QUALITY IN THE RURAL SETTING COROMANDEL PENINSULA

INTRODUCTION

Thames hospital and it’s emergency department

The quality framework team – what it’s been like

3 audit topics

THAMES HOSPITAL

Waikato DHB - 4 rural hospitals – Thames, Taumaraunui, Te Kuiti, Tokoroa – the 4Ts

Variable skill base, resources and facilities

Neale Thornton January 2008

Neale Thornton February 2007

• Coromandel Peninsula from Waihi north and Hauraki Plains

• Drive Time: 90 minutes to base

• Population: 26000 year round Summer population 120900

• Presentations to ED: 15000 pa

• Seasonal fluctuations, same infrastructure

• Retrieval for severe trauma

Catchment Thames Hospital

ED ATTENDANCES ANNUAL VARIATION

• 48 bed IPU - Medical, Surgical, AT&R

• High Acuity Room (3 beds)

• Operating Theatres

• Emergency Department 15 beds

• Midwife-led Birthing Unit

• Radiology 08.00-18.00 then on call

• Laboratory 07.00-22.00 then on call

• Outpatients

Facilities/Services-Thames Hospital

MEDICAL STAFFING

ED mix MO and rural hospitalists – extended role outside ED

Physicians and surgeons based Thames Daylight SHOs, rural registrar training Visiting AT&R Many transfers – complexity, speciality,

destination, weekends and PH,

PATIENT TRANSPORT SERVICE

Developed a PTS service enabling a scheduled transfer of patients between Thames and Waikato hospitals.

St John’s with skilled transfer nurse

Treatment en route

Two way

Neale Thornton January 2008

• Quality Framework Team:

Clinical Lead (0.3FTE), CNM, 2IC (0.2FTE)

• Monthly meetings of team

• Feedback of results via M&M, ED business meetings, and heads of departments

• Some support by request from IS and CASU.

Application of the Quality Framework

Neale Thornton January 2008

DATA COLLECTION – DON’T REINVENT THE WHEEL!

Use what already is available – eg LOS data, time to be seen by decision making clinician

DATA COLLECTION

What goes in must come out – eg requesting reports by specific discharge codes.

DATA COLLECTION

Getting into hot water – analysing complaints, incidents and sentinel events

Themes

DATA COLLECTION

Actively gathering feedback from patients and staff

DATA COLLECTION

Number 8 wire – develop our own audit tools from scratch

Eg left before being seen – recoded, data collected daily, patient contacted next day, themes, safety.

DATA COLLECTION – TRYING TO SEE THE WOOD FOR THE TREES!

Unplanned representation rates within 48 hours of ED attendance

55 pages of raw data for 1 month After 3 hours sifting - 20 patients Several alternative reports available Filtering data to give useful reports.

ED LOS - 6 H TARGET – KPI 95%

Reasons for breach: July 2014 – 21 breaches

Cause of Breach Number

Bed access block 7

Department in Overload 0

Awaiting Transfer 3

Awaiting Results (CT) 1

Lack of resource – telemetry, watch 2

Uncertain destination 5

Administration – patient not placed in SSU/computer issue

2

Ongoing care – patient acuity 1

6 HOUR TARGET

Transfers CT Departmental overload, summer,

inadequate staffing Actions taken January 2015, re audit

coming

MORTALITY RATES FOR #NECK OF FEMUR

July 2013 – June 2014

38 patients presented to Thames with fractured neck of femur.

8/38 subsequently died within 30 days. 30 day mortality = 21% (expected rate = 10%)

11/38 died within 4 months. 4 month mortality = 29% (expected rate = 20%)

12/38 died within one year. One year mortality = 31.5% (expected rate = 30%)

WHY IS THIS?

Time from injury to surgery – longer for rural patients

Multiple delays in patient’s journey Must be in base hospital to be put on surgical list

What can be done? Use of NoF clinical pathway Discussion with CD orthopaedics Discussion with St John re priority transfer Dissertation topic

TIME TO ANTIBIOTICS IN SEPSIS

July 2013 - June 2014

Total: 19 patients; 17 met criteria at triage, 2 had received IV antibiotic prior to ED

Average time to first antibiotics: 2 hours 47 minutes

Deaths: 2/17 (11.7%)

Total no patients received 1st antibiotic dose within 60 min (Sepsis 6 goal) 3/15 - 20%

TIME TO ANTIBIOTICS IN SEPSIS

After the initial audit, a sepsis treatment pathway was implemented in Thames ED. This pathway is based on the Waikato sepsis pathway and follows international guidelines for sepsis treatment in ED.

TIME TO ANTIBIOTICS IN SEPSIS

Re-audit: Oct 2014 to Feb 2015 (5/12 period)

10 patients presented to Thames ED with “sepsis” diagnosis

9 patients met sepsis criteria

Average time to first antibiotics: 108 minutes (1 hour and 48 minutes)

Deaths: 1/9 = 11.1% mortality

Use of Sepsis Pathway: 2/9 = 22.2% use

Total no patients received 1st antibiotic dose within 60 minutes (Sepsis 6 goal) 1/9 = 11.1%

BENEFIT OF SEPSIS PATHWAY

Average time to antibiotic – 2h 47m prior to pathway -1h 48m after pathway.

Antibiotic within 60 min - 20% to 11%

Use of sepsis pathway 22.2%

TIME TO ANTIBIOTICS IN SEPSIS : ACTION Promotion of use of sepsis pathway and

assessment tool Audit nursing documentation - use of

assessment tool Place pathway at triage to ensure that

paperwork is accessible Re-audit Sept 2015 Better awareness among medical staff.

Locums too.

FUTURE DIRECTION

ISSUES SPECIFIC TO THAMES

Sometimes difficult to compare statistics directly- due to transport and available services.

No IS service on site so getting specific data can be delayed.

Small team, time constraints Small team, ability to bring about

change

LOST IN THE BUSH – WHEN TO ASK FOR HELP!

How to define ED overcrowding measures?

Time to analgesia tool?

BENEFITS OF QUALITY FRAMEWORK

Quality is not geographical – it applies to rural hospitals as much as metropolitan hospitals

Unsuspected areas for improvement have been unearthed (Thames is a goldmining town!)

It is encouraging to align ourselves with national framework and see how we compare

OVERVIEW OF AUDITS UNDERTAKEN

Patient journey time stamp

ED LOS

  Waiting time from triage until time seen by decision making clinician

ED overcrowding ED occupancy >100%ED demographic measures

UPRA

ED quality processes M&MSentinel eventsComplaint review and responseStaff experience evaluations

Patient experience measures

Patient experience evaluationsLeft before seeing doctor or decision making clinician

OVERVIEW

Clinical quality audits Mortality rates for #NOF and STEMI  Time to thrombolysis  Time to adequate analgesia  Time to antibiotics in sepsis  Procedural sedation  Others – DVT, cellulitis, pneumonia, transfers

outside scheduled PTS

Documentation and communication

Nursing notes, medical notes, medication

Performance of SSU  Education and training profile

Appropriate orientation with feedback

Departmental education programme

 

Administration profile Designated quality team