10th Mortality and harm reduction in CWM TAF HEALTH BOARD...Cwm Taf Health Board Insert name of...
Transcript of 10th Mortality and harm reduction in CWM TAF HEALTH BOARD...Cwm Taf Health Board Insert name of...
Cwm Taf Health Board Insert name of presentation on Master Slide
Mortality and harm reduction
in CWM TAF HEALTH BOARD
10th June 2011
Cwm Taf Health Board
Leadership
Improve
information &
communication
Review quality of coding data
Review standard of record keeping
Share Learning from mortality and Global
Trigger tool (GTT) reviews
Establish Quality Improvement & Safety
Steering Group
Improving
Leadership
Reduce Mortality
& harm
GTT each acute site monthly
PCCT Pilot in 1 local GP practice
Undertake 50 mortality reviews consecutively
Take forward GTT findings for year 2009/10
with specific reference to quality of record
keeping
Pilot shared notes within community hospital
setting
Using Trend data to target mortality reviews to
areas of apparent concern
Expand mortality and GTT review teams
Cwm Taf Health Board
Leadership
• Establishment of Quality Improvement & Safety Steering Group– Primary & Secondary Care
Representation
– Includes Trainee & SAS Doctors
• Director Walk rounds continue to take place on a Friday to both Acute & Community Hospital Setting (July 2010 to Jan 2011 – 35)
• New walk round documentation introduced
Monthly Number of walkrounds undertaken
Cwm Taf Health Board
0
1
2
3
4
5
6
7
8
9
Jul 2010 Aug 2010 Sep 2010 Oct 2010 Nov 2010 Dec 2010 Jan 2011
New process and
documentation introduced
Cwm Taf Health Board
Mortality
• Improved Quality of Coding
• Weekly mortality reviews using Global Trigger Tool
• Engagement with CHKS to fully understand our data
• Using trend data to target areas of apparent concern
Risk Adjusted Mortality Index
(Acute Sites Trend)
60
70
80
90
100
110
120
Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar
2009/10 2010/11
2009/1
1
Acute Sites Linear (Acute Sites)
Risk Adjusted Mortality Index
(Acute Sites)
60
70
80
90
100
110
120
130
Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar
2009/10 2010/11
2009/1
1
PCH RGH Acute Sites Linear (Acute Sites)
Reduce Harm & Mortality
Cwm Taf Health Board
Surgical Complications
• Speciality Reviews
• Implementation of
WHO/NPSA
Surgical Checklist
• Normothermia
measures in place
• Appropriate Hair
removal introduced
across the health
board
General Surgery RAMI Trend
40
60
80
100
120
140
160
180
Ap
r'09
May
Ju
n
Ju
l
Au
g
Sep
Oct
No
v
Dec
Jan
Feb
Mar
Ap
r'10
May
Ju
n
Ju
l
Au
g
Sep
Oct
No
v
Dec
Jan
Feb
Mar
2009/1
1
General Surgery Linear (General Surgery)
Cwm Taf Health Board
WHO/NPSA
Surgical Checklist
• Implemented across Health Board
• Monthly audit undertaken on both District General Hospital Sites
Surgical Complications
Compliance with WHO / NPSA Surgical Checklist
Cwm Taf Health Board
0%
20%
40%
60%
80%
100%
120%
Jul 2010 Aug 2010 Sep 2010 Oct 2010 Nov 2010 Dec 2010 Jan 2011
Compl iance Average (100%) Lower l imit 99%) Upper l imit 100%)
Cwm Taf Health Board
Normothermia
• Normothermia measures in Place
• Data captured and reported on a monthly basis
Surgical Complications
Compliance with peri-operative normothermia
Cwm Taf Health Board
0%
10%
20%
30%
40%
50%
60%
70%
80%
Jul 2010 Aug 2010 Sep 2010 Oct 2010 Nov 2010 Dec 2010 Jan 2011
Compl iance Average (51%) Lower l imit 33%) Upper l imit 68%)
Cwm Taf Health Board
Pre-op Hair Removal
• Appropriate Pre-operative hair removal methods introduced across Health Board
• Monitoring and reporting processes developed
Surgical Complications
Compliance with appropriate pre-operative hair removal
Cwm Taf Health Board
0%
20%
