Transcript www.gbhn.ca

Improving Quality & Patient Safety
Evidence Based Order Sets
An effective solution to the complex challenge
of improving patient care and safety
© Trillium Health Centre 2006
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
Order Set Committee
Chris O’Connor, Katharine DeCaire, Zelia Campos, Bruce Tugwood,
Pam Johnson, Allan Mills, Vera Jovanovic, Catherine Scaletta
© Trillium Health Centre 2006
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
© Trillium Health Centre 2006
Current Context:
The Need for Order Sets
© Trillium Health Centre 2006
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
© Trillium Health Centre 2006
Modern Case Treatments
Antibiotic treatment- fast
Strict glycemic control
Activated Protein C
Communicate with and
support patient family
Early goal directed fluid
therapy
Proper sedation/pain relief
DVT prophylaxis
Correct electrolytes
Early feeding
Elevate the head of the bed
Low tidal volume ventilation
Bowel routine
Steroids
Mouth care
Pepcid to prevent
GI bleeding
Ongoing investigations
© Trillium Health Centre 2006
© Trillium Health Centre 2006
© Trillium Health Centre 2006
© Trillium Health Centre 2006
© Trillium Health Centre 2006
Context:
Massive Gap Between the Possible and the Actual
Quality
Misuse, under use, overuse on a massive scale:
Crossing the Quality Chasm 2001
Safety
Medical error is common:
Institute Of Medicine Report on Error 2000
Variation in Care
Variability in care not explained by patient
preferences or different disease patterns:
British Medical Journal 2002; 325: 961-964
© Trillium Health Centre 2006
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
© Trillium Health Centre 2006
Context: Gaps in the Care of Patients Admitted to Hospital
with an Exacerbation of Chronic Obstructive Pulmonary Disease
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
© Trillium Health Centre 2006
Where do we go from here?
Traditional Methods to Change Clinician Behavior
Written Materials/guidelines
Audit and Feedback
Academic Detailing
Local Opinion Leaders
Zero to moderate effectiveness at best
Not scaleable
Limited Scope
Not durable
© Trillium Health Centre 2006
Solution:
Order Sets a Clinical Decision Support Tool
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
© Trillium Health Centre 2006
© Trillium Health Centre 2006
© Trillium Health Centre 2006
©
© Trillium
Trillium Health
Health Centre
Centre 2006
2006
© Trillium Health Centre 2006
Order Sets: Key Benefits
Safety
Reduced transcription errors
Reduced errors of omission
Reduced errors in medication dosing
Quality
Improved compliance with evidence-based best practices
Standardization of care
Efficiency
Decreased time to write and process orders
Reduction in physician call-backs
Reduction in missed orders
Critical enabler for computerized practitioner
order entry
© Trillium Health Centre 2006
Order Sets:
Improving Care
© Trillium Health Centre 2006
Order Set Adoption
80
70
60
50
% Use of Order
Sets
40
30
20
10
0
Oct-Nov 2003
April-Dec
Feb-Mar 2005
Dec-05
© Trillium Health Centre 2006
Data Collection
Primary outcome DVT Prophylaxis Rates:
Random Chart audit from three time periods
October-November 2003
April – December 2004
February – 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.
© Trillium Health Centre 2006
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
© Trillium Health Centre 2006
Impact of Order Set Use on DVT Prophylaxis Orders
45
40
35
30
% Orders w ith DVT
Prophylaxis
25
Order Set
No Order Set
20
15
10
5
0
Oct-Nov 2003
April-December 2004
Feb-March 2005
© Trillium Health Centre 2006
35%
30%
Monthly DVT Prophylaxis Rates
Improved Format + Content
Order Sets Introduced
25%
20%
15%
10%
5%
0%
rAp
03
ay
M
03
4
5
3
4
3
4
4
5
4
3
3
3
4
4
4
3
4
3
4
04 -04
05
-0
-0
-0
-0
-0 ul-0
-0
-0
-0 n-0 ul-0
-0
-0
rrt-0 ov-0 ec-0
t-0 ov-0 ec-0
r
b
b
n
n
n
y
p
p
g
g
a
a
c
c
p
e
e
a
J
J
Ju
O
Ja
F
M
A
Ju
O
Ja
F
M
Se
N
D
Se
N
D
Au
M
Au
© Trillium Health Centre 2006
Use of Low Molecular Weight Heparin
1000
LMWH Introduced into Medical Order Sets
900
800
Number of Doses
700
600
500
400
300
200
100
0
05
na
J
05
be
F
ar
M
05
rAp
05
ay
M
05
05
nu
J
5
l-0
Ju
05
gu
A
05
pe
S
O
5
.0
ct
N
5
.0
ov
D
5
.0
ec
06
n.
a
J
06
b.
e
F
6
.0
ar
M
6
r.0
p
A
© Trillium Health Centre 2006
50
LMWH Introduced Into Order Sets
Monthly DVT Prophylaxis Rates (%)
45
40
35
30
25
LMWH
Regular Heparin
20
15
10
5
0
05
na
J
05
be
F
5
-0
ar
M
5
r-0
p
A
ay
M
05
05
nu
J
5
l-0
Ju
05
gu
A
05
pe
S
O
05
ct.
