Parallel Session: So Just How Effective Are We?

Reducing cardiac arrests in the Acute Admissions Unit :A Quality Improvement Journey

Dan BeckettConsultant in Acute Medicine

Forth Valley Royal HospitalSPSP Fellow

Situation

• Combined surgical and medical admissions unit • 46 beds (but elastic walls...)• Admits 1500 patients per calendar month• In July 2011 moved from Stirling Royal Infirmary to Forth Valley Royal

Hospital

Background

Stirling Royal Infirmary, 2010

Assessment

• AAU morbidity and mortality meetings established in 2010• Failure to rescue

• Recognition• Response

• Resuscitation attempts undertaken on patients with terminal illness• Limited learning from adverse outcome

Recommendation

• Aim statement developed• FMEA (Failure Modes Effects Analysis) undertaken• Driver diagram developed

• Structured response to the deteriorating patient• Improved end of life care• Improved learning from adverse events

• Measurement plan agreed• Process, Outcome and Balancing measures • Use of data for improvement vs data for scrutiny• Sharing of data with board, staff, patients and relatives

Cardiac arrests in AAU per 1000 admissions

UCL

LCL0

1

2

3

4

5

6

7

8

9

Au

g-1

0

Se

p-1

0

Oct-

10

No

v-1

0

De

c-1

0

Ja

n-1

1

Fe

b-1

1

Ma

r-1

1

Ap

r-1

1

Ma

y-1

1

Ju

n-1

1

Ju

l-1

1

Au

g-1

1

Se

p-1

1

Oct-

11

No

v-1

1

De

c-1

1

Ja

n-1

2

Fe

b-1

2

Ma

r-1

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Ap

r-1

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Ma

y-1

2

Ju

n-1

2

Ju

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Au

g-1

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Se

p-1

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Oct-

12

No

v-1

2

De

c-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-1

3

Ap

r-1

3

Rate

Safety meetings start

Structured response tested

Move to FVRH

Poor patient flow from AAU starts

2.8/1000 to 0.8/1000 admissions = 72% reduction

2222 calls in AAU per 1000 admissions

UCL

LCL0

2

4

6

8

10

12

14

Au

g-1

0

Se

p-1

0

Oct-

10

No

v-1

0

De

c-1

0

Ja

n-1

1

Fe

b-1

1

Ma

r-1

1

Ap

r-1

1

Ma

y-1

1

Ju

n-1

1

Ju

l-1

1

Au

g-1

1

Se

p-1

1

Oct-

11

No

v-1

1

De

c-1

1

Ja

n-1

2

Fe

b-1

2

Ma

r-1

2

Ap

r-1

2

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

No

v-1

2

De

c-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-1

3

Ap

r-1

3

Rate

Safety meetings start

Structured response tested

Move to FVRH

Poor patient flow from AAU starts

Use of data to soothe the naysayers

• ‘The reduction in rate of cardiac arrests in AAU has purely been achieved by moving patients out of AAU earlier so they have their cardiac arrests elsewhere...’

• ‘The reduction in rate of cardiac arrests in AAU is due solely to patients having DNACPR decisions made earlier in their admission’