40%
60%
80%
100%
120%
Jul 2010 Aug 2010 Sep 2010 Oct 2010 Nov 2010 Dec 2010 Jan 2011
Compl iance Average (92%) Lower l imit 84%) Upper l imit 100%)
Cwm Taf Health Board
Mortality Review • Monthly speciality review of mortality cases
– Trauma & Orthopaedics
– General Surgery
– 30 day mortality after anaesthetic
• Multi-disciplinary reviews
• Reviews have highlighted – Improved communication between the Surgical and Anaesthetic
Teams
– Improved communication with the teams and the patient/family in explaining risks of surgery
• Reviews have led to – An improved rehabilitation process with the majority of Ortho-
geriatric rehabilitation taking place at Community Hospital
– Joint Care taking place between Orthopaedics and Care of the Elderly
Reduce Harm & Mortality
Cwm Taf Health Board
Global Trigger Tool
• Weekly review – 10 notes per week
• Top Triggers– Readmission within 30 days
– Complication of procedure or treatment
Reduce Harm & Mortality
Cwm Taf Health Board
Reduction in
Clostridium Difficile
• Achieved reduction in
Clostridium Difficile by
20% (started from low base rate)
• Implementation of
Clostridium Difficile
Care Pathway
• Hand Hygiene audits
undertaken
• Environmental Audits
undertaken
Clostridium Difficile Incidences
0
2
4
6
8
10
12
14
16
18
Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11
Month
Nu
mb
er
Number
PCH
RGH
Healthcare Associated Infections
Cwm Taf Health Board
Hand Hygiene
• Weekly Hand Hygiene Audits undertaken
• Verification Audits undertaken by Infection Prevention & Control Team
• Feedback provided to Clinical Teams on a weekly basis
Compliance with hand hygiene
Cwm Taf Health Board
0%
20%
40%
60%
80%
100%
120%
Jul 2010 Aug 2010 Sep 2010 Oct 2010 Nov 2010 Dec 2010 Jan 2011
Compl iance Average (75%) Lower l imit 23%) Upper l imit 100%)
Healthcare Associated Infections
Cwm Taf Health Board
Transforming Care Targets- How are we measuring up?
Increase Direct Care Time [DCT] to at least 70%
-Average increase of 19%-Highest DCT to date is 80%
Increase Patient satisfaction to at least 95%
-Average increase of 7%-Highest result to date is 98%
Increase Staff satisfaction to at least 95%
-Average increase of 5%-Highest result to date is 92%
Transforming Care
Cwm Taf Health Board
MR
SA
c.D
iff
Me
d E
rro
rs
Fa
lls
Pre
ssu
re
Ulc
ers
Co
mp
lain
ts
609 609 609 78 419 429
Transforming Care
Highest Days Since
Cwm Taf Health Board
Introduced Skin
Bundle
Transforming Care
Pressure Ulcers
• Skin bundle rolled across Cwm Taf Health Board
Ward Example
Cwm Taf Health Board
Introduced patient Care
Rounding
Transforming Care
Falls
• Implementation
of Risk
Assessment
Documentation
• Patient care
Rounding
Ward Example
Cwm Taf Health Board
Staff member returned to work
and not aware of new process
Transforming Care
Ward Example
Medication Errors
Cwm Taf Health Board Transforming Care
Achievements
• 50% reduction in time taken for handovers
• 28% reduction in time wasted locating
equipment and information
• 45% reduction in interruptions to nursing staff
• 69% reduction in time spent in medicines
administration
• 68% reduction in Admin
Cwm Taf Health Board
•„This is Me‟ –This leaflet was developed by the Alzheimer's Society , it aims to provide professionals with
information about the person with dementia as an individual. This will enhance the care and support
given while the person is an unfamiliar environment
•Patient Care Round [PCR]–is the scheduling of regular nursing rounds, at least once every two hours ,that incorporates
specific actions linked to the Fundamentals of Care. The intended outcome of PCR is improved
patient safety and experience.