05
v.
o
N
05
c.
e
D
06
n.
a
J
06
b.
e
F
6
.0
ar
M
6
r.0
p
A
© Trillium Health Centre 2006
Impact of Order Set Use on Protocol Use
70
60
50
40
%Orders
Order Set
30
No Order Set
20
10
0
Standardized Insulin
Standardized
Scale
Potassium Protocol
Standardized
Diabetic Diet
© Trillium Health Centre 2006
Impact of Order Set Use on Documentation
100
90
80
70
60
%Orders
50
Order Set
No Order Set
40
30
20
10
0
Admitting Diagnosis
Documented
Allergies Documented
Code Status
Documented
© Trillium Health Centre 2006
Order Set Impact on Order Content
90
80
70
60
50
%Orders
Order Set
40
No Order Set
30
20
10
0
Zoplicone
QHS PRN
Lorazepam
QHS PRN
Ordering of PRN order for Allied Health
Urea
ECG
Consult
© Trillium Health Centre 2006
Impact of Order Sets on Order Process
100
90
80
70
60
%Orders
50
Order Set
No Order Set
40
30
20
10
0
Numbering of
pages
Dating of
Orders
Timing of
Orders
Signing of
Orders
© Trillium Health Centre 2006
Management of DKA in ICU
100%
90%
80%
70%
60%
50%
No order Set
Order set
40%
30%
20%
10%
0%
Code status
Endocrine consult
Urine C&S
Urine R&M
DVT Prophylaxis
Standard ICU
protocols
© Trillium Health Centre 2006
ER/ICU Survey Results: Order Set Impact
40
35
Responses
30
25
Improved Process of Care Delivery
20
Improved Quality of Care
Reduced Time to Use
15
Reduced Transcription Error Risk
10
5
0
Strongly
Agree
Agree
Neutral
Disagree
© Trillium Health Centre 2006
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
© Trillium Health Centre 2006
The Order Set Challenge
© Trillium Health Centre 2006
The Order Set Challenge
Order Sets Must Be:
Current
Evidence Based and Best Practice
Authoritative
Easy to Use
Comprehensive
Reliable and safe
Clinically Intelligent
© Trillium Health Centre 2006
The Order Set Challenge
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
© Trillium Health Centre 2006
Current Status of Order Sets
© Trillium Health Centre 2006
Current Status of Order Sets
Lack of Recognition of Order Set Importance
Order Set Design
Often no standardized structure
Structure is not modular
Lack 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
© Trillium Health Centre 2006
Current Status of 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 project
Duplication of effort
Reduced quality
Slow implementation of best practices
Consumption 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
© Trillium Health Centre 2006
Order Set Innovation
© Trillium Health Centre 2006
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 Health Centre 2006
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
© Trillium Health Centre 2006
Trillium Order Set Innovation
Excellence in Order Set Design
5 years of iterative improvement in order set design
Integration of real world feedback
Intelligent knowledge representation to increase usability
and clinical impact
Order Set Process
Real 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 Health Centre 2006
Trillium Order Set Innovation
Order Set Content
Over 250 order sets developed
Order sets used in every health system
Content 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 content
Order set committee provide process knowledge
© Trillium Health Centre 2006
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 solution
Save organizations time, money and reduce demand on
limited organizational resources
Improve quality
Local ownership and adaptation of tools
© Trillium Health Centre 2006
Open Source Order Sets
Standardized Order Set Design
Standardized structure to order set content based on DAVID
Rules of correct formatting at all levels of order set content
Clear syntax of order set content
Designed to anticipate CPOE
Modular Format
Best practices are contained in functional groups
Facilitates the spreading of best practices across different order sets
and across health systems
Over 300 modules including many high value best practice modules
such as deep vein thrombosis prophylaxis, bowel care, pain control,
electrolyte management
Order Set Lifecycle
Order Set Committee
Interdisciplinary membership
Robust methodology for development, approval, implementation and
maintenance
© Trillium Health Centre 2006
Open Source Order Sets
Large Library of Developed Content
Over 250 order sets and clinical protocols
Comprehensive interdisciplinary content
Incorporation of real world experience
Will grow to over 600 order sets in the next year
Order Set Web Page
Web accessible data base to store library of order set content
Order sets clearly organized, searchable by many different
criteria and relationships between order sets and clinical
protocols clearly established
Order Set Project Support
On-site and remote support including physician, nursing,
pharmacy
Goal is rapid knowledge transfer
© Trillium Health Centre 2006
Order Set Project Outline
Establish an Order Set Committee
Best practices around order set lifecycle
Catalogue and upgrade legacy order set content
Convert to standardized modular format
Integrate new best practice content as appropriate
Standardization of best practices across the organization
Approval of new and upgraded order sets by the Order Set
Committee
Develop and Implement Order Sets
Utilization of library of best practice content
Adapt Open Source Order Sets to local health system needs
New sets developed by content experts at Grey Bruce
Comprehensive communication plan to facilitate adoption
© Trillium Health Centre 2006
Order Set Project Outline
Store order sets on an intranet accessible
database
Collection of data for metrics
The 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 use
Order set adoption
Adherence to best practices
Before/after, cross-sectional analysis
© Trillium Health Centre 2006
Benefits
Save time
Save money
Improve the quality and safety of patient care
Large 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 use
Increase 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
© Trillium Health Centre 2006
Future
The forces driving the need for
order sets are accelerating
Medical knowledge is increasing
Complexity of treatments is increasing
Effectiveness of treatments is increasing
Care is delivered by large interdisciplinary teams
Computerized Physician Order Entry requires order sets
Recognition that effective orders must achieve many
objectives simultaneously
Quality
Safety
Workflow
Resource utilization
© Trillium Health Centre 2006
Why We Are Doing This?
© Trillium Health Centre 2006
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
© Trillium Health Centre 2006
Why We Are Doing This?
Order Sets Save Lives
Order Sets Deliver Better Care
Order Sets Improve Efficiency
© Trillium Health Centre 2006
“Standardize and automate
that which is routine about a
patient’s care so the clinician
can focus on what is unique
about each patient”
© Trillium Health Centre 2006
Thank You!
Chris O’Connor M.D. FRCPC
Katharine De Caire ACNP
© Trillium Health Centre 2006