The art of the possible ideasPresentation Transcript
Methods for Improvement Where are the Ideas? David I Gozzard Quality Improvement Fellow Health Foundation
An International Movement of Movements?
The Entire UK Is Engaged
To make the safety of patients everyone’s highest priority
No avoidable death and no avoidable harm
Leadership for safety
Reducing harm from deterioration
Reducing harm in critical care
Reducing harm in perioperative care
Reducing harm from high risk medicines
5.5 million people
Scottish Patient Safety Programme
37 acute hospitals
15% reduction in mortality
30% reduction in adverse events
5.5 million inhabitants
Health care is a public task
5 regions that are responsible for health care
38 hospital units
Rapid Response Systems
Central Line Bundle
Surviving Sepsis Campaign
Save 3000 lives during campaign period
All regions present at campaign start
Cover 75% of discharges
33 million people
10 interventions + 2 pilots
1035 teams enrolled
80% of acute care hospitals enrolled
All regional health organizations outside of Quebec enrolled
Reduce adverse events by 40-100% dependent upon intervention
http://kyodokodo.jp/ “ PARTNERS for Patient Safety ” National Campaign for Patient Safety in Japan Japan
3 million people
1000 Lives Campaign
All Hospitals, Primary Care and Ambulance services
Critical Care/Rapid response
Healthcare associated infection
General medical and surgical care
To save 1000 lives, and
Avoid 50,000 cases of harm
in 2 years from April 2008
Deploy Rapid Response Teams …at the first sign of patient decline
Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction …to prevent deaths from heart attack
Prevent Adverse Drug Events (ADEs) …by implementing medication reconciliation
Prevent Central Line Infections …by implementing a series of interdependent, scientifically grounded steps
Prevent Surgical Site Infections …by reliably delivering the correct perioperative antibiotics at the proper time
Prevent Ventilator-Associated Pneumonia …by implementing a series of interdependent, scientifically grounded steps
100,000 Lives Campaign
Reduce Surgical Complications – Adopt “SCIP”
Prevent Harm from High Alert Medications
Prevent MRSA Infections
Reduce Readmissions from Congestive Heart Failure
Prevent Pressure Ulcers
Get Boards on Board
5 Million Lives Campaign
Reducing Surgical Complications
Reduce surgical complications by 25 percent by December 2008 by reliably implementing the changes in care recommended by the Surgical Care Improvement Project (SCIP)
Four Key Interventions
Surgical Site Infection Prevention
Beta Blockers for Patients on Beta Blockers prior to Admission
Venous Thromboembolism Prophylaxis
Ventilator-Associated Pneumonia Prevention
Reduce Surgical Site Infections
Appropriate use of antibiotics
Appropriate hair removal
Postoperative glucose control (major cardiac surgery patients cared for in an ICU)*
Perioperative normothermia (colorectal surgery patients)*
* These components of care are supported by clinical trials and experimental evidence in the specified populations; they may prove valuable for other surgical patients as well.
The American College of Cardiology / American Heart Association Task Force on Practice Guidelines: “ Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina, symptomatic arrhythmias, hypertension, or other ACC/AHA Class I guideline indications ” (ACC/AHA Practice Guidelines. JACC. 2006; 47(11); 2342-2355).
In a study of 140 patients who received beta blockers preoperatively, eight patients had their beta blockers discontinued postoperatively and mortality was 50 percent, compared to mortality of 1.5 percent in the other 132 patients who had beta blockers continued (odds ratio 65.0, P<.001).
(Shammash JB, Trost JC, et al. Am Heart J. 2001;141(1):148-153)
What Does the Evidence Tell Us?
Venous Thromboembolism Prophylaxis (VTE)
Deep vein thrombosis (DVT) is estimated to occur in 10 to 40 percent of general surgical patients when prophylaxis is not provided.
In a study cited by the American College of Chest Physicians (ACCP), autopsies of surgical patients who died within 30 days postoperatively revealed that 32 percent had had a PE and it was the cause of death for most (Lindblad B, Eriksson A, Bergqvist D. Br J Surg. 1991;78:849-852).
