Peter Toohey, Patient Safety Improvement Manager, UCLPartners

#QIinAKI #QIinSepsis @UCLPartnersPSP @pete_toohey

The UCLPartners Patient Safety Programme: Update

Patient Safety Priority Matrix

Together, Sepsis & AKI account for two thirds of potential mortality avoided from the top 8 interventions nationally

3

Intervention Potential Benefit –

Lives saved (per 100,00)

PYLL (per 100,00) <75

1 Implementation of NICE guideline on Acute Kidney Injury 19 (PYLL reduction all ages

estimated at 161)

2 Implementation of the Sepsis Six Care Bundle 18 -

3 Implementation of British Thoracic Society Care Bundle for community acquired pneumonia

6 83

4 Increased prescription of anti-thrombotics (warfarin) for patients with atrial fibrillation

4 28

5 Earlier stage of diagnosis of cancer 3 29

6 Intermittent Pneumatic Compression to prevent post stroke Deep Vein Thrombosis

2 14

7 Prevention of Venous Thromboembolism 2 -

8 Increased update of cardiac rehabilitation 1 10

Reconfiguration of hyper acute stroke services along the lines of London stroke services reconfiguration was also identified as a priority, although assessments of the relative benefits of national roll-out are complex

Source: NHS England

The IHI breakthrough series collaborative engine

UCLPartners Sepsis Collaborative Driver Diagram

Reliable identification & treatment of sepsis

in UCLP partner organisations

Outcome: Reduction in mortality

in pilot population

20% by March 2017

Recognise-Prompt identification of

patient with Sepsis

Evalutate-Follow-up review

Inform-Immediate referral to

doctor/nurse able to deliver treatment

Treat-Timely care delivery (e.g., iv

antibiotics within 1 hour)

AIM PRIMARY DRIVERS

Education and Awareness

Process measurement plan Review ≥10 patient records each month where patients’ ≥18 years old, on non-elective / emergency pathway, for active treatment; likely to have sepsis, e.g. blood cultures taken in first 24hours, or in ICD-10 codes A40/A41. Denominator is number of patients’ reviewer identifies with evidence of severe / ‘red flag’ / new definition sepsis – or septic shock – in the ED (or ward). Numerator values are numbers of patients with evidence for each of eight recommended indicators.

Culture of Safety & Quality Improvement

Patient & Family Centred Care

Reliable screening

Recheck after treatment Antimicrobial stewardship

Reliable referral process, communications & documentation

Reliable, timely treatment & source control

SECONDARY DRIVERS

Education Training

Executive sponsorship Clinicial leadership M.D.T. working Measurement

Patient involvement

1. All six vital signs recorded within 15 minutes of presentation (RR, SpO2, HR, BP, AVPU / GS, including New Confusion, temperature)

2. The word ‘sepsis’ written / highlighted / ticked in patient record within 1 hour of presentation

3. Documented iv antibiotics within 1 hour of presentation

4. Blood cultures obtained within hour

5. ≥500 mL iv fluid given within 1 hour of presentation (unless clear contra-indication)

6. Documented review within 3 hours after presentation (+/-30 mins.)

7. Evidence of escalation if not improved (no reduction in NEWS score / NEWS score still ≥5)

8. Documented review of antimicrobial therapy within 48 hours of presentation

KEY MEASURES

‘STOP AKI’- Driver Diagram

Reduce 30 day mortality following admission with AKI by 25% from baseline

value

To increase by 25% proportion of patients

who recover renal function (20% baseline creatinine) at 30 days

Improved patient experience and wellness

scores**

* Staff awareness and engagement campaign* Recruit AKI improvement team and MDT champions in acute admitting areas and ED* Staff training and education programme in admitting areas* Launch local guideline/pathway/’bundle’, AKI outreach team

Door to recognition of AKI less than 4 hours*

Door to Relief of obstruction less than 36 hours*

Door to fluids and/or antibiotics in

sepsis/hypoperfusion AKI less than 6 hours*

Door to cessation of nephrotoxins where drug toxicity contributory less

than 12 hours*

Training on fluid assessment in ED/AMU, rapid cannulation, nurse led-resuscitation, grab bags or sepsis trolley, antiobiotic guidance, senior review for fluid assessment

all AKI

Increase imaging capacity for ED/acute medicine patients with AKI, radiological prioritisation of AKI requests, use of CT KUB if limited US capacity, strengthen

pathways or outreach systems/telemdicine for urology or interventional radiology support

Staff education, incorporate AKI nephrotoxin screening in medicines reconciliation/nursing admission/medical admission/consultant ward round review, e-prescribing screening and decision support for AKI, early pharmacy review all AKI

patients

AIM PRIMARY DRIVERS(COLLABORATIVELY

AGREED)

EXAMPLE: SECONDARY DRIVERS (LOCALLY DESIGNED AND TESTED)

Door to therapy of renal disease for primary renal disease AKI less than 72

hours*

Blood test at triage, point of care creatinine, fast-track blood sample delivery,priority ED and acute medicine laboratory runs, install LIMS detection algorithm

with biochemistry phone out to teams, install LIMS detection algorithm with automated e-alert, AKI status in admission proforma (nursing or medical)

Staff education, urine dipstick all patients, fastrack and phoneback of all AKI diagnostic bloods, streamline specialist nephrology consultations, increase nephrology rounding or telemedicne, fastrack nephrology transfers with

appropriate escalation

** Primary and secondary drivers are currently being worked up with the AKI Patient Experience and Wellness Working Group.

The IHI breakthrough series collaborative engine

We are here

Key messages from the projects and learning sessions

Insights from the project

• Trusts giving or enabling dedicated time to do this project/participate is key

• Sharing and learning from the learning sessions and webinars is extremely positive (feedback from participating teams and individual team members)

High impact actions for leadership

• Share the data with your board, quality and safety committee

• Create visibility and acknowledge team’s efforts

• Ensure and maintain executive sponsorship

• Ensure the team have dedicated time where possible to work as a team with defined roles and members to support this work

Peter Toohey, Patient Safety Improvement Manager, UCLPartners

Thank you!

#QIinAKI #QIinSepsis @UCLPartnersPSP @pete_toohey