•Relative Rounding -This is dedicated time for patient/relative/carer communication,
whereby nursing staff actively seek out relatives/carers,
giving them the opportunity to ask any questions.
•Patient Rest Time - Being in hospital can be physically and emotionally tiring for patients, an undisturbed
rest period gives them the opportunity to recuperate.
•Nursing Documentation
•at the bedside -
Patient documentation is often time consuming and frequently performed at the nurses
station .Moving patients documentation to the bedside puts nursing staff back at the patients
bedside.
Relatives are asked to contact the ward between 10am and 12pm midday with all non-urgent
telephone enquiries. This ensures that the nursing staff can give the information and time
needed and are not being pulled away from patient care activities.
•Phone Calls after 10am -
Other Initiatives
Cwm Taf Health Board
• Fully established multi-disciplinary Thrombosis Committee
• Thrombrophylaxis Policy approved June 2010
• Thromboprophylaxis Risk Assessment Forms localised and launched December 2010
• Audit processes being developed and implemented
• Thromboprophylaxis Education Programme developed
Hospital Acquired Thrombosis
Cwm Taf Health Board
DVT/PEDVT/ PE Incidences
0
10
20
30
40
50
60
70
Oct-
09
Nov-
09
Dec-
09
Jan-
10
Feb-
10
Mar-
10
Apr-
10
May-
10
Jun-
10
Jul-
10
Aug-
10
Sep-
10
Oct-
10
Nov-
10
Dec-
10
Jan-
11
Feb-
11
Mar-
11
Month
Nu
mb
er Number
PCH
RGH
Approval of
Thromboprophylaxis PolicyLaunch of Risk Assessment Forms
Hospital Acquired Thrombosis
Cwm Taf Health Board
Mortality General Medicine RAMI Trend
60
70
80
90
100
110
120
130
Ap
r'09
May
Ju
n
Ju
l
Au
g
Sep
Oct
No
v
Dec
Jan
Feb
Mar
Ap
r'10
May
Ju
n
Ju
l
Au
g
Sep
Oct
No
v
Dec
Jan
Feb
Mar
20
09
/11
General Medicine Linear (General Medicine)
Reduce Mortality & Harm
Cwm Taf Health Board
Rapid Response to
Acute Illness
• Regular Audit of compliance with MEWS
• 100% compliance in ITU with
– Severe Sepsis Bundle
– CVC Insertion & Maintenance Bundle
– VAP Bundle
• Outreach Teams in place on both sites
– 9 month Review (July 2010 to April 2011)
Cwm Taf Health Board
Main aims of
outreach service• Identifying the deteriorating patient and
averting/facilitating timely admissions to ITU
• Support and seamless care to patients
transferred from ITU to the wards
• Education of ward staff in the identification
and management of the deteriorating patient
Rapid Response to Acute Illness
Cwm Taf Health Board
Origin of the
referralsReferral made by
Ward nurse
Anaesthsetics/ITUNurse Pracs
Reg/SPR
SHO
ICU Consultant
Arrest Call
Clinical site/Bed ManagerMedica/Surgicall ConsultantWard Sister
HO/FY1
Physio
Recovery Nurse
Diabetic Nurse
Resp Nurse
Rapid Response to Acute Illness
Cwm Taf Health Board
Time of referrals
• 108 referrals made between 08:00-12:00
