DELIRIUM PREVENTION.. A NON - PHARMACOLOGICAL …...•Pre-delirium care bundle
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HAP/VAP care bundle interventions - a UK approach
Dr R G MastertonNHS Ayrshire & Arran
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How Hazardous Is Health Care?
1
10
100
1,000
10,000
100,000
1 10 100 1,000 10,000 100,000 1,000,000
10,000,000
Number of encounters for each fatality
Tota
l liv
es lo
st p
er y
ear
REGULATEDHAZARDOUS(>1/1000)
ULTRA-SAFE(<1/100K)
Health Care
Mountain Climbing
Bungee Jumping
Driving
Chemical Manufacturing
Chartered Flights
Scheduled Airlines
European Railroads
Nuclear Power
(Leape and Amalberti)
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Healthcare Quality Strategy• 3 Quality Ambitions
– Mutually beneficial partnerships between patients, their families and those delivering healthcare services. Partnerships which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making.
– No avoidable injury or harm from the healthcare they receive, and that they are cared for in an appropriate, clean and safe environment at all times.
– The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, with no wasteful or harmful variation.
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Healthcare Quality Strategy• 3 Quality Ambitions
– Mutually beneficial partnerships between patients, their families and those delivering healthcare services. Partnerships which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making.
– No avoidable injury or harm from the healthcare they receive, and that they are cared for in an appropriate, clean and safe environment at all times.
– The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, with no wasteful or harmful variation.
Person centred
Harm
Waste & Variation
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Quality Measurement Framework
Quality Outcome Measures
HEAT
Supporting local and national quality indicators
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1 2 3 4 5
QUALITY INITIATIVES COST REDUCTION PROGRAMMES
Costs more Cost neutral Improves quality Quality neutral Reduces qualityreduces costs
3
Healthcare Quality & Cost
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“To do things differently, we must see things differently. When we see
things we haven’t noticed before, we can ask questions we didn’t know to
ask before.”
John Kelsch, XeroxQuality Health care in America Project
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Care Bundle
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HAP Guideline RecommendationsGrade Prevention Diagnosis Treatment
A 11 5 5
B 10 0 6
C 9 5 3
D 8 2 3
GPP 60 6 10
Masterton et al. J Antimicrob Chemother. 2008;62:5-34.
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HAP Guideline RecommendationsGrade Prevention Diagnosis Treatment
A 11 5 5
B 10 0 6
C 9 5 3
D 8 2 3
GPP 60 6 10
Masterton et al. J Antimicrob Chemother. 2008;62:5-34.
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1. Set of around 5 evidence-based interventions that apply to all patients with a common disease.
2. Ensure the delivery system means the interventions are delivered.
3. Compliance is “all” or “nothing.” 4. Measure outcomes to ascertain benefits.5. Develop the will to deliver “all the time every
time”.
Masterton. Intensive Care Med. 2009;35:1149-51.
What is a “Care Bundle”?
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Success of Care Bundles in Healthcare Environment
• Institute of Healthcare Improvement ‘100K Lives Campaign’ in USA has now become the ‘5 Million Lives Campaign’
Care Bundles demonstrated to be highly effective:– Central Line Bundle has reduced bloodstream infections– Ventilator Bundle has reduced ventilator associated pneumonia
• Care Bundles to prevent HCAI are advocated High Impact Interventions in the Department of Health ‘Saving Lives’ delivery programme
Seven Care Bundles published to date:– Most for insertion/care of indwelling catheters/devices– Care Bundle for prevention of spread of Clostridium Difficile includes an
element for prudent antibiotic prescribing
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Severe Sepsis Bundles
•Bundle use = consistent and significant improvement in survival•Antibiotic administration, timing and appropriateness = maximum outcome benefit.
Khan et al. Indian J Crit Care Med. 2010 ;14: 8–13
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• The New Treatment Paradigm
• VAP Care Bundle
• Antimicrobial Care Bundle
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THE NEW TREATMENT PARADIGM
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The New Treatment Paradigm• Start with the appropriate empiric antibiotic first
in nosocomial infections• If appropriate, change antibiotic dosage or
therapy based on resistance and pathogen information
• Recognise that prior antimicrobial administration is a risk factor for the presence of resistant pathogens
• Know the unit’s resistance profile and choose antibiotics accordingly
• Administer antibiotics at the right dose for the appropriate duration
Masterton. Int J Antimicrob Agents. 2009 ;33:105-110.
