measurement and reporting 15.10.08 presenter: chris hancock
Post on 28-Dec-2015
220 Views
Preview:
TRANSCRIPT
• “The normal range for resp rate is 40-60 bpm”• “This guys BP has normally been 70/40 for two days
– what’s the panic?”• “We can’t give him more oxygen – he’s got COPD”• “There is no point phoning the Doctor – they never
come”• “Don’t rush when nurses phone – they get hysterical
easily”• “I only accept referrals from other consultants”• He’s been going off for hours but no one will do
anything” • “We use the masks with the holes in so patients can
use a straw to drink”
Measurement and Reporting
NCEPOD (2005)
• Case note review of 469 of 560 deaths – 42% suboptimal management after hospital admission– 11-16% deficiencies in resuscitation and physiological
management – 66% were grossly unstable for more than 12 hours before
referral
• Improving care of the acutely ill patient requires improving process control & reliability
Measurement and Reporting
In Wales
• 8000 annual level 3 admissions• 40% of admissions that receive poor care
show a mortality increase of about 20% • Mortality is approximately 640 per year• Conservative estimate and does not include
those patients who deteriorate and die prior to ICU admission.
Measurement and Reporting
“If you fly on a plane, you have a one in 10M chance of being killed. If you go into hospital, you have a one in 300 chance – and not from the illness you went in with.”
• Sir Richard Branson Vice President of the Patient’s association
Measurement and Reporting
1000 Lives Campaign • The aims of the 1000 Lives Campaign are to
prevent 1000 deaths and 50,000 episodes of harm in the two years to March 2010
• All Trusts and LHBs
• ICC – spread of bundles beyond ICU
• RRAI – NICE CG 50 and Sepsis care bundles
Measurement and Reporting
WCCIP
• Mean national aggregate compliance for the period April 2007 – March 2008 by bundle was: -– Ventilator care bundle - 97.82%.– Central Venous Catheter Maintenance (CVCM) care
bundle - 97.11%.– Central Venous Catheter Insertion (CVCI) care bundle -
94.71%.• Many units reported zero CRBSI for several months
or are routinely reporting time between infections.• Improvements in outcomes include reduction in
pharmacy costs, reductions in ALVT and a reduction in mortality.
Measurement and Reporting
Ventilator bundle – 97.82%
Feb-07Dec-07Oct-07Aug-07J un-07Apr-07Feb-07Dec-06Oct-06Aug-06J un-06
100.00%
90.00%
80.00%
_X=97.82%
Feb-07Dec-07Oct-07Aug-07J un-07Apr-07Feb-07Dec-06Oct-06Aug-06J un-06
90.00%
60.00%
30.00%
_X=97.11%
Feb-07Dec-07Oct-07Aug-07J un-07Apr-07Feb-07Dec-06Oct-06Aug-06J un-06
102.00%
96.00%
90.00%
_X=94.71%
UCL=103.43%
LCL=85.99%
6
11
566
113
3
665
11
I Chart of Vent Bundle
I Chart of CVC bundle
I Chart of CVCI bundle
Measurement and Reporting
CVC maintenance bundle (CVCM) - 97.11%
Feb-07Dec-07Oct-07Aug-07J un-07Apr-07Feb-07Dec-06Oct-06Aug-06J un-06
100.00%
90.00%
80.00%
_X=97.82%
Feb-07Dec-07Oct-07Aug-07J un-07Apr-07Feb-07Dec-06Oct-06Aug-06J un-06
90.00%
60.00%
30.00%
_X=97.11%
Feb-07Dec-07Oct-07Aug-07J un-07Apr-07Feb-07Dec-06Oct-06Aug-06J un-06
102.00%
96.00%
90.00%
_X=94.71%
UCL=103.43%
LCL=85.99%
6
11
566
113
3
665
11
I Chart of Vent Bundle
I Chart of CVC bundle
I Chart of CVCI bundle
Measurement and Reporting
The WCCIP Database
• Areas outside the ICU
• Measurement for improvement rather than judgement
• 1000 Lives requires only monthly prevalence
• Critical Care Strategic Framework
• Handover of database
Care Bundle Compliance• Ventilator in other ICUs
• CVCM and CVCI in OT, A&E, CCU etc
• 2 Sepsis bundles and sepsis 6
Measurement and Reporting
Resources
• Monthly conference call– ICC – 1st Wednesday– RRAI – 2nd Wednesday
• Events – Sepsis – 23rd Oct– North Network – 4th Dec– National - January
• Extranet workgroups
Measurement and Reporting
Key Contacts
• Gwent – Kate Hooton
• Cwm Taf – Robert Williams
• Velindre – Lisa Miller
• C+V – Mike Spencer
Measurement and Reporting
Lessons from WCCIP and SPI
• The intervention must be owned by the people who are implementing it
• The same people must “own” the audit process
• Recognise local expertise
Measurement and Reporting
PDSA
• Rapid feedback• Accuracy is not the most important factor • Wide circulation• Put in prominent place (back of toilet
door)• Act upon it
Measurement and Reporting
Make it relevant and easy to do• Congruent with SSC, WHAIP etc
• ALoS, ALVT, DToC– Already part of CCMDS
– Reporting delay 1 – 3 months
Measurement and Reporting
Severe Sepsis Bundles• Mortality rates are very high – around 30 –
50%.
• Globally, sepsis kills about half a million people a year: as many as myocardial infarction.– Surviving Sepsis Campaign: International Guidelines for
Management of Severe Sepsis and Septic Shock 2008. Crit Care Med. 2008; 36(1): 296-327
• In Wales this possibly equates to the deaths of between 700-1100 people in ICU annually.
• But we don’t know
Measurement and Reporting
Sepsis Bundles
• Management Bundle evidence weakened• Most effective treatments are simple
interventions such as giving oxygen, large volumes of intravenous fluids and antibiotics. – Rivers E et al. Early goal-directed therapy in the
treatment of severe sepsis and septic shock. N Engl J Med 2001; 345: 1368-1377
• No need to do both the Resus bundle and sepsis 6
Measurement and Reporting
Severe Sepsis Outcomes?• Surviving Sepsis Campaign Database
• Developing a Sepsis Trigger Tool
Measurement and Reporting
Mandatory Measure
• Cardiac Arrest Call Rate– Universally used
– Background noise constant
– Rate rather than number
Measurement and Reporting
RRAI Measures• No. of calls for medium and high risk
– 2 hospitals measuring this as no of outreach calls
– Dependant on system
• DNAR– Number of DNARs increases as CACR
decreases– 1 hospital records the number of times that
outreach intervention results in DNAR– 1 Trust centrally records all DNAR orders
Measurement and Reporting
• Qualitative review of treatment prior to deterioration– Linked to critical incident reporting
– Provides feedback to frontline staff
Conclusion• Ventilator associated pneumonia
(VAP) rate• Central venous catheter-related
bloodstream infection (CRBSI) rate• Days between a CRBSI• Percentage compliance with ventilator
bundle• Percentage compliance with CVC
insertion bundle• Percentage compliance with CVC
maintenance bundle• Percentage compliance with sepsis
management bundle• Percentage compliance with sepsis
resuscitation bundle • Percentage compliance with ‘sepsis
six’
• ALOS on mechanical ventilation• ICU ALOS Monthly rate of delayed
transfers of care• Percent compliance with hand
hygiene• Percentage achievement of daily
goals• Number of cardiac arrest calls• Number of calls for rapid response to
medium and high risk acute illness• Qualitative review and feedback on
outcomes of cardiac arrest and rapid response calls.
• Number of do not attempt resuscitation (DNAR) orders
top related