• 204 referrals made between 12:00-20:00
• Most referrals are taken between 14:00
and 17:00
Rapid Response to Acute Illness
Cwm Taf Health Board
Reasons for the
referrals
Rapid Response to Acute Illness
Cwm Taf Health Board
Referral rates
•
27
47
38
47
30
35
27
22
27
31
0
5
10
15
20
25
30
35
40
45
50
July August September October November December January February March April
Rapid Response to Acute Illness
Cwm Taf Health Board
MEWS Scores on
initial referral
0
5
10
15
20
25
30
35
40
45
MEW
S 0
MEW
S 1
MEW
S 2
MEW
S 3
MEW
S 4
MEW
S 5
MEW
S 6
MEW
S 7
MEW
S 8
MEW
S 9
MEW
S 10
MEW
S 11
MEW
S 12
Series1
Rapid Response to Acute Illness
Cwm Taf Health Board
Number of patients with delay in
referral according to triggering MEWS ≥ 5
7.4
5.86.2
7 76.6
8
5
88.5
7
5
7
6 6
5
8
0
2
4
6
8
10
12
14
Rapid Response to Acute Illness
Cwm Taf Health Board
Admissions to
ITU averted
55%
24%
20%
1%
Number of Admissions Averted
Possibly
Definetly
N0
<Not entered>
Rapid Response to Acute Illness
Cwm Taf Health Board
Hospital Mortality of
Follow-ups
• Acknowledge limitations of analysing such
data
• Pre-outreach (9months):
– 379pts left ITU alive, of whom 39pts died
prior to hospital d/c (10% mortality)
• Post-outreach (9months):
– 371pts left ITU alive, of whom 34pts died
prior to hospital d/c (9% mortality)Rapid Response to Acute Illness
Cwm Taf Health Board
Interview Quotations
• “…there is a stark contrast in the quality of care that critically
ill patients receive at night compared to the day; because
there aren‟t any critical care nurses…make Outreach 24hrs
and I have no doubt there will be a major improvement to
overall mortality and morbidity”
» (Surg SPR)
• “…we weren‟t realy sure what to expect initially, but they realy
have proven their worth with their input, suggestions, advice
and ability to work as part of the multi-disciplinary team…”
• (Ward Staff Nurse)
Rapid Response to Acute Illness
Cwm Taf Health Board
Interview Quotations
• “The obvious failures are the patients that Outreach aren‟t
informed about….” (ITU SPR)
• “…Friendly, approachable, knowledgeable, supportive yet
not intrusive, helpful. They share their skills readily and are
informative helping me to achieve targets by their approach
used to achieve comfort, dignity and general improvement in
patient care and outcome…. I hope their role continues
because they enhance my personal aims in providing
excellent care and I would like to say „thank you for being
there‟…”
(Ward Staff Nurse)
Rapid Response to Acute Illness
Cwm Taf Health Board
A Patient’s JourneyS- 36yr old male admitted 1/7 previously with hx of gastritis, diagnosed with pancreatitis on grounds of a raised amylase (790).
B- Recent redundancy and stresses, treated for symptoms of gastritis with GP 1/52 previously. Nil PMHx of note.
