Parallel Session: So Just How Effective Are We?

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NHSScotland is constantly striving to increase efficiency and productivity whilst improving quality and effectiveness. In this session, delegates heard directly from colleagues who have changed their systems to deliver more effective care and how they value difference and variation within the NHS, using evidence to affect change. Delegates also had the opportunity to see some real examples from various settings across NHSScotland where evidence-based practice has been used to change systems and processes and how this has made a difference to patient outcomes, experience and value.

See more on the 2013 NHSScotland Event website http://www.nhsscotlandevent.com/resources/resources2013/resources

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Parallel Session: So Just How Effective Are We?

  1. 1. Reducing cardiac arrests in the Acute Admissions Unit : A Quality Improvement Journey Dan Beckett Consultant in Acute Medicine Forth Valley Royal Hospital SPSP Fellow
  2. 2. Situation • Combined surgical and medical admissions unit • 46 beds (but elastic walls...) • Admits 1500 patients per calendar month • In July 2011 moved from Stirling Royal Infirmary to Forth Valley Royal Hospital
  3. 3. Background Stirling Royal Infirmary, 2010
  4. 4. Assessment • AAU morbidity and mortality meetings established in 2010 • Failure to rescue • Recognition • Response • Resuscitation attempts undertaken on patients with terminal illness • Limited learning from adverse outcome
  5. 5. Recommendation • Aim statement developed • FMEA (Failure Modes Effects Analysis) undertaken • Driver diagram developed • Structured response to the deteriorating patient • Improved end of life care • Improved learning from adverse events • Measurement plan agreed • Process, Outcome and Balancing measures • Use of data for improvement vs data for scrutiny • Sharing of data with board, staff, patients and relatives
  6. 6. Cardiac arrests in AAU per 1000 admissions UCL LCL0 1 2 3 4 5 6 7 8 9 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 Rate Safety meetings start Structured response tested Move to FVRH Poor patient flow from AAU starts 2.8/1000 to 0.8/1000 admissions = 72% reduction
  7. 7. 2222 calls in AAU per 1000 admissions UCL LCL0 2 4 6 8 10 12 14 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 Rate Safety meetings start Structured response tested Move to FVRH Poor patient flow from AAU starts
  8. 8. Use of data to soothe the naysayers • ‘The reduction in rate of cardiac arrests in AAU has purely been achieved by moving patients out of AAU earlier so they have their cardiac arrests elsewhere...’ • ‘The reduction in rate of cardiac arrests in AAU is due solely to patients having DNACPR decisions made earlier in their admission’
  9. 9. Dealing with the non-believers... 2222 call rate outwith AAU per 1000 admissions UCL LCL 0 1 2 3 4 5 6 7 8 9 10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Rate
  10. 10. 30 day mortality - all patients CAU/AAU UCL LCL 0% 1% 2% 3% 4% 5% 6% 7% 8% May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Percent 17% DROP IN 30 DAY MORTALITY SINCE MOVING TO FVRH = 16 LIVES SAVED PER MONTH Safety initiatives started Move to ward based team at FVRH SIGNIFICANT SHIFT IN MORTALITY
  11. 11. HSMR 0.0 0.5 1.0 1.5 2.0 Oct- Dec 2006 Jan- Mar 2007 Apr- Jun 2007 Jul- Sep 2007 Oct- Dec 2007 Jan- Mar 2008 Apr- Jun 2008 Jul- Sep 2008 Oct- Dec 2008 Jan- Mar 2009 Apr- Jun 2009 Jul- Sep 2009 Oct- Dec 2009 Jan- Mar 2010 Apr- Jun 2010 Jul- Sep 2010 Oct- Dec 2010 Jan- Mar 2011 Apr- Jun 2011 Jul- Sep 2011 Oct- Dec 2011 Jan- Mar 2012 Apr- Jun 2012 Jul- Sep 2012p StandardisedMortalityRatio Standardised Mortality Ratio (SMR) Regression line HSMR October 2006 – September 2012 (19.5% reduction)
  12. 12. Total number of admissions to critical care per month 0 20 40 60 80 100 120 140 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 MedianMeasure Move to ward based team at FVRH Safety initiatives started
  13. 13. Proportion of patients admitted to critical care on Day 0 UCL LCL 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Percent Safety initiatives started Move to ward based team at FVRH
  14. 14. Importance of data and measurement • Use of data for improvement • Sepsis 6 • Compliance with structured response checklists • Use of data for scrutiny • Cardiac arrests • Mortality • Sharing of data Patients with NEWS4 sepsis getting the sepsis6 bundle within 60 minutes UCL LCL0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Percent Number of patients referred to palliative care 0 10 20 30 40 50 60 70 80 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Median Measure
  15. 15. Acknowledgements • Sharon Oswald • Monica Inglis • Iain Wallace • SPSP • The whole AAU multidisciplinary team! • daniel.beckett@nhs.net • @djbeckett
