Download - Sustaining Quality
Sustaining Quality
“Expectations will always exceed capacity. The service must always be changing, growing and improving…”.
Aneurin Bevan, 1948
Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised
controlled trialsGordon C S Smith, Jill P Pell. BMJ 2003;327;1459-1461
• Aim: To determine whether parachutes are effective in preventing major trauma related to gravitational challenge.
• Design: Systematic review of randomised controlled trials
• Results: Our search strategy did not find any randomised controlled trials of the parachute.
Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised
controlled trialsGordon C S Smith, Jill P Pell. BMJ 2003;327;1459-1461
Conclusion:
As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials.
Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data.
We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute
“Society’s huge investment in technological innovations that only modestly improve efficacy,
by consuming resources needed for improved delivery ofcare, may cost more lives than it saves.”
“Health, economic, and moral arguments make the case for spending less on technological advances and more
on improving systems for delivering care.”
Fidelity vs Efficacy
$29 Billion
$32 Billion
$100 Million
0.002%
The aspirin example
• In patients who have had a stroke or TIA aspirin reduces risk by 23%
• 100,000 patients – 23,000 fewer strokes
• 58% of eligible patients receive aspirin = 13,340 fewer strokes
Two options
• Fidelity – increase to 100% of eligible patients = 9,660 strokes
• Efficacy – requires a proportional improvement over aspirin of 74%
• Clopidogrel = 10% more efficacy than aspirin
Outcome Aims
• Mortality: 15% reduction• Adverse Events: 30% reduction• Ventilator Associated Pneumonia: 0 or 300 days
between• Central Line Bloodstream Infection: 0 or 300
days between• Blood Sugars w/in Range (ITU/HDU): 80% or >
w/in range• MRSA Bloodstream Infection: 30% reduction• Crash Calls: 30% reduction
Example Interventions• Critical Care
– Ventilator acquired pneumonia bundle, central line• Ward
– Early rescue – Communication
• Medicines– Medicines reconciliation
• Theatres– Surgical pause– Infection prevention/control
• Leadership– Safety walkrounds– Executive leadership board patient safety profile
GRI VAP Prevention Bundle Sampled one day per week - varied day
Aim >95% Reliability by May 2009
30%
40%
50%
60%
70%
80%
90%
100%
Jun-
08
Aug-0
8
Oct-08
Dec-0
8
Feb-0
9
Apr-0
9
Jun-
09
Aug-0
9
Oct-09
Dec-0
9
All 4 components ofbundle
30° head up
Chlorhexidine used as part ofdaily mouth care
responsive to command; hadsedation hold; or describedexclusion
described weaning target ordescribed exclusion
AIM - how much by when
Daily Goals Sheet
Head-up redundancy
Script of questions to ask doctors
Re-testing at daily goals: handing script, using script, change daily goals sheet
DG sheet - reformatted,Prompts added
GRI VAP Prevention Bundle Reliability and VAP rate per 1000 ventilator days
Aim: > 95% reliability by March 2009
0
5
10
15
20
25
Aug-0
7
Oct-07
Dec-0
7
Feb-0
8
Apr-0
8
Jun-
08
Aug-0
8
Oct-08
Dec-0
8
Feb-0
9
Apr-0
9
Jun-
09
Aug-0
9
Oct-09
Dec-0
9
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Ventilator Associated Pneumoniarate per 1000 ventilator days
Median over first 6 months
Ventilator Associated Pneumoniacare bundle reliability (%)
AIM
DG sheet
Script of questions to ask Drs
Retesting at DG sheet; handling sript; change DG sheet
DG sheet change; prompts added
Last VAP 02/01/2009
GRI ICU Percentage had Daily Goals Setand Reviewed > 1 time
0%
20%
40%
60%
80%
100%
Jul-0
8
Sep-0
8
Nov-0
8
Jan-
09
Mar
-09
May
-09
Jul-0
9
Sep-0
9
Nov-0
9
Daily Goals Set and Reviewed > 1 time in the day Aim #1 >80% by March 2009, Aim #2 >95% by June 2009
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jun-
08
Aug-0
8
Oct-0
8
Dec-0
8
Feb-0
9
Apr-0
9
Jun-
09
Aug-0
9
Oct-0
9
Dec-0
9
GRI ICU Monthly Average Length of Stay (days)
02468
10121416
Jan-
03
Jul-0
3
Jan-
04
Jul-0
4
Jan-
05
Jul-0
5
Jan-
06
Jul-0
6
Jan-
07
Jul-0
7
Jan-
08
Jul-0
8
Jan-
09
Jul-0
9
Jan-
10
Days
UCL
LCL
Process Avg
Daily Goals & VAP Prevention bundle start
But Does It Work Outside SPSP?But Does It Work Outside SPSP?
Acute pain management in orthopaedicsAcute pain management in orthopaedics
GRI Acute Pain Bundle in Elective OrthopaedicsAIM: > 95% Reliability by January 2010 - for the red dot
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Apr-0
9
May
-09
Jun-
09
Jul-0
9
Aug-0
9
Sep-0
9
Oct-09
Nov-0
9
Dec-0
9
Jan-
10
All 4 components ofbundle implemented
Prescribed oral analgesics
Oral analgesics written upregularly not prn
Got Step 2 oral analgesic at22:00
≥ 6 pain recordings on chartin first 24 hours
Aim:Start data collection
Meet Julie – ward manager – set AIMSAIMS
Test drug recognition with recovery room nurses
Meet anaesthetists SH, CR, TMcL, JD – describe tests with recovery nurses
Test script of questions for recovery nurses to use 2 days per week
Spread to 5 days per week
Acute Pain in Elective Orthopaedics: Primary Hip & Knee ReplacementProcess AIM: Bundle reliability > 95% by end of Jan 2010Outcome AIM: Reduce both classifications of pain by 50%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
Acute Pain Bundle reliability
Aim
Patients with one or more episodeof moderate or severe pain in first24 hours (%)
Median for moderate or severe painfor 1st 6 months
Patients with one or more episodeof severe pain in first 24 hours (%)
Median for severe pain for 1st 6months
Only 45% patients with no or only mild pain in 1st 24 hours postoperatively
75% patients with no or only mild pain in 1st 24 hours postoperatively
526 patients 337 patients
Winter review
• Patient safety walk rounds continued during the winter period
• Daily monitoring and reporting of 8 hour trolley waits in the Emergency Departments
• An action tracker has been established to ensure that the key lessons for improvement are being progressed
• Data:– Breach Analysis of A&E waiting times– Boarder numbers– Delayed Discharges– Elective cancellations– Re-admission rates
The Healthcare Quality Strategy for NHSScotland
• Person-Centred - Mutually beneficial partnerships between patients, their families, and those delivering healthcare services which respect individual needs and values, and which demonstrate compassion, continuity, clear communication, and shared decision making.
• Clinically Effective - The most appropriate treatments, interventions, support, and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated.
• Safe - There will be no avoidable injury or harm to patients from healthcare they receive, and an appropriate clean and safe environment will be provided for the delivery of healthcare services at all times.
“We look to Scotland for all our ideas of civilisation.”
Voltaire (Francois Marie Arouet, 1694–1778)