Dealing with the non-believers...2222 call rate outwith AAU per 1000 admissions

UCL

LCL

0

1

2

3

4

5

6

7

8

9

10A

ug-1

0

Sep

-10

Oct

-10

Nov

-10

Dec

-10

Jan-

11

Feb-

11

Mar

-11

Apr

-11

May

-11

Jun-

11

Jul-1

1

Aug

-11

Sep

-11

Oct

-11

Nov

-11

Dec

-11

Jan-

12

Feb-

12

Mar

-12

Apr

-12

May

-12

Jun-

12

Jul-1

2

Aug

-12

Rate

30 day mortality - all patients CAU/AAU

UCL

LCL

0%

1%

2%

3%

4%

5%

6%

7%

8%

Ma

y-1

0

Ju

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Ju

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0

Au

g-1

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Se

p-1

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Oct-

10

No

v-1

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De

c-1

0

Ja

n-1

1

Fe

b-1

1

Ma

r-1

1

Ap

r-1

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Ma

y-1

1

Ju

n-1

1

Ju

l-1

1

Au

g-1

1

Se

p-1

1

Oct-

11

No

v-1

1

De

c-1

1

Ja

n-1

2

Fe

b-1

2

Ma

r-1

2

Ap

r-1

2

Ma

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Ju

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Ju

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Au

g-1

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Se

p-1

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Oct-

12

No

v-1

2

De

c-1

2

Ja

n-1

3

Percent

17% DROP IN 30 DAY MORTALITY SINCE MOVING TO FVRH

=

16 LIVES SAVED PER MONTH

Safety initiatives

started Move to ward based

team at FVRH

SIGNIFICANT SHIFT IN MORTALITY

HSMR

0.0

0.5

1.0

1.5

2.0

Oct-Dec2006

Jan-Mar2007

Apr-Jun

2007

Jul-Sep2007

Oct-Dec2007

Jan-Mar2008

Apr-Jun

2008

Jul-Sep2008

Oct-Dec2008

Jan-Mar2009

Apr-Jun

2009

Jul-Sep2009

Oct-Dec2009

Jan-Mar2010

Apr-Jun

2010

Jul-Sep2010

Oct-Dec2010

Jan-Mar2011

Apr-Jun

2011

Jul-Sep2011

Oct-Dec2011

Jan-Mar2012

Apr-Jun

2012

Jul-Sep

2012p

Sta

ndard

ised M

ort

alit

y R

atio

Standardised Mortality Ratio (SMR) Regression line

HSMR October 2006 – September 2012 (19.5% reduction)

Total number of admissions to critical care per month

0

20

40

60

80

100

120

140A

ug

-10

Se

p-1

0

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-10

No

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c-1

0

Jan

-11

Fe

b-1

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Ma

r-1

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Ap

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Ma

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Au

g-1

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Se

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No

v-1

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De

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Jan

-12

Fe

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Ma

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Ap

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Ma

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Jun

-12

MedianMeasure

Move to ward based

team at FVRH

Safety initiatives

started

Proportion of patients admitted to critical care on Day 0

UCL

LCL

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Au

g-1

0

Se

p-1

0

Oct

-10

No

v-1

0

De

c-1

0

Jan

-11

Fe

b-1

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Ma

r-1

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Ap

r-1

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Ma

y-1

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Jun

-11

Jul-

11

Au

g-1

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Se

p-1

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Oct

-11

No

v-1

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De

c-1

1

Jan

-12

Fe

b-1

2

Ma

r-1

2

Ap

r-1

2

Ma

y-1

2

Jun

-12

Percent

Safety initiatives

started

Move to ward based

team at FVRH

Importance of data and measurement• Use of data for improvement

• Sepsis 6• Compliance with structured response checklists

• Use of data for scrutiny• Cardiac arrests• Mortality

• Sharing of data

Patients with NEWS4 sepsis getting the sepsis6 bundle within 60 minutes

UCL

LCL0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Oct

-11

No

v-1

1

De

c-1

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Jan

-12

Fe

b-1

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Ma

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Ap

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Ma

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Jun

-12

Jul-

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Au

g-1

2

Se

p-1

2

Oct

-12

No

v-1

2

De

c-1

2

Jan

-13

Fe

b-1

3

Ma

r-1

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Percent

Number of patients referred to palliative care

0

10

20

30

40

50

60

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80

Ja

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Fe

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Oct-

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No

v-1

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De

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Ju

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Oct-

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No

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Ma

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MedianMeasure

Acknowledgements

• Sharon Oswald• Monica Inglis• Iain Wallace• SPSP• The whole AAU multidisciplinary team!

• [email protected]• @djbeckett

Effective Haemophilia Care

in Scotland

• A severe inherited X-linked bleeding disorder• Untreated males suffer spontaneous bleeding in joints, soft tissues

and brain• Treatment strategies: ‘on demand’ or ‘prophylaxis’

• ‘On demand’ patients may suffer 2-6 bleeds per month -> chronic joint damage

Background - Haemophilia

• Six Haemophilia Treatment Centres in Scotland [2 west + 4 east]• Recombinant coagulation products are managed as part of the risk

share scheme: total cost for 2012/13 was £24.5million

• UK Annual Report 2009-10Identified geographical variation in mean annual coagulation product use per patient with severe haemophilia

Background

• A review was commissioned by Board Chief Executives’ in 2011 to assess clinical practice and product usage across the six centres

• Review highlighted:- Subtle variation in clinical practice - No standard way to measure clinical outcomes or quality of care