  16. 16. Effective Haemophilia Care in Scotland
  17. 17. • A severe inherited X-linked bleeding disorder • Untreated males suffer spontaneous bleeding in joints, soft tissues and brain • Treatment strategies: ‘on demand’ or ‘prophylaxis’ • ‘On demand’ patients may suffer 2-6 bleeds per month -> chronic joint damage Background - Haemophilia 
  18. 18. • Six Haemophilia Treatment Centres in Scotland [2 west + 4 east] • Recombinant coagulation products are managed as part of the risk share scheme: total cost for 2012/13 was £24.5million • UK Annual Report 2009-10 Identified geographical variation in mean annual coagulation product use per patient with severe haemophilia Background
  19. 19. • A review was commissioned by Board Chief Executives’ in 2011 to assess clinical practice and product usage across the six centres • Review highlighted: - Subtle variation in clinical practice - No standard way to measure clinical outcomes or quality of care • Recommendations: - Developmental of standardised protocols - Development of key performance and clinical outcome indicators Background
  20. 20. Centres worked together to - produce standard policies and protocols in relation to dosing, stock holding and management - develop key performance and clinical outcome indicators - produce a clinical audit form to capture dataset in relation to the indicators
  21. 21. Largely confined to treatment of severe haemophilia • Performance indicators • % attending for 6-month review • Uptake of home treatment & home delivery of product • % severe patients receiving ‘standard’ prophylactic coagulation factor treatment • % patients receiving an excess amount of coagulation product per Kg in 6m • Outcome indicators - Patients with spontaneous major bleeds - Days missed from school/work because of bleeds - Patients on standard prophylaxis remaining bleed free - Patients having had joint replacement or arthrodesis Performance & Clinical Outcome Indicators
  22. 22. • Policies and Protocols have been implemented in all centres • Clinical Audit Forms are completed for moderate and severe users of recombinant products 6-monthly from January 2012 • Data is recorded in clinics based on information provided by patients • The Data has been recorded on the Clinical Audit System • Allowing comparative clinical audit across the Haemophilia Centres Systems & processes adopted in clinical practice
  23. 23. % severe patients on home therapy 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Aberdeen Dundee Inverness Edinburgh Glasgow Edinburgh- Paed Yorkhill - Paed
  24. 24. % severe patients receiving standard prophylaxis 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Aberdeen Dundee Inverness Edinburgh Glasgow Edin burgh- Paed Yorkhill - Paed 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Aberdeen Dundee Inverness Edinburgh Glasgow Edin burgh- Paed Yorkhill - Paed % patients with a spontaneous major bleed
  25. 25. % severe patients losing >5 school or work days as result of bleeding % severe patients free of spontaneous bleeds 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Aberdeen Dundee Inverness Edinburgh Glasgow Edinburgh- Paed Yorkhill - Paed Treatment Centre 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Aberdeen Dundee Inverness Edinburgh Glasgow Edin burgh- Paed Yorkhill - Paed
  26. 26. Improving quality and effectiveness of care Policies and Protocols have driven changes in practice - formalised processes and ensures a standardised approach across all centres Clinical Audit reports: - demonstrate patient outcomes - allows centres to review and discuss the most clinically appropriate and effective care for patients - Scottish peer review meetings established to discuss ‘exception cases’ - highlight where targeted work is required to drive improvements in clinical care
  27. 27. Disinvestment in NHS Lothian.......... “just say NO!”
  28. 28. Disinterested in NHS Lothian.......... “just say NO!”
  29. 29. Disinvestment in NHS Lothian.......... Attempting to use evidence to change practice.....
  30. 30. Just say NO! • ..............it’s not affordable • ..............it’s not possible • Difficult in a “free” healthcare system • Politically damaging • Withdrawal of what is already available is unpopular with patients and doctors. • Can’t just say NO!!!
  31. 31. Priority setting...... Which one? • Patient- did we ask?? Most important?!??! • Financial- don’t need to ask!! • Quality- what questions to ask? • Outcomes- Was the question biased? • Many more.................... -Croydon list -McKinsey
  32. 32. Lothian RILCV process. • Identify area of interest • Contact clinicians and seek “buy in” • Assessment of health intelligence (HIU and ISD, BQBV dashboard) • EVIDENCE REVIEW -efficacy -cost effectiveness -controversy in literature -impact of change • ENGAGE STAKEHOLDERS • Develop plan • Enact and review plan
