10th mortality and harm reduction in cwm taf health board...cwm taf health board insert name of...

Cwm Taf Health Board Insert name of presentation on Master Slide

Mortality and harm reduction

in CWM TAF HEALTH BOARD

10th June 2011

Cwm Taf Health Board

Leadership

Improve

information &

communication

Review quality of coding data

Review standard of record keeping

Share Learning from mortality and Global

Trigger tool (GTT) reviews

Establish Quality Improvement & Safety

Steering Group

Improving

Leadership

Reduce Mortality

& harm

GTT each acute site monthly

PCCT Pilot in 1 local GP practice

Undertake 50 mortality reviews consecutively

Take forward GTT findings for year 2009/10

with specific reference to quality of record

keeping

Pilot shared notes within community hospital

setting

Using Trend data to target mortality reviews to

areas of apparent concern

Expand mortality and GTT review teams


Leadership

• Establishment of Quality Improvement & Safety Steering Group– Primary & Secondary Care

Representation

– Includes Trainee & SAS Doctors

• Director Walk rounds continue to take place on a Friday to both Acute & Community Hospital Setting (July 2010 to Jan 2011 – 35)

• New walk round documentation introduced

Monthly Number of walkrounds undertaken


0

1

2

3

4

5

6

7

8

9

Jul 2010 Aug 2010 Sep 2010 Oct 2010 Nov 2010 Dec 2010 Jan 2011

New process and

documentation introduced


Mortality

• Improved Quality of Coding

• Weekly mortality reviews using Global Trigger Tool

• Engagement with CHKS to fully understand our data

• Using trend data to target areas of apparent concern

Risk Adjusted Mortality Index

(Acute Sites Trend)

60

70

80

90

100

110

120

Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar

2009/10 2010/11

2009/1

1

Acute Sites Linear (Acute Sites)

Risk Adjusted Mortality Index

(Acute Sites)

60

70

80

90

100

110

120

130


2009/10 2010/11

2009/1

1

PCH RGH Acute Sites Linear (Acute Sites)

Reduce Harm & Mortality


Surgical Complications

• Speciality Reviews

• Implementation of

WHO/NPSA

Surgical Checklist

• Normothermia

measures in place

• Appropriate Hair

removal introduced

across the health

board

General Surgery RAMI Trend

40

60

80

100

120

140

160

180

Ap

r'09

May

Ju

n

Ju

l

Au

g

Sep

Oct

No

v

Dec

Jan

Feb

Mar

Ap

r'10

May

Ju

n

Ju

l

Au

g

Sep

Oct

No

v

Dec

Jan

Feb

Mar

2009/1

1

General Surgery Linear (General Surgery)


WHO/NPSA

Surgical Checklist

• Implemented across Health Board

• Monthly audit undertaken on both District General Hospital Sites


Compliance with WHO / NPSA Surgical Checklist


0%

20%

40%

60%

80%

100%

120%


Compl iance Average (100%) Lower l imit 99%) Upper l imit 100%)


Normothermia

• Normothermia measures in Place

• Data captured and reported on a monthly basis


Compliance with peri-operative normothermia


0%

10%

20%

30%

40%

50%

60%

70%

80%




Pre-op Hair Removal

• Appropriate Pre-operative hair removal methods introduced across Health Board

• Monitoring and reporting processes developed


Compliance with appropriate pre-operative hair removal


0%

20%

40%

60%

80%

100%

120%




Mortality Review • Monthly speciality review of mortality cases

– Trauma & Orthopaedics

– General Surgery

– 30 day mortality after anaesthetic

• Multi-disciplinary reviews

• Reviews have highlighted – Improved communication between the Surgical and Anaesthetic

Teams

– Improved communication with the teams and the patient/family in explaining risks of surgery

• Reviews have led to – An improved rehabilitation process with the majority of Ortho-

geriatric rehabilitation taking place at Community Hospital

– Joint Care taking place between Orthopaedics and Care of the Elderly



Global Trigger Tool

• Weekly review – 10 notes per week

• Top Triggers– Readmission within 30 days

– Complication of procedure or treatment



Reduction in

Clostridium Difficile

• Achieved reduction in

Clostridium Difficile by

20% (started from low base rate)

• Implementation of

Clostridium Difficile

Care Pathway

• Hand Hygiene audits

undertaken

• Environmental Audits

undertaken

Clostridium Difficile Incidences

0

2

4

6

8

10

12

14

16

18

Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11

Month

Nu

mb

er

Number

PCH

RGH

Healthcare Associated Infections


Hand Hygiene

• Weekly Hand Hygiene Audits undertaken

• Verification Audits undertaken by Infection Prevention & Control Team

• Feedback provided to Clinical Teams on a weekly basis

Compliance with hand hygiene


0%

20%

40%

60%

80%

100%

120%



Healthcare Associated Infections


Transforming Care Targets- How are we measuring up?