• Recommendations:- Developmental of standardised protocols- Development of key performance and clinical outcome indicators

Background

Centres worked together to - produce standard policies and

protocols in relation to dosing, stock holding and management

- develop key performance and clinical outcome indicators

- produce a clinical audit form to capture dataset in relation to the indicators

Largely confined to treatment of severe haemophilia• Performance indicators

• % attending for 6-month review• Uptake of home treatment & home delivery of product• % severe patients receiving ‘standard’ prophylactic coagulation factor

treatment• % patients receiving an excess amount of coagulation product per Kg in 6m

• Outcome indicators- Patients with spontaneous major bleeds- Days missed from school/work because of bleeds- Patients on standard prophylaxis remaining bleed free- Patients having had joint replacement or arthrodesis

Performance & Clinical Outcome Indicators

• Policies and Protocols have been implemented in all centres

• Clinical Audit Forms are completed for moderate and severe users of recombinant products 6-monthly from January 2012

• Data is recorded in clinics based on information provided by patients

• The Data has been recorded on the Clinical Audit System

• Allowing comparative clinical audit across the Haemophilia Centres

Systems & processes adopted in clinical practice

% severe patients on home therapy

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Aberdeen Dundee Inverness Edinburgh Glasgow Edinburgh-Paed

Yorkhill -Paed

% severe patients receiving standard prophylaxis

0%

10%

20%

30%

40%

50%

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70%

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90%

100%


Yorkhill -Paed

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Yorkhill -Paed

% patients with a spontaneous major bleed

% severe patients losing >5 school or work days

as result of bleeding

% severe patients free of spontaneous bleeds

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Yorkhill -Paed

Treatment Centre

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Yorkhill -Paed

Improving quality and effectiveness of carePolicies and Protocols have driven changes in practice- formalised processes and ensures a standardised approach across all

centres Clinical Audit reports:- demonstrate patient outcomes - allows centres to review and discuss the most clinically appropriate and

effective care for patients- Scottish peer review meetings established to discuss ‘exception cases’

- highlight where targeted work is required to drive improvements in clinical care

Disinvestment in NHS Lothian..........“just say NO!”

Disinterested in NHS Lothian..........“just say NO!”

Disinvestment in NHS Lothian..........Attempting to use evidence to change practice.....

Just say NO!

• ..............it’s not affordable• ..............it’s not possible• Difficult in a “free” healthcare system• Politically damaging• Withdrawal of what is already available is unpopular with

patients and doctors.• Can’t just say NO!!!

Priority setting...... Which one?

• Patient- did we ask?? Most important?!??!• Financial- don’t need to ask!!• Quality- what questions to ask?• Outcomes- Was the question biased?• Many more.................... -Croydon list

-McKinsey

Lothian RILCV process.

• Identify area of interest• Contact clinicians and seek “buy in”• Assessment of health intelligence (HIU and ISD, BQBV dashboard)• EVIDENCE REVIEW -efficacy

