secondary Outcomes: Assess in second chart period
Multiple Quality metrics assessed.
© Trillium Health Centre 2006
DVT: The Preventable Epidemic
DVT is the formation of blood clots in the legs
DVT is very common in hospitalized patients
DVT can cause death or serious disability
There is excellent treatment to prevent DVT if patients get it
Many studies have shown that many patients do not get this treatment which can save their lives
“The disconnect between evidence and execution as it relates to DVT prevention
amounts to a public health crisis” - S. GoldHaber, Associate Professor Harvard Medical School, 2003
The order sets contained a section with treatment to prevent DVT
© Trillium Health Centre 2006
0
5
10
15
20
25
30
35
40
45
% Orders with DVT Prophylaxis
Oct-Nov 2003 April-December 2004 Feb-March 2005
Impact of Order Set Use on DVT Prophylaxis Orders
Order Set
No Order Set
© Trillium Health Centre 2006
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100
200
300
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500
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800
900
1000
Num
ber o
f Dos
esUse of Low Molecular Weight Heparin
LMWH Introduced into Medical Order Sets
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5
10
15
20
25
30
35
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45
50M
onth
ly D
VT P
roph
ylax
is R
ates
(%)
LMWH
Regular Heparin
LMWH Introduced Into Order Sets
© Trillium Health Centre 2006
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Code status Endocrine consult Urine C&S Urine R&M DVT Prophylaxis Standard ICUprotocols
Management of DKA in ICU
No order Set
Order set
© Trillium Health Centre 2006
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5
10
15
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30
35
40
Res
pons
es
StronglyAgree
Agree Neutral Disagree
ER/ICU Survey Results: Order Set Impact
Improved Process of Care Delivery
Improved Quality of Care
Reduced Time to Use
Reduced Transcription Error Risk
© Trillium Health Centre 2006
The Order Set Advantage
Addresses the challenges facing medicine today:
Scalable
Durable
Broad Scope
No significant process redesign to implement
No significant education
Work in line with ordering process augmenting
physician knowledge
Preserve autonomy
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The Order Set Challenge
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The Order Set Challenge
Order Sets Must Be:
Current
Evidence Based and Best Practice
Authoritative
Easy to Use
Comprehensive
Reliable and safe
Clinically Intelligent
© Trillium Health Centre 2006
Order Sets are Complex!
Typical medical admission order set has 130 order elements in the set
Interdisciplinary
Multiproccess
Integration with other care documents and activities
Over 400 different order sets for a typical hospital
Standardization, integration across systems is critical
The Order Set Challenge
© Trillium Health Centre 2006
Current Status of Order Sets
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Current Status of Order SetsLack of Recognition of Order Set Importance
Order Set DesignOften no standardized structure Structure is not modularLack of integration with other processes/documents
Order set life cycle not well established No dedicated Order Set Committee at most hospitals Most often P+T/MAC based process, occasionally process is distributed to the level of the health systems
Best practices often not scaled across departments
Lack of version control
No measurement of metrics
Each hospital has its own structure and approach to order sets
© Trillium Health Centre 2006
No good library of content
No standardization of format, content or processes between organizations
Limited ability to share order set content between organizations
Each Organization must create its own order set projectDuplication of effortReduced qualitySlow implementation of best practicesConsumption of limited hospital resources Organization may lack content expertise in all the subject areas need for order sets Organization may lack knowledge of order set best practices in design and order set lifecycle
External resources for order sets currently are very limited
Current Status of Order Sets
© Trillium Health Centre 2006
Order Set Innovation
© Trillium Health Centre 2006
Trillium’s Order Set Project
2001: Order set development begins in ICU
Rapid Cycle improvement of order set design
2002: Order set development in other departments
2003: Standardized order set format established
2004: Current Order Set Committee established
2006: Standardized order sets in use in every Health System
Over 250 order sets currently in use
Admission order set use > 90% in most health systems
© Trillium Health Centre 2006
Trillium Order Set Project
Winner of the first Ministry of Health award for Innovation in Patient Safety and Quality
Expanded Commitment to Order Set Development and Implementation
Order Set Project now has six dedicated FTEs
Goal of expanding content by over 400 order sets in the next year
Preparation for CPOE. Order sets developed for use in current paper ordering environment and in CPOE system
© Trillium Health Centre 2006
Excellence in Order Set Design5 years of iterative improvement in order set design
Integration of real world feedback
Intelligent knowledge representation to increase usability and clinical impact
Order Set ProcessReal time integration of authoritative content expertise into order sets
Dedicated Interdisciplinary Order Set Committee
9 member committee that meets weekly
Clearly established processes for all aspects of the order set lifecycle – initiation, development, approval implementation and maintenance