A- O/E pt in toilet passing coffee ground vomit. Encouraged pt to return to bed area for assessment. Pt in extremis:
R- Fluid challenge
Insert IDC
ABG following 1.5l fluid in 2hours (r/v acid-base)
Senior R/v (SPR in OT – will r/v in 1hour)
If acidosis improving with fluid, continue aggressive fluid resus
If acidosis worse despite filling for ITU R/v
Further venous access
Rpt U+Es in 4 hours – if ARF worse despite filling consider ITU R/v
R/v if further investigations re. abdo required
Rapid Response to Acute Illness
Cwm Taf Health Board
Anticoagulation :Re-engineering out-patient clinics
• Royal Glamorgan Hospital (RGH) INR clinics changed to pharmacist led, Point of Care Testing (POCT) in September 2008
• Implemented computer dosing and patient management system in RGH clinic
• Audit data demonstrates improvements:
• Developed standard primary care clinical protocols for POCT
• Future actions:
– To roll out POCT model across LHB, including primary care clinics
– Development of training program for both primary and secondary care practitioners
Previous Re-Engineered
INR INR
Service Service
DNA 10% 3.2%
Time In Range (TIR) 57% 73%
Documented Clinical Information 46% 100%
Medicines Management
Cwm Taf Health Board
AnticoagulationAll Cwm Taf Outpatient INR clinics
Cwm Taf – All
outpatient INR
clinics
% of patients
with INRs
>5 and >8
Cwm Taf out-patient INR clinics - total % patients with INR >5 & >8
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10
Month
% o
f o
ut-
pat
ien
ts
CT % patients >5
CT % patients >8
Linear (CT % patients >8)
Linear (CT % patients >5)
Medicines Management
Cwm Taf Health Board
Anticoagulation: INR
Cwm Taf Total
% of INR tests >5
and >8
(inpatients &
outpatients)
Cwm Taf % INR tests >5 & >8
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
Apr -08
Jun0
8
Aug
08
Oct08
Dec0
8
Feb
09
Apr09
Jun0
9
Aug
09
Oct09
Jan-10
Mar-10
May
-10
Jul-1
0
Sep
-10
Nov-10
Jan-11
Mar-11
May
-11
% t
ests % INR tests
>5
% INR tests
>8
Linear (%
INR tests
>5)
Medicines Management
Cwm Taf Health Board
8am- Patients arrive at
YCR and queue (no
appointment system)
Nurse collects yellow
books (YB)
Match up YB with
white card and attach
stickers
Patients called into
blood room for blood
test
Bloods transported to
RGH Pathology by taxi
Most patients leave the
clinic
YBs sent to receptionist
to “book in” to Pathology
system
YB to another
receptionist to book
into clinic on PAS
system Patients who stay to see
doctor wait in main
waiting room or call back
at 11am
Blood results entered
into Pathology system
10.30 - Doctor arrives,
nurse gets results and
doctor decides on dose of
warfarin
YB given to nurse in
consulting room where
prepared and receive
blood results (2 piles)
Dose and next
appointment written on
YB, put in envelope
and posted to patient
If patient needs a
change in dose that day
– telephoned after clinic
finished
Process map –
current INR service
Medicines Management
Cwm Taf Health Board
Patient leaves with
all information
and next
appointment date
Patient arrives at
RGH just before
appointment time
Receptionist
books patient into
clinic on PAS
system
Patient waits to be
called in
Patient called in
clinic and finger
prick blood test,
result,
consultation and
new date given
Process map –
Re-designed POCT service
Medicines Management
Cwm Taf Health Board
Patient Experience
How does service compare with previous
arrangements?
much better
better
no difference
worse
Medicines Management
Cwm Taf Health Board
Patient Experience –Hospital or GP monitoring?
A Pie Chart Showing Patients' Preference for a GP- or RGH-
Provided Anticoagulation Clinic
GP
28%
RGH
35%
No Preference
37%
Medicines Management
Cwm Taf Health Board
Patient Story
• Mrs M, age 52
• Warfarin for 6 years following heart valve
replacement
• Originally unstable INR, monitored in UHW,
then transferred to RGH out-patients
• Experience was of long waiting times, often
here all morning (“Warfarin day out”)
• INR was quite unstable, sometimes required
injections to stop it going too low.