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Rello et al. Crit Care Med 2003;31:2807–2808
Septic shock0
10
20
30
40
50
SepsisSevere shock
43
2320
Improved survival rate (%)
Getting it right……………
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The Clock is ticking……………
0102030405060708090
0.5 1 2 3 4 5 6
Delay in treatment (hours) from hypotension onset
Surv
ivia
l (%
)
Each hour off delay carries 7.6% reduction in survival
Kumar et al. Crit Care Med 2006; 34:1589-1596.
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The New Paradigm in a Care Bundle
• Secondary analysis of prospective before–after study
• Intervention: emergency department sepsis bundle
• Bundle components– Patient identification– Fluid resuscitation– Vasopressor administration– Antibiotic recommendations
Shorr, et al. Crit Care Med 2007;35:1257–1262
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p=0.009
0
20 000
40 000
60 000
80 000
100 000
Cost
per
pat
ient (
US $)
GroupBefore After
Mortality reduced with protocol from 48.3% to 30.0% (p=0.04)
Tota
l cos
t (US
$)
Group
0
20 000
40 000
60 000
80 000
Before After
Total group Survivors
Shorr, et al. Crit Care Med 2007;35:1257–1262
The New Paradigm in a Care Bundle
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Total cost differential: $573,000
0
400
800
1,200
1,600
2,000
Total ICU Ward Pharmacy Lab Rad RT ED OR Misc
Costs
(US$
x 10
00)
Before After
Shorr, et al. Crit Care Med 2007;35:1257–1262
The New Paradigm in a Care Bundle
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Median LOSPre: 10 daysPost: 7.5 days
Prop
ortio
n of s
ubjec
tsre
maini
ng ho
spita
lised
p=0.0023
0.0
0.2
0.4
0.6
0.8
1.0
0 10 20 30 40Length of stay (days)
Pre-interventionPost-intervention
Shorr, et al. Crit Care Med 2007;35:1257–1262
The New Paradigm in a Care Bundle
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VAP CARE BUNDLE
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The “Care Bundle” Approach
• VAP Care Bundle– 5 simple, basic, universally accepted
components• Bed elevation• Sedation vacation• Daily weaning assessment• Peptic ulcer prophylaxis• DVT prophylaxis
Craven. Chest;2006;130:251-260
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VAP Care Bundle – The Top Ten
600 620 640 660 680 700 720
De-escalate in responding patients once culture results available
Monotherapy in preference to combination therapy in those not at risk for pseudomonas or MDR
Sedation vacation and weaning protocol
Short duration of treatment therapy - 8 days if patient on appropriate regimen and not infected by MDR pathogen
Assess response within 72 hours
SD for mechanically ventilated patients greater than 48 hours
Non invasive ventilation preferred
Oral care with chlorhexadine
Immediate treatment following microbiological sampling
Empiric therapy based on knowledge of local pathogens and assessment of risk factors
PreventionDiagnosisTreatment
Rello et al. J Crit Care. 2010 May 26. [Epub ahead of print] & Intensive Care Med. 2010;36:773-80.
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VAP Care Bundle Treatment
600 620 640 660 680 700 720
De-escalate in responding patients once culture results are available
Monotherapy in preference to combination therapy in those not at risk for pseudomonas or MDR
Short duration of treatment therapy - 8 days if patient on appropriate regimen and not infected by MDR pathogen
Assess response within 72 hours
Immediate treatment following microbiological sampling
Empiric therapy based on knowledge or local pathogens and assessment of risk factors
Rello et al. J Crit Care. 2010 May 26. [Epub ahead of print] & Intensive Care Med. 2010;36:773-80.
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Impact of IHI VAP Improvement Bundle
The key components of the Ventilator Bundle are:
1. Elevation of the Head of the Bed 2. Daily "Sedation Vacations" and Assessment
of Readiness to Extubate 3. Peptic Ulcer Disease Prophylaxis 4. Deep Venous Thrombosis Prophylaxis5. Daily Oral Care with Chlorhexidine
Al-Tawfiq et al. Am J Infect Control. 2010 Apr 17. [Epub ahead of print].
