Transcript The identification of clinical indicators for the COAG

The identification of clinical
indicators for the Council of
Australian Governments (COAG) Long
Stay Older Patients (LSOP) initiative
Jo Tropea
Program manager
Clinical Epidemiology & Health Service
Evaluation Unit, RMH
Acknowledgements
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CEHSEU project team
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Caroline Brand
Bhasker Amatya
Alex Gorelik
Wendy Lemaire
Project Expert Advisory Group
 DHS project team
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Background information
2004 national functional decline guidelines
developed
 2007 an update of high level evidence and
recommendations by DHS
 In Victoria as part of the national COAG
LSOP – ICOP and HARP CDM initiatives
 Development of an implementation
resource toolkit for minimising functional
decline (DHS - NARI)
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Clinical indicator project
Background information
10 FD care domains:
 Cognition and emotional health – delirium,
dementia & depression
 Mobility, vigour and self care
 Continence
 Nutrition
 Skin integrity
 Medication management
 Person centred care
 Assessment
Clinical indicators project
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Identify existing evidence based clinical indicators
(CI)
CI are intended to capture any changes in
structures, processes and/or outcomes of
health care associated with the implementation of
the FD toolkit
Structure – attributes of the settings in which
care occurs (eg equipment, HR)
Process – what is actually done in giving and
receiving care
Outcome – measures describe the effects of care
on health status of patients
Purpose of the indicator set
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Primary purpose
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To assess the impact of activities designed to
minimise functional decline (FD) among older
hospitalised people
Secondary purposes
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To measure effectiveness of FD guideline
implementation
To monitor and drive improvement design to
optimise health outcomes related to FD
Methods of CI identification & selection
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Identify existing indicator sets
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Literature review
Knowledge from previous projects
Assess the identified indicator sets
 Summarised the potential indicator set
 Selection of draft indicators
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EAG assessed each indicator in three
consensus rounds
Used a modified Delphi technique
CEHSEU
Project team
Are they applicable to patient
population and FD domains?
NO
Exclude
YES
Round 1 consensus method
R1 results:
Group median scores
Score frequencies
R2 results:
Group median scores
Score frequencies
Round 2 consensus method
Consensus ‘exclude with
recommendation for
future development’
Round 3 consensus method
Consensus ‘exclude’
Include in final set
Results
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Literature review
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55 international and national indicator sets
identified, 14 met the inclusion criteria
From these sets we selected 63 individual
indicators
Limitations – limited evidence base,
mainly expert opinion
Mapped across FD care domains & according to
type of indicator
FD care domain
Cognition (8)
Structure
Process
Outcome
-
8
1*
Mobility (15)
Continence (2)
Nutrition (3)
Skin (10)
-
3
2
3
6
12
5*
Medication (10)
P-C care (5)
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8
2
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4
1
Assessment (5)
Others (5)
-
5
5
1*
* Includes an indicator which can be used to measure a process &
outcome
Round 1 of the consensus method
All 13 EAG members participated in R1
 Summary of literature review and each
indicator set provided
 Instruction manual
 Assessed each indicator according to
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Importance and relevance to the purposes of
the project
Scientific attributes
Practicality to implement
Assessment of cognitive function #4.1 (ACHS Internal medicine)
Definition
Indicator Topic: Assessment of cognitive function.
Numerator
Total number of patients admitted to a geriatric medicine or geriatric rehabilitation
unit for whom there is documented assessment of mental function on
admission or during admission when more appropriate, during the 6 month
time period
Denominator
Total number of patients admitted to a geriatric medicine or geriatric rehabilitation
unit, during the 6 month time period
Data source
Clinical data
Administrative data
Type of indicator
Process
Level of evidence
Unsure, not provided.
Name of data set
Australian Council on Healthcare Standards (ACHS) Internal Medicine Clinical
Indicators (Indicator 4.1)
Other
Assessment of cognitive function must be performed using Mini Mental State
Examination (MMSE) or the Abbreviated Mental Test Score (AMTS).
