Transcript Care Bundle - Healthcare Improvement Scotland

Development and Testing
Safety Improvement in Primary
Care 1 and 2
Aims: SIPC1
To enable 50 Primary Care teams to:
1. Identify and reduce harm to patients
2. Improve reliability of care for patients
On High Risk Medications
With Heart Failure
3.Develop safety Culture
4.Involve Patients in QI
Aims: SIPC2
‘Look at areas of major clinical risk to patients as
they move across the health system.’
• Medication Reconciliation
• Results Handling
• Communication after outpatient clinics
The Tools
•Collaborative
•Bundles
•Patient Involvement
•Trigger Tools
•Safety Climate
•
Care Bundle
A care bundle is a set of interventions that,
when used together, significantly improve
patient 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.
‘CLABs are not an inevitable product of complex ICU care but the result of highly variable
and therefore unreliable care delivery that predisposes to infection.’
What is a care bundle?
Key Requirements for Care Bundles
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4 or 5 elements
Across Patients Journey
Creates teamwork
Mixture easy and hard
• All or nothing
Care Bundle Development
Reviewed literature / guidelines
Discussed with colleagues
Spoke to ‘bundle experts’ from IHI
Spoke to patients
Piloted the care bundle
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
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 Lothian Guidance/ INR Star/ RAT?
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 Lothian Guidance/ INR Star/ RAT?
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.
Potential to free up appts
INR Blood Tests
Dalkeith Medical Practice
• Dr Richard Conlan
• Kevin Lawrie (Practice Manager)
• Hazel Thomson (Practice Nurse)
Can you improve efficiency?
Tests per patient
Dec-10 – Dalkeith introduced the RAT system
Aug-11 – Dalkeith started the SIPC project
3.0
2.5
2.0
1.5
1.0
0.5
0.0
Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec10 10 10 10 10 10 10 10 10 10 10 11 11 11 11 11 11 11 11 11 11 11 11
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Test per patient before RAT = 2.2 average
Test per patient after RAT = 1.4 average
Saving = almost 100 appointments per month
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
Warfarin Bundle
Practice Code
1111111
Practice Name
abcde
Comments
Patient
Month and
comments
Please circle response as appropriate
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?
1
Y
N
Y
N
Y
N
Y
N
Y
N
2
Y
N
Y
N
Y
N
Y
N
Y
N
3
Y
N
Y
N
Y
N
Y
N
Y
N
4
Y
N
Y
N
Y
N
Y
N
Y
N
5
Y
N
Y
N
Y
N
Y
N
Y
N
6
Y
N
Y
N
Y
N
Y
N
Y
N
7
Y
N
Y
N
Y
N
Y
N
Y
N
8
Y
N
Y
N
Y
N
Y
N
Y
N
9
Y
N
Y
N
Y
N
Y
N
Y
N
10
Y
N
Y
N
Y
N
Y
N
Y
N
Collecting your data
What does our data tell us?
NHS Lothian Data Collection
NHS Lothian Data Collection
Its about what you do with the
data…….
Like What?
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Practice meeting
Notice board
Process mapping
Ask patients
Try changing something….
Measure the effect.
Our Experience
Craigmillar Medical Practice
Our Experience
• Bundle changed to make it more relevant for
the practices.
• HCA collects the information for the last three.
• GP then goes through records and collects
information for the first two.
• Generally all the bundles score highly.
• Most difficult is face to face education every
three months.
Improving Warfarin Management
• Driving force was compliance with the bundle.
• Practices then tried to improve their system:
- PDSA’s
- Process Mapping
- Patient Involvement
Now what?
• Bundles helped us understand our system.
• Bundles raised awareness.
• Bundles allowed us to make improvements to
the system, both for staff and patients.
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
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
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
What about other bundles?
DMARDS
Medication Reconciliation
Pressure Ulcers
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)
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.
Medication Reconciliation Bundle
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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?
Meds rec data – NHS Greater
Glasgow and Clyde
Meds Rec Care Bundle Compliance (%)
Median
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%
Primary Care Prevention of Pressure Ulcers
Inclusion
Patients visited by the District Nurse
Exclusions
One off visits by the District Nurse
Process Measure ( Care Bundle)
Patients on district nursing caseload will have a waterlow pressure ulcer risk assessment
undertaken on the first visit and an assessment and score recorded on CNIS.
If found to be at risk (waterlow > 10) a SSKIN care plan will be completed to reflect the level of
risk identified from the risk assessment and will include a positioning and repositioning
regime.
Patients will be reassessed at each visit and if there is any change in physical or mental health
a repeat risk assessment will be undertaken and recorded.
Outcome Measures
Number of days between no new pressure ulcers found on patients on district nurse case load.
Number of new pressure ulcers developed in the district nurse case load in the last month.
The safety cross will be used to inform the above outcome measures
A SICP1 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”
Questions?
Patient
Involvement
Patient Involvement
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Education about drugs
Self management
Process mapping
Questionnaires
Practice Focus Groups
Feedback
Patients
Responsive enthusiastic patients appreciate
being Involved
“The main learning was that they appreciate
being involved in their own care”
“Barriers have just been ourselves”