Transcript Care Bundle

Improving the reliability of care in high risk areas
Why Focus on Warfarin Management?
Warfarin is the second most
common cause of adverse drug
events in emergency departments
Incidence of major bleeding in
patients prescribed warfarin
ranged from 0% to 16%, and the
incidence of fatal bleeding was 0%
to 2.9%.
Warfarin
Patient Story
Where are the risks in prescribing and
monitoring patients on warfarin?
Improving Reliability Using
Data and Care Bundles
Getting started with data
• “Education, education, education”
Tony Blair 1997
• “It’s the economy, stupid”
Bill Clinton 1991
• No politician has yet said:
– “Data, data, data”
– “It’s the data, stupid”
Getting started with data
• Warfarin sheets audit
No (%) of patients with element
recorded
Name and date of birth
36 (100)
Phone number
36 (100)
Diagnosis
31 (86)
Planned duration
18 (50)
Target INR
21 (59)
Care Bundle
A care bundle is a set of evidence based interventions
that when used together significantly improve
outcomes
Peter Provonost (ITU physician at Johns Hopkins Hospital, Baltimore, Maryland )
Simple message:
‘Evidence Based practice…
Culture Change…
Measurement of change…’
Peter Provonost’s Care Bundle
A simple 5 item checklist protocol would greatly reduce
infections when inserting a central venous catheter
Doctors should:
•Wash their hands with soap.
•Clean the patient’s skin with chlorhexidine antiseptic.
•Put sterile drapes over the entire patient.
•Wear a sterile mask, hat, gown and gloves.
•Put a sterile dressing over the catheter site
‘An intervention to decrease catheter-related bloodstream infections in the ICU’
Pronovost P, et al. (December 2006)
N. Engl. J. Med. 355 (26): 2725–32.
Ja
n08
Ap
r- 0
8
Ju
l-0
8
O
ct
-0
8
Ja
n09
Ap
r- 0
9
Ju
l-0
9
O
ct
-0
9
Ja
n10
Ap
r- 1
0
Ju
l-1
0
O
ct
-1
0
Ja
n11
Ap
r- 1
1
Ju
l-1
1
Central line infection
rate
(per thousand line days)
12
6
2
92% reduction
10
8
2.34
4
0.18
0
What is a Bundle?
• Aim to ensure patients receive optimum care at
every contact
• Structured way of improving processes of care to
deliver enhanced patient safety and clinical
outcomes
What is a Care Bundle?
4 or 5 elements of care
Across Patients Journey
Creates teamwork
Mix of easy and hard
All or nothing
Small frequent samples
Bundle vs Audit
• Audit – identifies whether individual measures are
being implemented
• Bundle - data collection tool to sample whether
optimum care is being delivered
How does this apply to Warfarin management?
Process Map
Warfarin Bundle
Is there evidence that the last advice re warfarin dosing given to patient
followed current Lothian Guidance/ INR Star/ RAT?
Is there evidence that the last advice re the interval for blood testing given to
patient followed current Lothian Guidance/ INR Star/ RAT?
Has patient been taking the advised dose since last blood test?
INR is taken within 7 days of planned repeat INR?*
Face to face education recorded every 6 months?*
Overall compliance out of 5
Warfarin Bundle
Is there evidence that the last advice re warfarin dosing given to patient
followed current Guidance
The use of a dosing algorithm can significantly improve
anticoagulant control
Kim, Y.K. et al Journal of Thrombosis and Haemostasis,2010 8,101–106.
Computerized dosing has been shown to increase the overall
percentage time for which patients are in their target INR range and
in some studies to reduce the frequency of testing of patients.
Poller, L., Journal of Thrombosis and Haemostasis, (2008b) 6,935–943.
Warfarin Bundle
Is there evidence that the last advice re the interval for blood testing given to
patient followed current Guidance?
The use of a dosing algorithm can significantly improve anticoagulant
control
Kim, Y.K. et al Journal of Thrombosis and Haemostasis,2010 8,101–106.