(i) The indicator is relevant and important to project purposes
Disagree
Agree
1
2
3
4
5
6
7
8
9
(ii) The indicator has robust scientific attributes
Disagree
Agree
1
2
3
4
5
6
7
8
9
(iii) The indicator is practical to implement
Disagree
Agree
1
2
3
4
5
6
7
8
9
Round 1
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Median group scores showed:
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47 (75%) were considered to be highly important and
relevant  median group score ≥ 7
7 (11%) were considered to be highly scientifically
robust
22 (35%) were considered to be highly practical to
implement
Comments
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Difficulties with implementation
Indicator definitions
Limited evidence base related to the indicator
Lack of reliable and accurate data
Round 2 of the consensus method
All 13 EAG members participated in R2
 Based on their individual rating and the
group median scores, EAG were asked to
prioritise inclusion of the indicator for:
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System surveillance at a State level
System surveillance at an organisational level
Supporting implementation of the FD
guidelines at an organisation or clinical team
level
Round 1 results
(i) The indicator is relevant and important to project purposes
Disagree
1
Frequency of
R1 responses
Agree
2
0
3
0
4
0
5
0
6
1
7
0
8
5
9
2
4
(ii) The indicator has robust scientific attributes
Disagree
1
Frequency of
R1 responses
Agree
2
0
3
2
4
2
5
1
6
2
7
2
8
2
9
1
0
(iii) The indicator is practical to implement
Disagree
1
Frequency of
R1 responses
Agree
2
0
3
0
4
0
5
2
6
1
7
5
8
1
9
1
2
Based on your scores and considering the group’s scores of the indicator
in Round 1, overall how would you prioritise inclusion of this indicator in
the draft indicator set for:
(i)
System surveillance at a State level
Low
1
High
2
3
4
5
6
7
8
9
(ii) System surveillance at an organisational level
Low
1
High
2
3
4
5
6
7
8
9
(iii) Supporting implementation of the functional decline guidelines at an
organisation or clinical team level
Low
1
Comments:
High
2
3
4
5
6
7
8
9
Round 2 results
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High group median scores ≥ 7
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35 (56%) for supporting implementation of the
guidelines
22 (35%) for system surveillance at an
organisational level
9 (14%) for system surveillance at a state
level
Round 3 – face to face meeting
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9 EAG members participated
DHS project team and DHS coding expert
Consensus reached to include 20 indicators in the
Most of the indicators
draft set
were modified slightly
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2
3
2
3
4
3
1
2
to suit the purpose of
cognition and emotional health
mobility, vigour and self-care the set, the local
context & best practice
continence
nutrition
skin integrity
medication management
person-centred care
assessment
Final set & recommendations
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19 indicators included in the final set
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Following EAG review – 2 falls indicators merged into 1
1. Cognition & emotional health
1.1 Cognitive screen
1.2 Screen for postoperative delirium
2. Mobility, vigour and self-care
2.1 Inpatient fall evaluation
2.2 Falls related injuries including fractures
3. Continence
3.1 Indwelling bladder catheter
3.2 Long-term urethral catheter use
4. Nutrition
4.1 Oral intake evaluation in hospital
4.2 Alimentation for patient who cannot eat
4.3 Nutritional supplementation of malnourished patients
Final set & recommendations
5. Skin integrity
5.1 Pressure ulcer risk assessment
5.2 Pressure ulcer preventive intervention
5.3 Pressure ulcer assessment
5.4 Identification of pressure ulcers (incidence)
6. Medication management
6.1 Current medications
6.2 Medication therapy changes
6.3 Sedative use at discharge
7. Person-centred care
7.1 Provision of written care plans to patients at discharge
8. Assessment
8.1 Discharge assessment
8.2 Assessment of physical function
Gaps identified & recommendations
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8 indicators were excluded with the
recommendation for further development
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Delirium evaluation – investigation for cause
Physical restraint indicators
Outcome indicators that assess unplanned and
unexpected hospital readmission rates within
14 days
Discharge destination
Hospital wide medication policies such as
review by clinical pharmacist
Recommendations
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Development of 8 structural indicators
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Education and training
Environmental audit
Person-centred care policy
Clinical program
Workforce planning and service model
Recommendations
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Key areas that require future process and
outcome indicator development
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Emotional health – process & outcome
Falls risk screening - process
Continence screening – process
Incidence of delirium, depression, falls,
incontinence (outcome)
Thank you