Medicines Management
Cwm Taf Health Board
Patient Story
• At first was apprehensive about change in service but quickly re-assured
• Biggest improvements are
– Much lower waiting times
– Immediate INR result
– Finger prick test (patient also has own machine)
– Keeps own Yellow Book and new dose given there and then
Medicines Management
Cwm Taf Health Board
Patient Story
• Mrs M feels INR control is now much
better
• Attends clinic every 3-4 weeks
• Reassured that back up advice always
available from clinic staff if needed (feels
more “in control” herself)
• Discusses medication changes with
pharmacists in clinic
Medicines Management
Cwm Taf Health Board
Patient Story
“I FEEL AS THOUGH I HAVE GOT MY
LIFE BACK – WARFARIN IS NOW A
PART OF IT”
Medicines Management
Cwm Taf Health Board
Stroke
1st Hours Bundle
% compliance with First Hours bundle
Cwm Taf Stroke patients
from Jan 2010 to Apr 2011
0
10
20
30
40
50
60
70
80
90
100
Jan
2010
Feb
2010
Mar
2010
Apr
2010
May
2010
Jun
2010
Jul
2010
Aug
2010
Sep
2010
Oct
2010
Nov
2010
Dec
2010
Jan
2011
Feb
2011
Mar
2011
Apr
2011Months
Cwm Taf Health Board
First Days Bundle
• CT scan – 82%
• Weekend admissions. Since whiteboard has been in use on AMU, all patients have been compliant
% compliance with First Days bundle
Cwm Taf Stroke patients
from Jan 2010 to Apr 2011
0
10
20
30
40
50
60
70
80
90
100
Jan
2010
Feb
2010
Mar
2010
Apr
2010
May
2010
Jun
2010
Jul
2010
Aug
2010
Sep
2010
Oct
2010
Nov
2010
Dec
2010
Jan
2011
Feb
2011
Mar
2011
Apr
2011Months
Stroke
Cwm Taf Health Board
First 3 Days Bundle
% compliance with First 3 Days bundle
Cwm Taf Stroke patients
from Jan 2010 to Apr 2011
0
10
20
30
40
50
60
70
80
90
100
Jan
2010
Feb
2010
Mar
2010
Apr
2010
May
2010
Jun
2010
Jul
2010
Aug
2010
Sep
2010
Oct
2010
Nov
2010
Dec
2010
Jan
2011
Feb
2011
Mar
2011
Apr
2011Months
Stroke
Cwm Taf Health Board
First 7 Days Bundle
% compliance with First 7 Days bundle
Cwm Taf Stroke patients
from Jan 2010 to Apr 2011
0
10
20
30
40
50
60
70
80
90
100
Jan
2010
Feb
2010
Mar
2010
Apr
2010
May
2010
Jun
2010
Jul
2010
Aug
2010
Sep
2010
Oct
2010
Nov
2010
Dec
2010
Jan
2011
Feb
2011
Mar
2011
Apr
2011Months
Stroke
Cwm Taf Health Board
Mortality Cardiology RAMI Trend
0
20
40
60
80
100
120
Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar
2009/10 2010/11
2009/1
1
Cardiology Linear (Cardiology)
Reduce Mortality & Harm
Cwm Taf Health Board
Chronic Heart Failure
• Initial audit October 2010
• 1000 lives implementation January 2011
• Repeat audit February 2011
Heart Failure
• Collect information about:– Accuracy of documentation in
notes
– Referrals to heart failure service
– Prescribing of ACE/ARB and
betablockers
– Warfarin prescribing in AF
– Impact of prompt stickers
Cwm Taf Health Board
Methods
• Baseline Audit– 100 patients randomly selected with a discharge diagnosis of
heart failure (ICD coding 150.0 – 150.9)
• Repeat Audit– 41 consecutive discharges from cardiology ward (44%
documented heart failure)
Heart Failure
Cwm Taf Health Board
Results
Diagnosed Heart Failure Baseline Repeat
Echo 67% 100%
Referred to Heart
Failure nursing service
42% 78%
ACE Inhibitor 90% 89%
Betablocker 68% 67%
Warfarin for AF 74% 100%
Heart Failure
Cwm Taf Health Board
Work streams
• Executive Leads & Operational Leads Identified
• Work stream groups being established
• Baseline audits & scoping exercises being undertaken
• Enhanced Recovery After Surgery
• Mental Health
• Improving Maternity Services
• Reducing Falls in the Community
Cwm Taf Health Board
Key Contact Information
Dr David Cassidy – Assistant Medical Director for Governance & Quality Improvement
Kellie Jenkins-Forrester – Clinical Governance Manager
Patient Care & Safety Unit
Cwm Taf Health Board
Administration Block
Dewi Sant
Pontypridd
CF37 1LB