Improving Quality, Evidence Based Implementation (Reliable Care Delivery)

1. Improving Quality,Evidence Based Implementation (Reliable Care Delivery) Andrew Longmate Shaun Maher Alison Hunter

2. Safety and Improvement • We want the best care for our patients using the best known evidence • All of us have been involved in raising standards over many years of professional life • Clinical professional culture and training instils intense personal responsibility for quality.

3. Many “Leaks” from research & practice Aware Accept Target Doable Recall Agree Done Valid Research If 80% is achieved at each stage then 0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 = 0.21 • Doubling time for knowledge is 19 years • Rate of uptake of new evidence is low • It takes between 17 and 20 years for wide acceptance of new things

4. Evidence Based Delivery added to complement EBM LOX-GNH145-20071113-BVJM

5. EBM LOX-GNH145-20071113-BVJM

6. Reliable Sepsis Resuscitation ? • 4 Hospitals • GRI • RAH • SRI • WIG

8. Basic Resus Bundle Compliance • Lactate measured within 6 hrs 100% • Blood cultures prior to Abx 33% • Abx given within 3 hours of admission 22% • Fluid bolus for low BP / Lactate > 4 89% • Overall compliance 11%

9. 20 patients to critical care from front door in 4 months. Only 55% (11 out of 20 ) received all elements of a basic bundle which included: • Serum lactate measured within 3 hours of admission • Blood cultures prior to antimicrobial administration • Broad-spectrum antibiotics within 3 hours of admission • Fluid resusitation within 6 hours for hypotension (SBP<90 or MAP<65)

11. ER Bundle Lactate Measured Blood Cultures Done Before Antibiotic Appropriate Antibiotic Given Proper Fluid Resuscitation Vasopressors if not Fluid Responsive ICU Bundle CVP & ScvO2 Measured Blood Transfusion or Ionotrop Given Glucose Control < 15 Achieved Steroids Given Appropriately Activated Protein ‘C’ Considered Vt Kept < 6 ml/kg PBW as needed

12. SICS/SICSAG • Research • Measurement (audit) • Are in a fantastic position to develop our expertise with delivery and implementation and become world leaders

13. DAILY GOALS Golden Jubilee National Hospital Heart & Lung Centre I.C.U.

14. BACKGROUND • Heart & Lung Centre formed March 2008 • 19 funded I.C.U. beds • Post cardiac & thoracic surgery, heart failure, interventional cardiology • 2 open units

15. WHY DAILY GOALS ? “The care team must understand clearly the goals of care that includes the tasks to be performed, care plan, and communication plan.” 1 “One means to facilitate the effective physician communication necessary to promote a collaborative environment is through the use of written “daily goals”2 1. Improving Communication in the ICU Using Daily Goals Peter Pronovost, Sean Berenholtz, Todd Dorman, Pam A. Lipsett, Terri Simmonds, and Carol HaradenJournal of Critical Care, Vol 18, No 2 (June), 2003: pp 71-75 2. Bringing quality improvement into the intensive care unit Tracy R. McMillan, MD; Robert C. Hyzy, MD Crit Care Med 2007 Vol. 35, No. 2 (Suppl.)

16. DAILY GOALS 1November 08 – 09 • Initially on paper format • Electronic patient record late summer 2009 • No system of review in afternoon/evening • Poor reliability & specificity of goals

17. SICSAG 09 - THE 5 WHYs • The 5 whys - process • The worksheet – back to paper • The ward round – embed the goals • ADEPT framework • Aim – set some • Process – redesign • Team – involve & engage

18. DAILY GOALS 2 – Jan 2010 - • Fellowship project • Start again – lots of small tests • Paper format – neon yellow • Set specific aims • Reliable, robust, reviewed • Simplified goals – initial focus on sedation & weaning • Utilise nursing staff, engage medical staff