-cost effectiveness-controversy in literature-impact of change

• ENGAGE STAKEHOLDERS• Develop plan• Enact and review plan

2008/09 2009/10 2010/11

NHS Board of residence 75+ 85+ All ages 75+ 85+ All ages 75+ 85+ All ages

Scotland 44.8 44.0 6.2 46.2 45.0 6.4 44.2 42.8 6.3

Ayrshire & Arran 60.0 58.3 9.1 57.8 54.9 8.9 46.0 44.9 7.5

Borders 58.7 61.4 8.7 72.3 73.2 10.6 65.8 66.8 9.7

Dumfries & Galloway 68.3 59.7 11.4 65.5 56.9 11.6 59.3 52.5 10.4

Fife 37.2 35.7 5.4 38.9 37.9 5.8 38.7 40.6 5.8

Forth Valley 54.4 53.6 6.9 50.4 49.9 6.9 56.7 55.5 7.4

Grampian 35.0 35.5 4.6 39.3 40.6 5.0 32.1 31.6 4.4

Greater Glasgow & Clyde 42.5 40.9 5.8 40.9 39.7 5.7 42.8 41.4 6.0

Highland 50.6 54.2 7.5 52.5 51.9 7.8 50.6 43.3 7.9

Lanarkshire 36.2 36.2 5.2 38.0 32.7 5.2 33.0 32.0 4.8

Lothian 42.8 41.3 5.2 43.4 42.5 5.4 42.3 40.3 5.3

Orkney 35.9 45.9 5.6 29.9 37.8 4.4 22.5 26.6 3.6

Shetland 42.1 42.3 5.4 20.0 27.8 3.4 19.3 18.4 2.9

Tayside 42.8 42.8 6.8 54.2 53.9 8.2 57.1 56.7 9.1

Western Isles 57.6 54.3 8.7 67.1 71.8 10.8 50.7 45.4 9.3

First quartile 38.5 41.0 5.4 39.0 38.4 5.2 34.4 34.1 5.0

Crude Rate of Cataract Interventions by NHS Board of residence (all) per 1,000 population, 2008/09 - 2010/11

Cataract RILCV process.

• Identify area of interest- Cataract• Contact clinicians and seek “buy in” – Oph & optoms• Assessment of health intelligence – 4500 operations, half coded, 35%

second eye• EVIDENCE REVIEW - impact of threshold

- value of 2nd eye surgery

Cataract RILCV process.

• Identify area of interest- Cataract• Contact clinicians and seek “buy in” – Oph & optoms• Assessment of health intelligence – 4500 operations, half coded• EVIDENCE REVIEW - impact of threshold

- value of 2nd eye surgery• ENGAGE STAKEHOLDERS – oph, other boards, RNIB, E&D unit, • Develop plan – Set threshold at driving test level plus other “soft”

measures run as a shadow audit• Enact and review plan – 5% reduction in referrals, 0.4% reduction

surgeries

Classes of interventions to target for decreased utilisation – Lancet Oncology Commission 2011

Over-utilisation

• Quicker to discuss TP than discussion of no treatment• Quicker to order a scan than history and exam• In breast cancer no benefit to follow up with tumour markers (Rosselli

JAMA, GIVIO study JAMA)• Many examples of futile care in last weeks and days of life (studies

suggest up to one third of cancer care costs)• In 2010 the US Patient Protection and Affordable Care Act established

a Patient Centred Outcomes Research Institute

Improving efficiency and value in cancer care

• Physician education!!!• Identifying interventions of marginal or no clear benefit with high cost- SR’s, meta-

A’s, comparative effectiveness research & RCT’s• Physician education focussed on tech skills- primary and continuing education

needs to incorporate understanding of cost-effectiveness!!!• Personalised medicine• More rapid adoption of innovation (sentinel & others)• Translational and clinically focussed research• Comparative effectiveness research and health-services research- how to deliver?• Development of outcome data (SCAN report), rapid learning healthcare system• Focus on end of life care: account for wishes of patients and families

Limitations of evidence

• RCT’s do not imply clinical significance ONLY statistical significance • NCI Canada reported median overall survival benefit of 0.33 months

for Erlotinib plus gemcitabine in advanced pancreatic cancer • Massive toxicity, FDA, EMA and SMC approved at cost of $500,000 per

life year gained (Threshold?? NICE 10%)• EUROCAN project- ethical, political and administrative barriers to

acquiring and sharing data on outcomes

Cancer surgery

• Hunter “an armed savage trying to render by force that which a civilised man would render by strategem”- Main method of cure for solid tumours globally

• In common cancers surgery alone 50% of direct costs (Warren JNCI 2008)

• Curative in absence of metastatic disease- little emphasis on defining staging

• ASCO 2010- ACOSOG Z0011 study showed no benefit of ALND in women with 1-3 positive SNB- Surgical bias!!!

• Challenge the surgical dogma (XS, trade-off)

Where are we with prioritisation?

• RILCV• Quality based commissioning• Guideline driven care (rationing)• We do not have or own the data!• Data not geographically/culturally sensitive• Data not appropriate to our healthcare system• Where are the outcomes for our organisations?? (31/62 vs survival)

Some solutions.....

• Consult widely on the questions and priorities• Commission and own the data• Share and collaborate on the data• Analytical methods that compare and that emphasise clinical benefit• Educate physicians with the data (challenge)• Use and implement changes• Rapidly adopt technological advances

We need to be able to do more than “just say no”

Thank you!

Dr Victor Lopes PhD FRCSAssoc Medical Director NHS Lothian

Parallel Session: So Just How Effective Are We?

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Transcript of Parallel Session: So Just How Effective Are We?