Communication & Education CCCF 2014

Lessons Learned from an Audit Program ECMO Performance Improvement

Program “ECMO-PIP”

Anne-Marie Guerguerian MD PhD

Critical Care Medicine, Hospital for Sick Children University of Toronto

Disclosures • Not a clinician educator • Regulatory:

• Membrane oxygenators used at SickKids are available through Health Canada’s Special Access Program

• Research funding: • Canadian Institutes of Health Research & Heart and Stroke

Foundation of Canada • Intellectual:

• Heart and Stroke Foundation of Canada Paediatric Resuscitation Task Force Member

• International Liaison Committee on Resuscitation Paediatric Task Force Member & Evidence Reviewer

Objectives

• To learn how a model of ‘barriers to physician adherence to clinical practice guidelines’ was adapted to a team of inter-professional health care providers caring for children on ECMO

• To understand why I believe communication strategies must continue to facilitate ‘in person’ dialogue – both perceptions and data

Context: Already a Mature Program

• > 20 years- now 25 years • Multidisciplinary and shared knowledge, skill,

experience, policy and procedures in place

ECMO Program

• Dedicated educators • Courses for internal & external development

Education Program

• External & internal benchmarking • Academic, Research , and Innovation

Quality Program

Clinical Context in PICU

• Overall Paediatric ICU mortality is low < 4-6% • Select conditions > 50% • Overall ECMO survival to ICU discharge ~45% • In 2004 and 2005, the number of patients

supported by ECMO ~ doubled

~ 42% survival vs. 5% overall in PICU

Team: Expanded & Growing

• 1989 – 2007 • Single unit • ~ 50-80 RNs • 5 ICU physicians • 3 Surgeons • 5 Perfusion specialists • 5-8 ECMO Specialists

• 2008 – 2014 • 2 Units: PICU & CCCU • 100-200 RNs • 10-15 ICU Physicians • 5 Surgeons • 7-11 Perfusion

specialists • 25 FTE ECMO Specialists

(40 individuals)

I’ve cared for 17 children on ecmo and

this is the first one who survives…

Variability & Dissatisfaction e.g.,

• “Some attendings want the core temp 33 others 34 others 35 - what is our policy?” why are they all different?

• “They want to do a wean trial…but the circuit is full of clots- what should I have said…”

• “I’ve noticed some specialists increase the blood flow to goal very quickly on cannulation … I think it may cause intracranial bleeds…how can we change this practice”

Variability & Dissatisfaction e.g.,

• “They did not have vascular access, so he added parenteral nutrition in the circuit…isn’t that a problem…”

• “We had air in the circuit- and the staff removed it by…but that’s not our policy…but I did not feel comfortable…and … what if…”

Variability & Performance e.g.,

“Some surgeons will not let us flash the

cannulas every 5-10 min during the

weaning trials and I am really worried they will clot and

stroke…but I don’t feel comfortable

saying so”

Moral distress & performance e.g.,

“The mother and father understand that their child is going to die likely tomorrow after weaning off – he is off the transplant list… but they do not want us to say anything around the bedside because they think he won’t understand…this is really difficult…and I’m not sure I can handle being assigned to this patient tomorrow…”

Improving Communication in ICU

• Median time: 20 min per patient • at bedside • Dialogue &

Written • “Were the goals

understood?”

Improving communication in the ICU using daily goals. Pronovost P1, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. J. Critical Care 2003

%

Need 1: Daily

• Dedicated: Time • Where: At the bedside • Who: With bedside team - leader with

members (no observers) • Why: To explain the rational and

operationalize the daily goals • How: verbal communication and order sheet

Model of Barriers to Physician Adherence to Clinical Practice Guidelines

Knowledge Attitudes Behaviour

Barriers Facilitators

Balance of factors affecting adherence to Clinical Practice Guidelines

Sequence of Behavior Change

Model of Barriers to Physician Team Adherence to Clinical Practice Guidelines: Internal & External

Knowledge Attitudes Behaviour

Lack of Familiarity • volume of information • guideline accessibility • time needed to stay informed • time to keep multidisciplinary team informed

Lack of Awareness • volume of information • guideline accessibility • time needed to stay informed • time to keep multidisciplinary team informed

Lack of Agreement with Specific Guidelines • interpretation of evidence • applicability to patient • not cost-beneficial • lack of confidence in guideline developer • lack of consensus within multidisciplinary team Lack of Agreement with Guidelines in General • “too cookbook” • too rigid to apply • biased synthesis • challenge to autonomy • not practical

Lack of Outcome Expectancy • physician or multidisciplinary team believes that performance of guideline recommendation will not lead to desired outcome

Lack of Self-Efficacy • physician or multidisciplinary team believes that he/she/they cannot perform guideline recommendations

Lack of Motivation or Inertia of Previous Practice from the physician or multidisciplinary team • habit • routines

External Barriers Environmental Factors • multidisciplinary decision • lack of functional team work • lack of time • lack of resources • organizational constraints • lack of reimbursement • perceived increase in malpractice liability Guideline Factors • guideline characteristics • presence of contradictory guidelines Patient Factors • inability to reconcile patient characteristics with guideline recommendations