19. Tests SUCCESSES • Paper format • Two goals • Utilising nurses • Agreeing a shared baseline • Encouraging redesign • Data • Process reliability • Outcomes FAILURES • Using nagging as an implementation strategy • Reading back & all other forms of excessive tinkering • Aligning with CIS

20. DAILY GOALS 2 Process Measure

21. Communication Measure

22. Outcome Measure Clinical Information System ?

23. Outcome Measure 8 data points below centre line demonstrates a shift in the process

24. Outcome Measure

25. Outcome Measures

26. OUTCOMES • Mean length of stay in non MCS patients reduced by 0.6 days & reduced variation • Communication measurably improved • VAP not improved but has allowed focus on failing elements of process

27. OUR LEARNING • Simpler is better • Setting an aim is essential • Visual cue is helpful • Agreeing a standard is indispensable • Medical leadership is vital • Testing gets buy - in • Measurement drives the improvement

28. References • Improving Communication in the ICU Using Daily Goals. Peter Pronovost, Sean Berenholtz, Todd Dorman, Pam A. Lipsett, Terri Simmonds, and Carol Haraden Journal of Critical Care, Vol 18, No 2 (June), 2003: pp 71-75 • Bringing quality improvement into the intensive care unit.Tracy R. McMillan, MD; Robert C. Hyzy, MD Crit Care Med 2007 Vol. 35, No. 2 (Suppl.) • Quality Health Care : a guide to developing and using indicators. Robert Lloyd Ph.D. Published by Jones and Bartlett, 2004 • http://www.indicators.scot.nhs.uk/SPC/Main.html

29. Bringing patients and their families into the ICU team A roadmap to person-centredness

30. Background – policy The Six Dimensions of Quality Care Safe Effective Patient Centred Efficient Timely Equitable (IOM 1999 – Crossing the Quality Chasm)

31. NHS Scotland Healthcare Quality Strategy (May 2010) Background – policy • Caring & compassionate staff • Good communication (inc. listening) • Collaboration (between provider & recipient) • Clean hospitals • Continuity of care • Clinical excellence

32. Background – impact? • Orthopaedics – LOS effic. outcomes • DiGioia et al (2009) (USA) • Neonatal / Paed. ICU – safety LOS • Ortenstrand et al (2010) (Swedish) • Cancer Care - safety Quality • Ponte & Peterson (2008) (USA) • GI Service Redesign- Waiting Adm LOS • Rejler et al (2007)(Swedish) What about adult ICU?

33. Background - literature Critical Care Family Needs Inventory (CCFNI) (Molter & Leske 1983) • Proximity & Access • Information • Assurance • Comfort & support Review of 57 Belgian ICU’s – ALL reported using restrictive visiting policies. Vandijck et al; Heart & Lung; March 2010 Families of pts in ICU suffer from significant levels of anxiety, depression, PTSD Jones et al; Int. Care Med 2004 Pochard et al; Crit Care Med 2001

34. Background – our experience • Sept 2006: Families experience of ICU • 23 families • Found it difficult to retain information • Found environment bewildering • Written communication would be helpful • Information about functioning of an ICU would be helpful • Would like visiting to be more flexible

35. Proposed Improvements • Invite families to participate in setting daily goals • Abolish restrictive visiting in favour of flexible visiting

49. Implementation • Daily Goals Tool • Lots of small tests over a 4 wk period Mar/Apr 2010 • 1pt 1 nurse, then 2, then 3, and all • Opportunity to iron out flaws & make tool fit for purpose • Raised awareness amongst staff, gave opportunity to get used to tool, ask questions, etc.

50. Implementation • Flexible Visiting • Evoked strong emotions! • Not amenable to small tests of change! • Informal coffee-room focus groups (Mar – July 2010) • Formal focus groups at tutorial time (Mar – July 2010) • 1-2-1 interviews with key personnel (Mar – Apr 2010) • Formation of guidance document & circulated for comment • August 2010 - implementation • Teething problems