Optimal Care Education
We need to arm everyone with the power of
knowledge to identify problems and work on change
Foreseeable Risks
Doors To Hip Fracture Knowledge
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Click For Very
Bare Bones Summary
VTE
Doors To Foreseeable Risks
Gastro-
Intestinal
Grief
& Loss Pneumonia Immobility Falls
Neuro-
vascular
Poly-
Pharmacy
Surgical
Site
Infection
CAUTI
Delirium Pain Anemia Cardio-
Vascular Malnutrition
Pressure
Ulcers Fluid
Balance
Care
Click On The Door You Wish To Open
Delirium Risk
1. Delirium may result in disability or death
2. Delirium has a sudden onset and fluctuating course where focus of mentation is limited
3. Investigate and eliminate underlying risk and causes
4. Important to know what the patient baseline was
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• Exit slides at any time by pressing the Esc key
Urine, lungs, skin, blood
Dehydration, hypovolemia
Sodium, potassium,
magnesium
Malnutrition, thiamine
deficiency, anemia
Angina, infarction,
congestive heart failure
Stroke or ischemia,
concussion
Urinary Retention,
constipation
Hypoxia (eg: COPD
exacerbation, PE )
Infection
Fluid disturbance
Electrolyte disturbance
Nutrition
Cardiovascular
Central Nervous
System
Elimination Problems
Pulmonary
Bleeding with anemia,
C. difficile colitis
Narcotics, steroids,
anticholinergic, NSAID
Gravol, Benadryl
Alcohol, sedative-
hypnotics, narcotics
Gastrointestinal
Medications
Over-the-counter
medicines
Substance Intoxication
or Withdrawal
Common Causes of Delirium
Click on boxes for specifics Click on boxes for specifics
Disordered thinking
Hallucinations
Inability to focus
Short term memory loss
Fluctuating confusion
Agitation
Paranoia or
delusions
Anxiety
Mood changes
Characteristics of Delirium
No, delirium is a medical
emergency
Hypoactive
Identifies the extent of
delirium
Zofran not gravol
Easy to distract
Cognitive assessment
method instrument.(CAMI)
PRISME is awesome.
Depression and
dementia.
General Anesthesia
Remove foley if at all
possible
Delirium Questions Click on Box for Answers
What tool identifies causes and
interventions for delirium?
What 2 other conditions can
delirium be mistaken for?
What anesthetic is more likely to
cause delirium?
Is delirium an indication to
sustain a foley catheter?
Is delirium routine and to be
expected?
What delirium type is sometimes
mistaken for depression?
Why is determining the patient
baseline behavior useful?
What is preferable when trying to
avoid delirium? Gravol or Zofran?
Is a delirious patient difficult to
distract?
What is a most useful screening
tool for delirium detection?
BC Hip Fracture
System Redesign Project:
Data-driven decision making
SSC-Funded Hip Fracture Redesign Initiative
BC Quality Forum
Feb 25, 2016
Triple Aim focus
1. Improve health of the Population: Evidence-based clinical practices
Early access to surgery
2. Enhance Patient /Provider Experience: Fewer complications; Better discharge planning & transitions in care btw
HCW and with community; Improved knowledge, skills of HCW
