Evidence 2 ExcellenceBC Emergency Medicine CommunityCollaborate, Innovate, Captivate

Province-Wide Collaborative for Harmonization of Care

Lana Newton, BAA (Hons)Kendall Ho, MD

Noreen Kamal, PEng, PhD(cand.)Julian Marsden, MD

Quality Forum 2013March 1st, 2013

The Genesis of E2E

• E2E was established in 2007 in response to feedback from the BC ED community which identified the need to:

1. provide effective networking, support, and demonstrable outcomes for emergency departments

2. Foster an interprofessional community of clinicians and administrators

3. Address the urban-rural divide

2009-2011 Collaboratives

• 38 teams from 26 sites

• 20 ED Flow Teams

• 18 Sepsis Teams

• Over 200 team members registered for the two collaboratives

• All Health Authorities are represented

E2E eCoP

• New eCoP launched in April 2010

• Resource Folders

• Discussion Forums

• Recordings of biweekly webinars

Aim

• To evaluate the ability of E2E to improve sepsis care in British Columbia– BC Patient Safety and Quality Council– UBC eHealth Strategy Office

• What are the contextual factors that influence clinical impact?

3-year CIHR funding-grant obtained in 2009

CIHR Sepsis Timeline

Measures: Clinical Outcomes

Statistical Process Control charting to examine:

• Goal 1: 1 litre fluid < 90 min.

• Goal 2: ABx given < 60 min.

• Goal 3: Bld cultures before ABx

• Considered 2 groups:– Sepsis patients: initial lactate <2 mmol/L– Severe sepsis: initial lactate >2 mmol/L

Results: clinical

Overall data captured

• Goal 1 (Fluid): 12 sites, n= 1,313

• Goal 2 (ABx): 13 sites, n= 1,591

• Goal 3 (BC): 13 sites, n=1,450

Results: Clinical

• Goal 1 (Fluid)– 4 had median of < 90 minutes to 1 litre fluid bolus (5 < 100 min.)

– Median range 66 - 158 minutes

• Goal 2 (ABx)– 1 site had median of < 60 minutes to antibiotics (7 < 100 min.)

– Median range 58 - 187 minutes

• Goal 3 (BC)– 7 sites achieved blood cultures before ABx in over 90% of cases

– Range 83% to 99.95%

SPC Charting: Examples from Successful Sites

Results: Collaborative-Wide

Results Pending: Contextual Factors

Level 2b: modification of knowledge and skills

Level 2a: change in attitudes

Level 3: transfer, a change in behavior

Level 4a: a change in the system

Level 4b: a change in patient outcome

Lessons Learned: Clinical Data

• Goal 1 (fluid) - met more frequently than goal 2• Goal 2 (ABx) - harder to reach• Both goals were obtained more frequently in

severe sepsis patient population• Goal 3 met with high conformity

– Less successful when patients severely septic

• SPC charting during data collection to better understand variation in complex system

Next Steps

• Create criteria for SPC charts to group sites by success

• Analyze QI activity data using evaluation framework, Kirkpatrick Model, to identify factors of success and barriers

• Engagement scale under development

• Look to evaluate framework and validate engagement scale on future collaborations

Collaborators

• Justyna Berzowska• Lawrence Cheng • Jennifer Cordeiro• Mike Ertel• Ran Goldman• Ali Gregory• Kendall Ho• Sandra Jarvis-Selinger• Noreen Kamal• Christina Krause• Julian Marsden• Lana Newton• Helen Novak-Lauscher

• Katie Procter• Sherry Stackhouse • Rob Stenstrom• David Sweet• Brent Woodley• Lindsay Zibrik

• UBC eHealth Strategy Office• BC Ministry of Health• BC Patient Safety & Quality

Council

THANK YOU

Questions

For the audience:

1.Engagement measures, or evaluation frameworks?

2.Factors identified through SPC use during a QI improvement initiative?

Team Self Assessment (Sepsis)

Engagement Scale Scoring

Raw ScoresAction Period Calls Monthly Reports Learning Sessions Clinical Data

max score 14 max score 12 max score 5 max score 12

1/3 of 14 0-4.67 1/3 of 12 0-4 1/3 of 5 0-1.67 1/3 of 12 0-4

4.68-9.34 4.1-8 1.68 - 3.34 4.1-8

9.35-14 8.1-12 3.35-5 8.1-12

Weighted Scores

Engagement Points

Activity low medium high

action period calls 1 2 3

monthly reports 2 4 6

learning sessions 3 6 9

clinical data 4 8 12

low bottom 1/3 of raw scores

medium middle 1/3 of raw scores

high top 1/3 of raw scores

Engagement Scale Results