  33. 33. 2008/09 2009/10 2010/11 NHS Board of residence 75+ 85+ All ages 75+ 85+ All ages 75+ 85+ All ages Scotland 44.8 44.0 6.2 46.2 45.0 6.4 44.2 42.8 6.3 Ayrshire & Arran 60.0 58.3 9.1 57.8 54.9 8.9 46.0 44.9 7.5 Borders 58.7 61.4 8.7 72.3 73.2 10.6 65.8 66.8 9.7 Dumfries & Galloway 68.3 59.7 11.4 65.5 56.9 11.6 59.3 52.5 10.4 Fife 37.2 35.7 5.4 38.9 37.9 5.8 38.7 40.6 5.8 Forth Valley 54.4 53.6 6.9 50.4 49.9 6.9 56.7 55.5 7.4 Grampian 35.0 35.5 4.6 39.3 40.6 5.0 32.1 31.6 4.4 Greater Glasgow & Clyde 42.5 40.9 5.8 40.9 39.7 5.7 42.8 41.4 6.0 Highland 50.6 54.2 7.5 52.5 51.9 7.8 50.6 43.3 7.9 Lanarkshire 36.2 36.2 5.2 38.0 32.7 5.2 33.0 32.0 4.8 Lothian 42.8 41.3 5.2 43.4 42.5 5.4 42.3 40.3 5.3 Orkney 35.9 45.9 5.6 29.9 37.8 4.4 22.5 26.6 3.6 Shetland 42.1 42.3 5.4 20.0 27.8 3.4 19.3 18.4 2.9 Tayside 42.8 42.8 6.8 54.2 53.9 8.2 57.1 56.7 9.1 Western Isles 57.6 54.3 8.7 67.1 71.8 10.8 50.7 45.4 9.3 First quartile 38.5 41.0 5.4 39.0 38.4 5.2 34.4 34.1 5.0 Crude Rate of Cataract Interventions by NHS Board of residence (all) per 1,000 population, 2008/09 - 2010/11
  34. 34. Cataract RILCV process. • Identify area of interest- Cataract • Contact clinicians and seek “buy in” – Oph & optoms • Assessment of health intelligence – 4500 operations, half coded, 35% second eye • EVIDENCE REVIEW - impact of threshold - value of 2nd eye surgery
  35. 35. Cataract RILCV process. • Identify area of interest- Cataract • Contact clinicians and seek “buy in” – Oph & optoms • Assessment of health intelligence – 4500 operations, half coded • EVIDENCE REVIEW - impact of threshold - value of 2nd eye surgery • ENGAGE STAKEHOLDERS – oph, other boards, RNIB, E&D unit, • Develop plan – Set threshold at driving test level plus other “soft” measures run as a shadow audit • Enact and review plan – 5% reduction in referrals, 0.4% reduction surgeries
  36. 36. Classes of interventions to target for decreased utilisation – Lancet Oncology Commission 2011
  37. 37. Over-utilisation • Quicker to discuss TP than discussion of no treatment • Quicker to order a scan than history and exam • In breast cancer no benefit to follow up with tumour markers (Rosselli JAMA, GIVIO study JAMA) • Many examples of futile care in last weeks and days of life (studies suggest up to one third of cancer care costs) • In 2010 the US Patient Protection and Affordable Care Act established a Patient Centred Outcomes Research Institute
  38. 38. Improving efficiency and value in cancer care • Physician education!!! • Identifying interventions of marginal or no clear benefit with high cost- SR’s, meta-A’s, comparative effectiveness research & RCT’s • Physician education focussed on tech skills- primary and continuing education needs to incorporate understanding of cost-effectiveness!!! • Personalised medicine • More rapid adoption of innovation (sentinel & others) • Translational and clinically focussed research • Comparative effectiveness research and health-services research- how to deliver? • Development of outcome data (SCAN report), rapid learning healthcare system • Focus on end of life care: account for wishes of patients and families
  39. 39. Limitations of evidence • RCT’s do not imply clinical significance ONLY statistical significance • NCI Canada reported median overall survival benefit of 0.33 months for Erlotinib plus gemcitabine in advanced pancreatic cancer • Massive toxicity, FDA, EMA and SMC approved at cost of $500,000 per life year gained (Threshold?? NICE 10%) • EUROCAN project- ethical, political and administrative barriers to acquiring and sharing data on outcomes
  40. 40. Cancer surgery • Hunter “an armed savage trying to render by force that which a civilised man would render by strategem”- Main method of cure for solid tumours globally • In common cancers surgery alone 50% of direct costs (Warren JNCI 2008) • Curative in absence of metastatic disease- little emphasis on defining staging • ASCO 2010- ACOSOG Z0011 study showed no benefit of ALND in women with 1-3 positive SNB- Surgical bias!!! • Challenge the surgical dogma (XS, trade-off)
  41. 41. Where are we with prioritisation? • RILCV • Quality based commissioning • Guideline driven care (rationing) • We do not have or own the data! • Data not geographically/culturally sensitive • Data not appropriate to our healthcare system • Where are the outcomes for our organisations?? (31/62 vs survival)
  42. 42. Some solutions..... • Consult widely on the questions and priorities • Commission and own the data • Share and collaborate on the data • Analytical methods that compare and that emphasise clinical benefit • Educate physicians with the data (challenge) • Use and implement changes • Rapidly adopt technological advances
  43. 43. We need to be able to do more than “just say no” Thank you! Dr Victor Lopes PhD FRCS Assoc Medical Director NHS Lothian

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