3. Reduce or Control per Capita Costs: Reduced LOS / costs; Improved patient flow; A systems approach to QI
Patient Journey : Indicators
12
% Transfer
TTS (%<48h)
Reasons
Living Arr
Demographics
Living Arr WB orders
% WB POD #1
Living Arr 4+12mo
PROMs 4+12mo
GP visit
FReSH Start Utility
Sites (22/28)
Pilot:
▪ Royal Jubilee
▪ Burnaby Hospital
▪ Kelowna General
▪ UHNBC
▪ St. Paul’s
▪ Richmond Hospital
▪ Vancouver General
▪ Lions’ Gate
13
Phase 2: SPREAD
• Nanaimo Gen
• Victoria Gen
• Campbell Riv (CRDGH)
• St Josephs (SJGH)
• Cowichan District
• Ridge Meadows
• Langley Memorial
• Royal Columbian
• Chilliwack Gen
• Abbotsford (ARHCC)
• Peace Arch (PADH)
• Surrey Memorial
• Vernon Jubilee
• Penticton Reg
• … growing
BC Hip Fracture Registry: Data Flow
Passively Collected Data
Actively Collected Data
USUAL
Administrative
data
NEW
Real-time data
(Prospective)
BCHFR
Database
• DAD
• Client Registry
• MSP
• BCAS
• Home Comm Care
• Pharmanet
Background Context – Data Collection Jun 2013-Sep 2015
▪ Demographics
▪ n = 4527 (Age >60, Total 4913)
▪ Mean age: 83 yrs (median 85y)
▪ Female: 70% (mean age 84y, SD10)
▪ Male: 30% (mean age 81y, SD 10)
▪ In Hospital #s: 2.6% (116/4527)
▪ % requiring transfer: 8% (360/4411)
(as at Sep ‘15)
Proportion of cases “transferred”
MultipleHospital Transfers % Transfer
No Yes
ARHCC 92% 8%
BH 100% 0%
CRDGH 71% 29%
KGH 98% 2%
LGH 79% 21%
NRGH 95% 5%
PADH 100% 0%
PRH 80% 20%
RH 99% 1%
RJH 96% 4%
SJGH 100% 0%
SMH 100% 0%
SPH 94% 6%
UHNBC 67% 33%
VGH 97% 3%
VIC GH 96% 4%
VJH 77% 23%
Grand Total 92% 8%
Abbotsford Burnaby Campbell River Kelowna Lions Gate
Richmond
Peace Arch Penticton
Nanaimo
Royal Jubilee St Joseph’s Comox Surrey Memorial St Paul’s Prince George Vancouver General Victoria General Vernon Jubilee
(as at Sep ‘15)
Living Arrangement Pre Admission
(as at Mar ‘15)
Liv Arr Pre
BH KGH LGH RH RJH SPH UHNBC VGH (Van) Grand Total
Home 56% 60% 76% 71% 62% 74% 76% 61% 66%
Home + support 6% 9% 0% 1% 9% 3% 1% 9% 5%
Long Term Care
Assisted Living 8% 10% 5% 11% 4% 5% 7% 8% 7%
Residential Care 26% 17% 15% 18% 25% 15% 14% 21% 19%
Other: 4% 4% 4% 0% 0% 3% 2% 1% 2% 2% 47
Grand Total 100% 2230
1596
587
71%
26%
A B C D E F G H
0%
20%
40%
60%
80%
100%
120%
0
100
200
300
400
500
600
700
800
12 24 36 48 >48h
Fre
qu
en
cy
TTS
Time btw Admission and Surgery
Time to Surgery – All sites (n=4367)
▪ Time from Admission to OR Entry/Surgery
▪ Average: 30 hrs 17 mins
19
49%
91%
(as at Sep ‘15)
Improvements in Time to Surgery (MoH P4P) (as at Mar ‘15)
Pilot Site
Historical*
Last 3y
First 4mo (May - Aug ‘13)
Mid 10mo (Nov ‘13- Aug 14)
Mid 7 mo (Sep ‘14 – Mar ‘15)
1149
Project to date (May ‘13- Mar ‘15)
All Sites 79% 90% 92% 90%
A 64% 70% 86% 93% (9/130) 87%
B 68% 76% 90% 94% (10/163) 90%
C 81% 86% 85% 92% (13/164) 88%
D 85% 95% 97% 94% (5/79) 95%
E 89% 77% 92% 96% (6/162) 91%
F 87% 78% 93% 89% (12/107) 89%
G 79% 71% 80% 72% (25/89) 77%
H 84% 75% 94% 95% (10/189) 91%
Proportion of cases operated within 48 hrs of admission *source: 2009/10, 2010/11, 2011/12 MoH
20
Reason for Delay at 24hrs / 48hrs (efficiency)