Computerized dosing has been shown to increase the overall percentage
time for which patients are in their target INR range and in some studies to
reduce the frequency of testing of patients.
Poller, L., Journal of Thrombosis and Haemostasis, (2008b) 6,935–943.
Warfarin Bundle
Has patient been taking the advised dose since last blood test?
The practice has to ensure that the patient is informed of the
correct advice regarding warfarin dosage for the patient to
be able to comply with the advice.
- Patient feedback
Warfarin Bundle
INR is taken within 7 days of planned repeat INR?*
Patient’s regular attendance for blood testing is associated with
better anticoagulation control.
Roswe AJ et al Circ Cardiovasc Qual Outcomes 2011 May 1; 4(3):276-82. Epub 2011 Apr 19.
Warfarin Bundle
Face to face education recorded every 6 months?*
There is good evidence that improved patient knowledge and
understanding of the use of warfarin improves anticoagulation control
Tang EO at al Ann Pharmacother. 2003 Jan; 37(1):34-9.
Warfarin Bundle
Is there evidence that the last advice re warfarin dosing given to patient
followed current Lothian Guidance/ INR Star/ RAT?
Is there evidence that the last advice re the interval for blood testing given to
patient followed current Lothian Guidance/ INR Star/ RAT?
Has patient been taking the advised dose since last blood test?
INR is taken within 7 days of planned repeat INR?*
Face to face education recorded every 6 months?*
Overall compliance out of 5
Its about what you do
with the data…….
Like What?
•
•
•
•
•
•
Practice meeting
Notice board
Process mapping
Ask patients
Try changing something….
Measure the effect.
Practice Feedback
• There is magic in graphs…
There is magic in graphs. The profile of a
curve reveals in a flash a whole situation –
the life history of an epidemic, a panic or an
era of prosperity. The curve informs the
mind, awakens the imagination,
convinces….
Henry D Hubbard, 1939
Bundle Compliance
Warfarin Bundle Compliance
100%
80%
60%
40%
20%
0%
14th 28th 14th 28th 11th 25th 9th 23rd 6th 20th 4th 18th 1st 15th 29th 12th 26th 10th 24th 7th 21st 5th 19th 2nd 16th
Feb Feb Mar Mar Apr April May May June June July July Aug Aug Aug Sept Sept Oct Oct Nov Nov Dec Dec Jan Jan
'11 '11 '11 '11 '11 '11 '11 '11 '11 '11 '11 '11 '11 '11 '11 '11 '11 '11 '11 '11 '11 '11 '11 '12 '12
Overall Lothian
Orchard
Lothian Practice Experience
“The care bundle was useful
because it identified gaps”
“You can see week by week,
month by month, whether or not
you are showing any
improvement, we seem to be
improving and that’s good”
Successes - Improved:
•
•
•
•
•
•
•
•
Patient Care
Systems
Knowledge, Skills & Attitudes
Safety Culture
Team-working
Patient Involvement
Less Stress
Efficiency
Less Stress for some staff in their
job
• “Staff member X who manages the
register and the recall for these patients,
it caused her an enormous amount of
stress prior to the programme”
“ Now that the programme is much more
streamlined and she feels more
confident and has taken much more
clinical responsibility”
Staff time-saving - patients being
more proactive
“staff member X doesn’t have to continually
phone people up every month, that is
quite a time saver for her, patients are
now more coming in cause they
understand the consequences potentially
of the side effects of the potential toxic
drugs”.
Does Bundle Compliance = better results?
Conan Doyle
Wave 1
Results <1.5 & >5
Lothian
14.0
12.0
10.0
8.0
6.0
4.0
2.0
0.0
Feb10
Mar10
Apr10
May10
Jun10
Jul10
Aug10
Sep10
Oct10
Nov10
Dec10
Jan11
Feb11
Mar11
Apr11
May11
Jun11
Jul11
Aug11
Sep11
Oct11
Nov11
Dec11
Jan12
Feb12
Potential to free up appointments
How well are we doing in NHS Lothian?
