© trillium health centre 2006 improving quality & patient safety evidence based order sets an...

© 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


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


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


Current Context:

The Need for Order Sets


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


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


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


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


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


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


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


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


Order Sets:

Improving Care


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


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.


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


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


0

100

200

300

400

500

600

700

800

900

1000

Num

ber o

f Dos

esUse of Low Molecular Weight Heparin

LMWH Introduced into Medical Order Sets


0

5

10

15

20

25

30

35

40

45

50M

onth

ly D

VT P

roph

ylax

is R

ates

(%)

LMWH

Regular Heparin

LMWH Introduced Into Order Sets


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


0

5

10

15

20

25

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


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


The Order Set Challenge



Order Sets Must Be:

Current

Evidence Based and Best Practice

Authoritative

Easy to Use

Comprehensive

Reliable and safe

Clinically Intelligent


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



Current Status of Order Sets


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


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


Order Set Innovation


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 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


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


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


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


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


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


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


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


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


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


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


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



“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”


Thank You!

Chris O’Connor M.D. FRCPC

Katharine De Caire ACNP

© trillium health centre 2006 improving quality & patient safety evidence based order sets an...

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