n=3282 <24h =1608 (49%)
<48h =2965 (90%)
▪ Administrative ▫ OR availability
▫ DxTests/Consults
▫ Transfers
▫ Bed availability
▫ Other / None ID
▪ Pt Readiness: ▫ Medical Instability
▫ Anticoagulation
▫ Delay in Dx
▫ Delay in consent
▫ Other
21
41.5% 35.5%
1.6%
1.7%
0.2%
2.5%
9.5% 4.4%
3.6%
0.3%
0.2%
1.0%
24h 48h
6% 4.1%
0.5%
0.5%
0.1%
0.8%
4% 2.1%
1.1%
0.2%
<0.1%
0.3%
(70%)
Reason for Delay @ 48hrs (n = 3282)
(by site)
22
DelayAt48h
ARHCC BH KGH LGH RH RJH SPH UHNBC VGH Grand Total
N/A 13 304 390 467 248 456 296 203 536 2913
Administrative: 27 17 30 7 32 18 36 26 193
PT Readiness: 1 17 21 20 7 14 7 21 18 126
Grand Total 14 348 428 517 262 502 321 260 580 3232
DelayAt48h
ARHCC BH KGH LGH RH RJH SPH UHNBC VGH Grand Total
N/A 93% 87% 91% 90% 95% 91% 92% 78% 92% 90%
Administrative: 0% 8% 4% 6% 3% 6% 6% 14% 4% 6%
PT Readiness: 7% 5% 5% 4% 3% 3% 2% 8% 3% 4%
A B C D E F G H I
(Change over time by site analysis pending)
Last 6 mo Full WB 88%
Non-WB 3%
Partial WB 11%
Post OP WB status ordered (n=3220)
▪ Goal: > 90% WBAT
23
WB Orders Postop
ARHCC BH KGH LGH RH RJH SPH UHNBC VGH Grand Total
Full WB 11 309 367 468 178 477 285 215 534 2844
Non-WB 3 15 26 18 6 17 10 19 114
Partial WB 3 36 46 16 66 19 16 34 26 262
Grand Total 14 348 428 510 262 502 318 259 579 3220
WB Orders Postop
ARHCC BH KGH LGH RH RJH SPH UHNBC VGH Grand Total
Full WB 79% 89% 86% 92% 68% 95% 90% 83% 92% 88%
Non-WB 0% 1% 4% 5% 7% 1% 5% 4% 3% 4%
Partial WB 21% 10% 11% 3% 25% 4% 5% 13% 4% 8%
A B C D E F G H I
Mobilisation POD#1
24
(Pending analysis by day of week, impact on LOS)
(as at Mar ‘15)
MobilisationDay1
ARHCC BH KGH LGH RH RJH SPH UHNBC VGH Grand Total
None 21% 13% 20% 12% 26% 20% 7% 23% 28% 19%
Bedside sit/dangle 14% 3% 17% 37% 17% 21% 30% 14% 15% 20%
Transfer to chair/stand 36% 63% 28% 17% 23% 20% 28% 23% 38% 30%
Walk 29% 21% 35% 34% 34% 39% 34% 40% 19% 31%
n=14
61%81%
A B C D E F G H I
Improvements in MEDIAN LOS
Pilot Site
First 4mo (May - Aug ‘13)
Last 6 mo (Sep ‘14 – Feb ‘15)
Project to date (May ‘13- Mar ‘15)
All Sites 12 11 12
A 20 16 16
B 8 9 10
C 8 7 10
D 13 8 10
E 20 13 18
F 11 9 12
G 6 8 7
H 11 12 12
Median LOS in Pilot site, across periods of pilot project 25
~ Target:
Swedish
Median LOS
10d
Discharge Destination
26
17%
46%
25%
CDN Avg In-hospital mortality: ~7-10%
BC Historical: 6.5% (2011/12)
DC Destination
BH KGH LGH RH RJH SPH UHNBC VGH (Van) Grand Total
Death 8% 4% 4% 5% 7% 7% 1% 3% 5%
Convalescent/Slow rehab 0% 28% 0% 4% 3% 3% 0% 25% 9%
Rehab facility 27% 2% 1% 12% 1% 19% 1% 9% 8%
Home 11% 31% 45% 28% 24% 36% 36% 22% 29%
Home w/ support 22% 11% 12% 21% 29% 10% 10% 13% 16%
LTC (new LTC) 6% 2% 7% 8% 11% 4% 4% 4% 6%
LTC (same + increased level of care) 3% 1% 1% 3% 5% 0% 3% 7% 3%
LTC (same facility) 22% 18% 14% 16% 18% 15% 10% 15% 16%
Other acute hospital 2% 3% 16% 2% 2% 7% 36% 4% 8%
A B C D E F G H
Follow-up information (mixed domains, PROMs)
▪ 4 mo and 12 mo ▫ Agree to answer: 4 mo: 86% / 12 mo: 70%
▫ 4 mo specific:
- Visit to Family MD
- New falls, Need for MD care
- Rate patient/family education
▫ Living arrangement (mortality)
