Sustaining Quality

“Expectations will always exceed capacity. The service must always be changing, growing and improving…”.

Aneurin Bevan, 1948

Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised

controlled trialsGordon C S Smith, Jill P Pell. BMJ 2003;327;1459-1461

• Aim: To determine whether parachutes are effective in preventing major trauma related to gravitational challenge.

• Design: Systematic review of randomised controlled trials

• Results: Our search strategy did not find any randomised controlled trials of the parachute.

Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised

controlled trialsGordon C S Smith, Jill P Pell. BMJ 2003;327;1459-1461

Conclusion:

As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials.

Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data.

We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute

“Society’s huge investment in technological innovations that only modestly improve efficacy,

by consuming resources needed for improved delivery ofcare, may cost more lives than it saves.”

“Health, economic, and moral arguments make the case for spending less on technological advances and more

on improving systems for delivering care.”

Fidelity vs Efficacy

$29 Billion

$32 Billion

$100 Million

0.002%

The aspirin example

• In patients who have had a stroke or TIA aspirin reduces risk by 23%

• 100,000 patients – 23,000 fewer strokes

• 58% of eligible patients receive aspirin = 13,340 fewer strokes

Two options

• Fidelity – increase to 100% of eligible patients = 9,660 strokes

• Efficacy – requires a proportional improvement over aspirin of 74%

• Clopidogrel = 10% more efficacy than aspirin

Outcome Aims

• Mortality: 15% reduction• Adverse Events: 30% reduction• Ventilator Associated Pneumonia: 0 or 300 days

between• Central Line Bloodstream Infection: 0 or 300

days between• Blood Sugars w/in Range (ITU/HDU): 80% or >

w/in range• MRSA Bloodstream Infection: 30% reduction• Crash Calls: 30% reduction

Example Interventions• Critical Care

– Ventilator acquired pneumonia bundle, central line• Ward

– Early rescue – Communication

• Medicines– Medicines reconciliation

• Theatres– Surgical pause– Infection prevention/control

• Leadership– Safety walkrounds– Executive leadership board patient safety profile

GRI VAP Prevention Bundle Sampled one day per week - varied day

Aim >95% Reliability by May 2009

30%

40%

50%

60%

70%

80%

90%

100%

Jun-

08

Aug-0

8

Oct-08

Dec-0

8

Feb-0

9

Apr-0

9

Jun-

09

Aug-0

9

Oct-09

Dec-0

9

All 4 components ofbundle

30° head up

Chlorhexidine used as part ofdaily mouth care

responsive to command; hadsedation hold; or describedexclusion

described weaning target ordescribed exclusion

AIM - how much by when

Daily Goals Sheet

Head-up redundancy

Script of questions to ask doctors

Re-testing at daily goals: handing script, using script, change daily goals sheet

DG sheet - reformatted,Prompts added

GRI VAP Prevention Bundle Reliability and VAP rate per 1000 ventilator days

Aim: > 95% reliability by March 2009

0

5

10

15

20

25

Aug-0

7

Oct-07

Dec-0

7

Feb-0

8

Apr-0

8

Jun-

08

Aug-0

8

Oct-08

Dec-0

8

Feb-0

9

Apr-0

9

Jun-

09

Aug-0

9

Oct-09

Dec-0

9

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ventilator Associated Pneumoniarate per 1000 ventilator days

Median over first 6 months

Ventilator Associated Pneumoniacare bundle reliability (%)

AIM

DG sheet

Script of questions to ask Drs

Retesting at DG sheet; handling sript; change DG sheet

DG sheet change; prompts added

Last VAP 02/01/2009

GRI ICU Percentage had Daily Goals Setand Reviewed > 1 time

0%

20%

40%

60%

80%

100%

Jul-0

8

Sep-0

8

Nov-0

8

Jan-

09

Mar

-09

May

-09

Jul-0

9

Sep-0

9

Nov-0

9

Daily Goals Set and Reviewed > 1 time in the day Aim #1 >80% by March 2009, Aim #2 >95% by June 2009

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jun-

08

Aug-0

8

Oct-0

8

Dec-0

8

Feb-0

9

Apr-0

9

Jun-

09

Aug-0

9

Oct-0

9

Dec-0

9

GRI ICU Monthly Average Length of Stay (days)

02468

10121416

Jan-

03

Jul-0

3

Jan-

04

Jul-0

4

Jan-

05

Jul-0

5

Jan-

06

Jul-0

6

Jan-

07

Jul-0

7

Jan-

08

Jul-0

8

Jan-

09

Jul-0

9

Jan-

10

Days

UCL

LCL

Process Avg

Daily Goals & VAP Prevention bundle start

But Does It Work Outside SPSP?But Does It Work Outside SPSP?

Acute pain management in orthopaedicsAcute pain management in orthopaedics

GRI Acute Pain Bundle in Elective OrthopaedicsAIM: > 95% Reliability by January 2010 - for the red dot

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr-0

9

May

-09

Jun-

09

Jul-0

9

Aug-0

9

Sep-0

9

Oct-09

Nov-0

9

Dec-0

9

Jan-

10

All 4 components ofbundle implemented

Prescribed oral analgesics

Oral analgesics written upregularly not prn

Got Step 2 oral analgesic at22:00

≥ 6 pain recordings on chartin first 24 hours

Aim:Start data collection

Meet Julie – ward manager – set AIMSAIMS

Test drug recognition with recovery room nurses

Meet anaesthetists SH, CR, TMcL, JD – describe tests with recovery nurses

Test script of questions for recovery nurses to use 2 days per week

Spread to 5 days per week

Acute Pain in Elective Orthopaedics: Primary Hip & Knee ReplacementProcess AIM: Bundle reliability > 95% by end of Jan 2010Outcome AIM: Reduce both classifications of pain by 50%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Acute Pain Bundle reliability

Aim

Patients with one or more episodeof moderate or severe pain in first24 hours (%)

Median for moderate or severe painfor 1st 6 months

Patients with one or more episodeof severe pain in first 24 hours (%)

Median for severe pain for 1st 6months

Only 45% patients with no or only mild pain in 1st 24 hours postoperatively

75% patients with no or only mild pain in 1st 24 hours postoperatively

526 patients 337 patients

Winter review

• Patient safety walk rounds continued during the winter period

• Daily monitoring and reporting of 8 hour trolley waits in the Emergency Departments

• An action tracker has been established to ensure that the key lessons for improvement are being progressed

• Data:– Breach Analysis of A&E waiting times– Boarder numbers– Delayed Discharges– Elective cancellations– Re-admission rates

The Healthcare Quality Strategy for NHSScotland

• Person-Centred - Mutually beneficial partnerships between patients, their families, and those delivering healthcare services which respect individual needs and values, and which demonstrate compassion, continuity, clear communication, and shared decision making.

• Clinically Effective - The most appropriate treatments, interventions, support, and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated.

• Safe - There will be no avoidable injury or harm to patients from healthcare they receive, and an appropriate clean and safe environment will be provided for the delivery of healthcare services at all times.

“We look to Scotland for all our ideas of civilisation.”  

Voltaire (Francois Marie Arouet, 1694–1778)

jason.leitch@scotland.gsi.gov.uk