measurement and reporting 15.10.08 presenter: chris hancock

Measurement and Reporting


15.10.08

Presenter: Chris Hancock

• “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”


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


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.


“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

http://images.askmen.com/galleries/men/richard-branson/pictures/richard-branson-picture-1.jpg


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


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.


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%


90.00%

60.00%

30.00%

_X=97.11%


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


CVC maintenance bundle (CVCM) - 97.11%


100.00%

90.00%

80.00%

_X=97.82%


90.00%

60.00%

30.00%

_X=97.11%


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


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


Resources

• Monthly conference call– ICC – 1st Wednesday– RRAI – 2nd Wednesday

• Events – Sepsis – 23rd Oct– North Network – 4th Dec– National - January

• Extranet workgroups


Key Contacts

• Gwent – Kate Hooton

• Cwm Taf – Robert Williams

• Velindre – Lisa Miller

• C+V – Mike Spencer


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


PDSA

• Rapid feedback• Accuracy is not the most important factor • Wide circulation• Put in prominent place (back of toilet

door)• Act upon it


Make it relevant and easy to do• Congruent with SSC, WHAIP etc

• ALoS, ALVT, DToC– Already part of CCMDS

– Reporting delay 1 – 3 months


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


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


Severe Sepsis Outcomes?• Surviving Sepsis Campaign Database

• Developing a Sepsis Trigger Tool


Mandatory Measure

• Cardiac Arrest Call Rate– Universally used

– Background noise constant

– Rate rather than number


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


• Qualitative review of treatment prior to deterioration– Linked to critical incident reporting

– Provides feedback to frontline staff


Questions

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

measurement and reporting 15.10.08 presenter: chris hancock

Documents

ventilator care bundle

icu measurement

sepsis care bundlesmeasurement

reportingventilator

poor care

wednesdayevents sepsis

lives campaign

ccu etc2 sepsis bundles