▫ EQ-5D
27
Visit FamilyMD
BH LGH RH RJH SPH UHNBC VGH(Van) Grand Total
No 8% 5% 7% 6% 12% 8% 17% 9%
Yes 92% 95% 93% 94% 88% 92% 83% 91%
n=985
A B C D E F G
Visit with Family MD by 4mo
▪ % visiting FP by 4 mo = 91%
28 (as at Mar ‘15)
Written information: Given / Used
▪ Received: 13% 71%
▫ Useful: 85% 91%
29
First 4 mo Last 4 mo
Follow-up information (mixed domains, PROMs)
▪ 4 mo and 12 mo ▫ Agree to answer: 4 mo: 86% / 12 mo: 70%
▫ 4 mo specific:
- Visit to Family MD
- New falls, Need for MD care
- Rate patient/family education
▫ Living arrangement (mortality)
▫ EQ-5D
30
Liv Arr @ 4mo DC Cohort LivArr Pre Net
BH LGH RH RJH SPH UHNBC VGH (Van) Grand Total 2230 change
Death 32 43 13 57 25 24 49 243 19% 424 -424Home 58 103 15 87 35 73 78 449
Home w/ support 29 23 3 57 10 10 62 194
LTC-Assisted living* 13 6 1 5 6 6 11 48
LTC-Residential* 64 54 10 73 26 22 69 318
Rehab / Conval 1 2 1 5 9 1% 22 47
Grand Total 197 229 42 281 102 136 274 1261
1596
587
-459
60
51%
29%
1137
647
Liv Arr 12mo CUMUL Death DC Cohort LivArr Net
BH LGH RH RJH SPH UHNBC VGH(Van) Grand Total 2230 Pre Change
Death 30% 25% 31% 38% 32% 38% 29% 31% 695 -695
Home 25% 38% 29% 21% 23% 36% 30% 29%
Home w/ support 8% 9% 9% 18% 11% 4% 16% 12%
LTC-Assisted living* 7% 3% 0% 3% 5% 2% 4% 4%
LTC-Residential* 30% 25% 31% 21% 29% 20% 21% 24%
41%
28%
914
624
-682
+37
1596
587
A B C D E F G
A B C D E F G
Living Arr at 4mo
31
Living Arr at 12mo
5% + new 14%
EQ 5D Results:
4 MO and 12 MO
▪ EQ 5D Index value (0 – 1)
▫ 4MO = 0.68 (0.27) 12MO = 0.37 (0.22)
32 UK Population
Norms
0.35
4 MO
12 MO
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
4 MO 12 MO
EQ 5D Index (0 (worst) - 1 (best) )
BCHFR Frihagen C Frihagen NC Blomfeldt
EQ 5D Results: for 4 MO and 12 MO survivors
▪ EQ 5D Index value (0 – 1)
▫ 4MO = 0.68 (0.27) 12MO = 0.37 (0.22)
33 Blomfeldt, BJJ 2005
Frihagen, Injury 2015
Major Achievements to date
▪ Data Management ▫ Agreements for project data ownership, privacy,
security, access, sharing
▫ Web-based tool for data collection
▪ Improvements in service delivery ▫ Improvements in Time to Surgery
▫ Improvements in LOS
▪ Colllaboration: ▫ Inter-disciplinary working groups
▫ Partnership with parallel provincial initiatives
34
Challenges
▪ Data collection fatigue
▫ Timely data analysis and report-out
▪ Sustained engagement of stakeholders
▫ Competing priorities
▪ HA investment required for projects to be
successful and sustainable
35
Indicators: NEXT STEPS
36
% Transfer
TTS (%<48h)
Reasons
Living Arr
Demographics
Living Arr WB orders
% WB POD #1
Living Arr 4+12mo
PROMs 4+12mo
GP visit
FReSH Start Utility
Previous Adm
Pharmanet Periop Med consult
Pharmanet @ DC
GP visit readmission
Pharmanet
Geriatrics/Med
Tests
Next Steps
▪ Linkage with MOH data bases
▪ Drill-down on data analyses
▪ Report out on Pilot Site experiences
▪ Focus on transitions in care
▪ Polypharmacy Risk Reduction in 3 sites
▪ Education modules, Local initiatives
▪ Sustainability
▪ Transfer to other disciplines/ conditions
37
BC Hip Fracture
Redesign Project
CATCHING THE WAVE