Modified from Cabana 1999

Need 2 : Monthly

• Forum • Face to face • All the health care providers involved • The effectors of change: educators • Safe: one year moratorium on managers’

attending meeting • Perceptions of reality • Data to reflect reality • Feedback and delegation to education team

ECMO/ECLS Performance Improvement Process ‘PIP’

DELIVERY OF CARE ON ECMO DELIVERY OF CARE ON ECMO

EVENT

NON STANDARD CARE INTERVENTION

ERROR ADVERSE EVENT &

COMPLICATION

LACK OF SATISFACTION

DEVICE MALFUNCTION

DEATH

ERROR

Quality Improvement Initiatives

• Clinical outcomes review forums • Individual patient inter-professional reviews • Objective data & team member perceptions

• Aligned to other performance improvement processes • Debriefing

• Real time team • Remote in time individual

• Benchmark with internal and external endpoints • Rapid cycling methodology

DURING THE EVENT

BEDSIDE NURSE

CALLS CODE BELL PREPARES TO COME OFF: ABC (BAGS- TURNS ON Rx) ECMO SPECIALIST & FELLOW MD AT BEDSIDE RT: FULL VENTILATION

ECMO SPECIALIST

REVIEWS CIRCUIT PAGES PERFUSION PREPARES TO COME OFF & RESTART ORDERS BLOOD FROM BLOOD BANK

FELLOW MD

CALLS STAFF MD CALL CVS FELLOW PREPARES TO COME OFF: FULL VENTILATION & HEMODYNAMIC SUPPORT

AFTER THE EVENT

ON CALL STAFF PHYSICIAN ENSURES ALL BELOW IS COMPLETED

BEDSIDE NURSE

NOTIFIES PARENTS PATIENT MANAGEMENT UPDATE

ECMO SPECIALIST REVIEWS CIRCUIT DOCUMENTATION OF PRE-’ECMO EVENT’ NOTE WITH ITEMS IN CIMS INCLUDING DEVICE # COMPLETES INCIDENT REPORT LEAVES A VOICE MAIL ON COORDINATOR’S PHONE

PERFUSIONIST

MONITORS PATIENT UNTIL ECMO SPECIALIST READY TO TAKE OVER REVIEWS CIRCUIT AND REMOVES CIRCUIT WITH ECMO SPECIALIST LEAVES MESSAGE WITH BIOMED TO REVIEW DEVICE AND PREPARES NEXT BACK UP PUMP

FELLOW MD EXPLAINES TO PARENT REVIEWS & PLANS FOR END ORGAN DAMAGE FOLLOW UP DOCUMENTS PRE-EVENT AND POST-EVENT CLINICAL STATUS INFORMS OTHER SERVICES PRN

ECMO coordinator follows up, reports to ECMO PIP, prepares information for ECLS/AT team communication

Monthly Gathering

• Face to face • 360 Pre-review and summary • Lead by a senior fellow • Data summary viewer with

senior data analyst of RAW data from medical record- no averages

• Includes feedback from the providers who are involved with follow up and bereavement

Monthly Gathering ‘What worked and what could be better’

• Perception and raw data • Documentation • Communication • Medico-surgical

management • Mechanical support

management • Patient action and program

action item

Raw data viewer

Data and perception aligned…

Reporting • Identified & De-identified • Rapid access & Automated

ECLS Activity Dashboard

Quality & Science Strong Foundation of Communication

• Improving single patient and family and program’s outcomes

• Balancing standard care and innovation • Standardization vs. Customization

Data Collection

• Per patient • Per interval of care & type of ECLS • Patient centric & program centric • Granularity & Integrity vs. effort needed for

collection • Assessment window [ECLS] vs. [ECLS] + later

[Outcome]

Communication allows to identify solutions to facilitate Behavior Change to Overcome Internal & External Barriers

Knowledge Attitudes Behaviour

Lack of Familiarity

Lack of Awareness Lack of Agreement with Specific and General Guidelines

Lack of Outcome Expectancy

Lack of Self-Efficacy

Lack of Motivation or Inertia of Previous Practice

External Barriers Environmental Factors Guideline Factors Patient Factors

Modified from Cabana 1999

Acknowledgements • Patients & Families • 25 years since 1989: Program’s founders D. Bohn, W. Williams & C. Gruenwald • Cardiovascular Surgery G. Van Arsdell & O. Honjo • 15 CCCU & PICU Staff Physicians and Fellows • Critical Care Medicine & Perfusion Services Teams Lynn Crawford • Bedside ECMO Specialists, RN, RTs, Physiotherapists, Pharmacists, Dieticians • Cardiovascular Surgery Fellows • Data analysts Helena Frndova & Norbert Chin • Greg Patterson Biomedical Engineer • Jason McCartney & Mark Todd Coordinators & A. Stanisic Perfusion Educator • Education Committee Afrothite Kotsakis • Outcomes Committee Ben Sivarajan • VAD Medical Director Tilman Humpl • ECMO Performance Improvement Fellows • Hematology-Thrombosis Leonardo Brandao • Psychology – Renee Sananes • Audiology – V. Papaioannou