Integration of order sets with other processes and documents
Trillium Order Set Innovation
© Trillium Health Centre 2006
Order Set ContentOver 250 order sets developedOrder sets used in every health systemContent is interdisciplinary addressing all aspects of a patient’s care
Web enabled searchable data base of all clinical decision support tools
Interdisciplinary development teams
Content experts own the contentOrder set committee provide process knowledge
Trillium Order Set Innovation
© Trillium Health Centre 2006
Open Source Order Sets
Based on Trilliums award winning Order Set Project
Dedicated to improving healthcare in Canada by facilitating the use of high quality, standardized evidence based order sets
Partnering with other Health Care Organizations to standardize and improve the quality and safety of patient care
Niagara Health System
Open Source Order Sets Provide a complete order set solutionSave organizations time, money and reduce demand on limited organizational resourcesImprove qualityLocal ownership and adaptation of tools
© Trillium Health Centre 2006
Open Source Order SetsStandardized Order Set Design
Standardized structure to order set content based on DAVIDRules of correct formatting at all levels of order set contentClear syntax of order set contentDesigned to anticipate CPOE
Modular FormatBest practices are contained in functional groupsFacilitates the spreading of best practices across different order sets and across health systemsOver 300 modules including many high value best practice modules such as deep vein thrombosis prophylaxis, bowel care, pain control, electrolyte management
Order Set LifecycleOrder Set Committee Interdisciplinary membershipRobust methodology for development, approval, implementation and maintenance
© Trillium Health Centre 2006
Open Source Order Sets
Large Library of Developed Content Over 250 order sets and clinical protocolsComprehensive interdisciplinary content Incorporation of real world experienceWill grow to over 600 order sets in the next year
Order Set Web PageWeb accessible data base to store library of order set contentOrder sets clearly organized, searchable by many different criteria and relationships between order sets and clinical protocols clearly established
Order Set Project SupportOn-site and remote support including physician, nursing, pharmacy Goal is rapid knowledge transfer
© Trillium Health Centre 2006
Order Set Project Outline
Establish an Order Set Committee Best practices around order set lifecycle
Catalogue and upgrade legacy order set contentConvert to standardized modular formatIntegrate new best practice content as appropriateStandardization of best practices across the organization Approval of new and upgraded order sets by the Order Set Committee
Develop and Implement Order SetsUtilization of library of best practice contentAdapt Open Source Order Sets to local health system needsNew sets developed by content experts at Grey BruceComprehensive communication plan to facilitate adoption
© Trillium Health Centre 2006
Order Set Project Outline
Store order sets on an intranet accessible database
Collection of data for metricsThe measurement of improved outcomes is an important part of an order set project Order sets can have a dramatic impact on easily measured quality metrics in a very short time period Open Source Order Sets will work with you to select the key metrics that can be used to evaluate your project
Number of order sets in useOrder set adoptionAdherence to best practicesBefore/after, cross-sectional analysis
© Trillium Health Centre 2006
BenefitsSave time
Save money
Improve the quality and safety of patient careLarge improvements of easily measured metrics in short periods of time
Improve order set design Increase order set use by physicians Increase the clinical impact of order set useIncrease the standardization of best practices across the healthcare system
Increase the knowledge base that can be used for order set development
Hospitals are no longer developing order set content in isolation
Improve the coordination of order sets with other order sets, documents and processes
Improved coordination of health care delivery in Ontario
© Trillium Health Centre 2006
Future
The forces driving the need for order sets are accelerating
Medical knowledge is increasing Complexity of treatments is increasingEffectiveness of treatments is increasingCare is delivered by large interdisciplinary teamsComputerized Physician Order Entry requires order setsRecognition that effective orders must achieve many objectives simultaneously
Quality Safety
Workflow Resource utilization
© Trillium Health Centre 2006
Why We Are Doing This?
© Trillium Health Centre 2006
Why We Are Doing This?
Share our award winning project with others
Collaborate with other healthcare organizations
Build a community of shared knowledge
Potential to transform healthcare
To standardize best practices across organizations
To facilitate clinicians practice
To improve the quality and safety of patient care we provide to all patients
Save Lives
© Trillium Health Centre 2006
Order Sets Save Lives
Order Sets Deliver Better Care
Order Sets Improve Efficiency
Order Sets Save Lives
Order Sets Deliver Better Care
Order Sets Improve Efficiency
Why We Are Doing This?
© Trillium Health Centre 2006
“Standardize and automate
that which is routine about a
patient’s care so the clinician
can focus on what is unique
about each patient”
“Standardize and automate
that which is routine about a
patient’s care so the clinician
can focus on what is unique
about each patient”
© Trillium Health Centre 2006
Thank You!
Chris O’Connor M.D. FRCPC
Katharine De Caire ACNP