How well are we doing in NHS Lothian?
Care bundles
1.
Shed new light on our current practice
2.
Act as a catalyst for improvement in care
3.
Can lead to increased awareness
Questions?
What about other bundles?
DMARDS
Medication Reconciliation
Results handling
DMARD Bundle
Only those prescribed Methotrexate or Azathioprine
• Full Blood Count in the last 6 weeks
• Action from abnormal results recorded
• Documented review of blood tests prior to issue of last prescription
• Ever had pneumococcal vaccine
• Documented the patient has been asked about side effects fo their
medication at their last blood test
• Compliance with full bundle (i.e. all of above)
How to access the bundle data
collection spreadsheet
Collecting your data
Entering your data
Automatically generated report
Month
Warfarin
dose
Target INR
Advise
recorded
INR within 7
days
Patient
Education
Overall
Compliant
June
60
50
50
60
50
20
July
50
50
50
70
50
10
August
80
60
50
80
40
30
September
90
80
70
80
50
30
October
80
100
70
90
40
40
November
80
80
60
80
50
50
December
80
90
70
80
70
50
January
70
90
90
90
80
60
ne
100
Ju
Au ly
Se g
pt ust
em
O ber
c
N t ob
ov
er e r
D mb
ec e
em r
b
Ja er
nu
ar
y
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
Ju
Percent compliance
Automatically generated Graphs
Warfarin dose
90
80
70
60
50
40
30
20
10
0
ne
Ju
Au ly
Se g
pt ust
em
O ber
N ctob
ov
er e r
D mb
ec e
em r
b
Ja er
nu
ar
y
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
Ju
Percent compliance
100
Target INR
90
80
70
60
50
40
30
20
10
0
ne
Ju
Au ly
Se g
pt ust
em
O ber
N ctob
ov
er e r
D mb
ec e
em r
b
Ja er
nu
ar
y
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
Ju
Percent compliance
100
Advise recorded
90
80
70
60
50
40
30
20
10
0
ne
Ju
Au ly
Se g
pt ust
em
O ber
c
N t ob
ov
er e r
D mb
ec e
em r
b
Ja er
nu
ar
y
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
Ju
Percent compliance
100
INR within 7 days
90
80
70
60
50
40
30
20
10
0
ne
Ju
Au ly
Se g
pt ust
em
O ber
c
N t ob
ov
er e r
D mb
ec e
em r
b
Ja er
nu
ar
y
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
Ju
Percent compliance
100
Written Education Provided
90
80
70
60
50
40
30
20
10
0
ne
90
Ju
Au ly
Se g
pt ust
em
b
O er
ct
N
ov obe
er r
D mb
ec e
em r
b
Ja er
nu
ar
y
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
#N
/A
Ju
Percent compliance
100
Warfarin
Overall Compliance
80
70
60
50
40
30
20
10
0
Example of Data
Composite Tayside
Composite Measure for 8 practices - Sept10-May11
100%
97%
93%
90%
83%
80%
84%
86%
84%
80%
70%
65%
71%
68%
59%
60%
62%
57%
55%
50%
85%
44%
46%
40%
35%
30%
20%
10%
0%
Wk1
Wk2
Wk3
Wk4
Wk5
Wk6
Wk7
Wk8
Wk9 Wk10 Wk11 Wk12 Wk13 Wk 14 Wk15 Wk16 Wk17 Wk18
* A new patient measure to be added in June will change the nature of the data with the composite likely to decrease initially.