Tips for Getting Started
Develop standard order sets for prophylaxis
Develop protocols for providing prophylaxis automatically, based on surgical procedure
Provide education and training for staff on the importance of VTE prophylaxis
Educate patients preoperatively about the prophylaxis they will receive and steps they can take to reduce risk
According to SCIP, “postoperative pneumonia occurs in 9 – 40% of patients and has an associated mortality of 30 - 45%”
Hospital mortality of ventilated patients who develop VAP is 46 percent
(Ibrahim EH, Tracy L, Hill C, et al. Chest . 2001;20(2):555-561)
VAP prolongs time spent on the ventilator, length of ICU stay, and length of hospital stay after discharge from the ICU
(Rello J, Ollendorf DA, Oster G, et al. Chest . 2002;22(6):2115-2121)
Four Key Changes
Elevation of the head of the bed to between 30 and 45 degrees
Daily “Sedation Vacation” and daily assessment of readiness to extubate
Peptic ulcer disease (PUD) prophylaxis
Deep vein thrombosis (DVT) prophylaxis (unless contraindicated)
Reducing Harm from High-Alert Medications
Reduce harm from high-alert medications by 50% by December 2008
What Are High-Alert Medications?
High-alert medications are more likely to be associated with harm that is both more common and likely to be more serious:
What Does the Evidence Tell Us? Several studies have identified adverse drug events as the single most frequent source of health care mishaps, continually placing patients at risk of injury. -Rozich JD, Haraden CR, Resar RK. Adverse drug event trigger tool: A practical methodology for measuring medication-related harm. Qual Saf Health Care . 2003;12:194-200. -Bates DW, Boyle DL, Vander Vliet VM, et al. Relationship between medication errors and adverse drug events. J Gen Intern Med . 1995;10:199-205. -Bates DW, Cullen DJ, Laird NM, et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA . 1995;274:29-34. -Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA . 1997;277:312-317.
Warfarin and insulins caused:
One in every seven estimated adverse drug events treated in emergency departments
More than a quarter of all estimated hospitalizations
In the elderly , insulin, warfarin, and digoxin were implicated in:
One in every three estimated adverse drug events treated in emergency departments
41.5% of estimated hospitalizations
Budnitz DS, Pollock DA, Weidenbach KN, et al. National surveillance of emergency department visits for outpatient adverse drug events . JAMA . 2006;296:1858-1866.
What Does the Evidence Tell Us?
Review of events in an adverse drug reaction database of 317 preventable ADEs, “…suggested that three high-priority preventable ADEs accounted for 50% of all reports:
(1) overdoses of anticoagulants or insufficient monitoring and adjustments (according to laboratory test values) were associated with hemorrhagic events,
(2) overdosing or failure to adjust for drug-drug interactions of opiate agonists was associated with somnolence and respiratory depression, and
(3) inappropriate dosing or insufficient monitoring of insulins was associated with hypoglycemia.”
Winterstein AG, Hatton RC, Gonzalez-Rothi R, Johns TE, Segal R. Identifying clinically significant preventable adverse drug events through a hospital's database of adverse drug reaction reports. American Journal of Health-System Pharmacy . 59;18:1742-1749.
What Does the Evidence Tell Us?
Prevent MRSA Infection
Reduce methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection by December 2008
Focus on “getting to zero”
MRSA Bloodstream Infections 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% A Vision For The Future? MRSA in Denmark Rosdahl VT et al. Infect Control Hosp Epidemiol 1991;12:83-88. 1960 1965 1970 1975 1980 1985 1990 1995
Or This? MRSA in the UK
What Does the Evidence Tell Us?
Rational Interventions Should Target Modes of MRSA Transmission
Person-person via hands of health care providers – by far the most important
Personal equipment (e.g., stethoscopes, PDAs) and clothing
Carriers on the hospital staff
Rare common-source outbreaks
Prevent Infection and Colonization
Colonized patients comprise the reservoir for transmission (“colonization pressure”).
High rates of MRSA colonization complicate empiric antibiotic therapy (e.g., vancomycin).
Colonized patients have a high rate of MRSA infection.
Nearly 1/3 develop infection, often after discharge
Colonization is long-lasting, and patients can transmit MRSA to patients in other health care settings (e.g., nursing homes), as well as to family members.
Five Key Interventions
Decontamination of the environment and equipment
Active surveillance cultures (ASCs)
Contact precautions for infected and colonized patients
Compliance with Central Venous Catheter and Ventilator Bundles
Tips: Hand Hygiene
Single most important intervention, especially after and before patient contact
Compliance rates of 40-50% no longer are acceptable
Hold staff accountable
Encourage patients and families to remind caregivers to practice hand hygiene
Alcohol hand rubs have made hand hygiene much easier