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• VAP prevention bundle resulted in reduction of VAP rates from (P < .001) :– Mean of 9.3 cases/1000 ventilator-d in 2006 – Mean of 2.3 cases/1000 ventilator-d in 2007– Mean of 2.2 cases/1000 ventilator-d in 2008
• Each VAP case increased:– attributable hospital LoS by 10 days– mean hospital cost by $40,000.
Al-Tawfiq et al. Am J Infect Control. 2010 Apr 17. [Epub ahead of print].
Impact of IHI VAP Improvement Bundle
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1. Elevation of the Head of the Bed to 30˚
2. Daily Sedation Break
3. Discussion of Extubation and Weaning
4. Daily x4 Oral Care with Chlorhexidine
Al-Tawfiq et al. Am J Infect Control. 2010 Apr 17. [Epub ahead of print].
VAP Care Bundle in The Ayr Hospital
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VAP in The Ayr Hospital
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VAP in The Ayr Hospital
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ANTIMICROBIAL CARE BUNDLE
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The Antimicrobial Care Bundle• At initiation:
– Document clinical rationale for antibiotic initiation
– Appropriate specimens sent to diagnostic microbiology laboratory (according to local policy)
– Antibiotic selected according to local policy and risk group (exclude allergy)
– Consider removal of foreign body/drainage of pus/surgical intervention
Cooke et al. Int J Antimicrob Agents. 2007;30: 25–29.
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The Antimicrobial Care Bundle
• For continuation:– Daily consideration of:
• de-escalation• intravenous–oral switch• stopping antibiotics (based on review of clinical picture
and laboratory results)
– Antibiotic drug levels monitored as required by local policy
Cooke et al. Int J Antimicrob Agents. 2007;30: 25–29.
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The Antimicrobial Stewardship Bundle
• Documentation of treatment rationale• Collection of appropriate specimens• Appropriate empirical selection of
antibiotics according to local surveillance and formulary
• De-escalation• Selection of appropriate agents for
definitive therapyToth et al. American Journal of Health-System Pharmacy, 2010;67: 746-749.
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• A total of 160 patients and 442 antibiotic orders were evaluated.– 168 interventions were made, with an
acceptance rate of 91%. – De-escalation rose from 72% to 90% (p = 0.01). – Compliance with all quality indicators rose from
16% to 43% (p < 0.001).
Toth et al. American Journal of Health-System Pharmacy, 2010;67: 746-749.
The Antimicrobial Stewardship Bundle
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Success Through EducationThe Change Team
Bloos et al. British Journal of Anaesthesia 2009;103: 232–7 .
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Success Through EducationThe Change Team
Bloos et al. British Journal of Anaesthesia 2009;103: 232–7 .
•No difference in VAP frequency Audit I (33.1%) and Audit II (32.4%, P=0.68).
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Success Through FeedbackThe Electronic Dashboard
Zaydfudim et al. Arch Surg. 2009;144(7):656-662.
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Success Through FeedbackThe Electronic Dashboard
Zaydfudim et al. Arch Surg. 2009;144(7):656-662.
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Success Through FeedbackThe Electronic Dashboard
Zaydfudim et al. Arch Surg. 2009;144(7):656-662.
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Success Through “MMP”The Multimodal Programme
Hawe et al. Intensive Care Med. 2009;35:1180-6.
Multimodal programme = staff education, process measurement , outcome measurement, feedback to staff and organisational
change.
• VAP prevention bundle compliance increased after active implementation.
• VAP incidence fell significantly from 19.2 to 7.5 per 1,000 ventilator days. • Rate difference (99% CI) = 11.6 (2.3-21.0) per 1,000 ventilator days; • Rate ratio (99% CI) = 0.39 (0.16, 0.96).
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What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make that will result in improvement?
Act Plan
Study Do
When you combine the 3 questions with the…
PDSA cycle, you get…
…the Model for Improvement
Success Through the IHI ToolThe Model for Improvement
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