Sep-10
Nov-10
Oct-10
Jan-11
Wave 1
Jan-11
Mar-11
Apr-11
Nov-11
Wave 1
Monthly
Wave 2
Wave 2
Apr-12
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
Jul-11
Apr-12
Jun-11
Mar-12
Feb-12
May-11
Jan-12
Dec-11
60%
Oct-11
70%
Sep-11
80%
Aug-11
Jul-11
Jun-11
Wave 1
Feb-11
May-11
30%
Apr-11
Mar-11
Feb-11
20%
Dec-10
Dec-10
10%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Nov-10
50%
Oct-10
60%
S
70%
Sep-10
40%
ug
-1
0
ep
-1
O 0
ct
-1
N 0
ov
-1
D 0
ec
-1
Ja 0
n1
Fe 1
b1
M 1
ar
-1
A 1
pr
-1
M 1
ay
-1
Ju 1
n11
Ju
l-1
A 1
ug
-1
S 1
ep
-1
O 1
ct
-1
N 1
ov
-1
D 1
ec
-1
Ja 1
n1
Fe 2
b1
M 2
ar
-1
A 2
pr
-1
2
A
80%
Aug-10
0%
% compliance
Aug-10
Wave 1& 2 Achievements
Achievement – Wave 1
Composite Measure for Wave 1 & 2 Practices
June 2010-April 2012
100%
90%
100%
90%
Patient Measure introduced
July2011
50%
40%
30%
20%
10%
0%
Wave 2
Care Bundle Wav e 1 & 2 Practice s
PDSA - Improve Compliance of Patients Attending Monthly Blood Monitoring
Ensure patients prescribed Methotrexate or
Azathoprine attend a monthly review for
blood monitoring
Patients complying by attending blood
monitoring will increase
Using a variety of engagement methods
Patients engaging
5 Stop repeat prescription until
they attend
4 Restrict the amount of repeat prescription
available to them to encourage attendance
3 Put a note on patients repeat prescription
2 Send information stating reasons for why it is important to attend
1 Invite patients who have
failed to comply by telephone
Tayside Vision Guideline
Side Effects
Reliable systems
“The practice team are more aware of the need to
adopt "failsafe" systems rather than assume 100%
adherence to systems”
Medication Reconciliation
Medication Reconciliation
• Unreliable at admission
• Inaccurate and delayed at discharge,
• Unreliable systems in place in primary care for updating
“The process of obtaining an up-to-date and accurate
medication list that has been compared with the most
recently available information and has documented any
discrepancies, changes, deletions or additions resulting in a
complete list of medication accurately communicated”
(Institute for Healthcare Improvement, www.IHI.org
Medication Reconciliation Measures
•
•
•
•
Has the Immediate Discharge Document been workflowed
on the day of receipt?
Has medicines reconciliation occurred within 2 working
days of the Immediate Discharge Document being
workflowed to the GP/Pharmacist
Is it documented that any changes to the medications have
been acted upon?
Is it documented that any changes to the medications have
been discussed with the patient or their representative?
Utilising I.T.
• Implementation of READ
Codes for Medicines
Reconciliation
• Development of
Guideline/Macros on Clinical
System
Meds Rec Care Bundle Compliance (%)
Median
Meds rec data – NHS Greater Glasgow and Clyde
100%
90%
70%
60%
50%
40%
30%
20%
10%
Month
Aug 12
Jul 12
Jun 12
May 12
Apr 12
Mar 12
Feb 12
Jan 12
Dec 11
0%
Nov 11
% compliance
80%
DVD Margaret
Results handling
No.
ITEM
1.
Test(s) results were reviewed by a practice clinician 2 working days
of being received by the practice?
2.
A definitive decision was recorded by a practice clinician on ALL test
results within 7 calendar days of being received by the practice?
3.
The decisions for ALL test results have been ‘actioned’ by the
practice, including the patient being informed as instructed?
(Where no actions are required record as Yes )
5.
All measured met
YES NO
Results
In addition please answer the following
During the past month have you carried out a process to identify results which
have not been returned to the practice
How many of these tests were not received by the practice………
Have a look at the bundles ?
Comments /Questions
Could you use them in your workplace?