Increase Direct Care Time [DCT] to at least 70%

-Average increase of 19%-Highest DCT to date is 80%

Increase Patient satisfaction to at least 95%

-Average increase of 7%-Highest result to date is 98%

Increase Staff satisfaction to at least 95%

-Average increase of 5%-Highest result to date is 92%

Transforming Care


MR

SA

c.D

iff

Me

d E

rro

rs

Fa

lls

Pre

ssu

re

Ulc

ers

Co

mp

lain

ts

609 609 609 78 419 429

Transforming Care

Highest Days Since


Introduced Skin

Bundle

Transforming Care

Pressure Ulcers

• Skin bundle rolled across Cwm Taf Health Board

Ward Example


Introduced patient Care

Rounding

Transforming Care

Falls

• Implementation

of Risk

Assessment

Documentation

• Patient care

Rounding

Ward Example


Staff member returned to work

and not aware of new process

Transforming Care

Ward Example

Medication Errors

Cwm Taf Health Board Transforming Care

Achievements

• 50% reduction in time taken for handovers

• 28% reduction in time wasted locating

equipment and information

• 45% reduction in interruptions to nursing staff

• 69% reduction in time spent in medicines

administration

• 68% reduction in Admin


•„This is Me‟ –This leaflet was developed by the Alzheimer's Society , it aims to provide professionals with

information about the person with dementia as an individual. This will enhance the care and support

given while the person is an unfamiliar environment

•Patient Care Round [PCR]–is the scheduling of regular nursing rounds, at least once every two hours ,that incorporates

specific actions linked to the Fundamentals of Care. The intended outcome of PCR is improved

patient safety and experience.

•Relative Rounding -This is dedicated time for patient/relative/carer communication,

whereby nursing staff actively seek out relatives/carers,

giving them the opportunity to ask any questions.

•Patient Rest Time - Being in hospital can be physically and emotionally tiring for patients, an undisturbed

rest period gives them the opportunity to recuperate.

•Nursing Documentation

•at the bedside -

Patient documentation is often time consuming and frequently performed at the nurses

station .Moving patients documentation to the bedside puts nursing staff back at the patients

bedside.

Relatives are asked to contact the ward between 10am and 12pm midday with all non-urgent

telephone enquiries. This ensures that the nursing staff can give the information and time

needed and are not being pulled away from patient care activities.

•Phone Calls after 10am -

Other Initiatives


• Fully established multi-disciplinary Thrombosis Committee

• Thrombrophylaxis Policy approved June 2010

• Thromboprophylaxis Risk Assessment Forms localised and launched December 2010

• Audit processes being developed and implemented

• Thromboprophylaxis Education Programme developed

Hospital Acquired Thrombosis


DVT/PEDVT/ PE Incidences

0

10

20

30

40

50

60

70

Oct-

09

Nov-

09

Dec-

09

Jan-

10

Feb-

10

Mar-

10

Apr-

10

May-

10

Jun-

10

Jul-

10

Aug-

10

Sep-

10

Oct-

10

Nov-

10

Dec-

10

Jan-

11

Feb-

11

Mar-

11

Month

Nu

mb

er Number

PCH

RGH

Approval of

Thromboprophylaxis PolicyLaunch of Risk Assessment Forms

Hospital Acquired Thrombosis


Mortality General Medicine RAMI Trend

60

70

80

90

100

110

120

130

Ap

r'09

May

Ju

n

Ju

l

Au

g

Sep

Oct

No

v

Dec

Jan

Feb

Mar

Ap

r'10

May

Ju

n

Ju

l

Au

g

Sep

Oct

No

v

Dec

Jan

Feb

Mar

20

09

/11

General Medicine Linear (General Medicine)

Reduce Mortality & Harm


Rapid Response to

Acute Illness

• Regular Audit of compliance with MEWS

• 100% compliance in ITU with

– Severe Sepsis Bundle

– CVC Insertion & Maintenance Bundle

– VAP Bundle

• Outreach Teams in place on both sites

– 9 month Review (July 2010 to April 2011)


Main aims of

outreach service• Identifying the deteriorating patient and

averting/facilitating timely admissions to ITU

• Support and seamless care to patients

transferred from ITU to the wards

• Education of ward staff in the identification

and management of the deteriorating patient

Rapid Response to Acute Illness


Origin of the

referralsReferral made by

Ward nurse

Anaesthsetics/ITUNurse Pracs

Reg/SPR

SHO

ICU Consultant

Arrest Call

Clinical site/Bed ManagerMedica/Surgicall ConsultantWard Sister

HO/FY1

Physio

Recovery Nurse

Diabetic Nurse

Resp Nurse



Time of referrals

• 108 referrals made between 08:00-12:00

• 204 referrals made between 12:00-20:00

• Most referrals are taken between 14:00

and 17:00



Reasons for the

referrals



Referral rates

•

27

47

38

47

30

35

27

22

27

31

0

5

10

15

20

25

30

35

40

45

50

July August September October November December January February March April



MEWS Scores on

initial referral

0

5

10

15

20

25

30

35

40

45

MEW

S 0

MEW

S 1

MEW

S 2

MEW

S 3

MEW

S 4

MEW

S 5

MEW

S 6

MEW

S 7

MEW

S 8

MEW

S 9

MEW

S 10

MEW

S 11

MEW

S 12

Series1



Number of patients with delay in

referral according to triggering MEWS ≥ 5

7.4

5.86.2

7 76.6

8

5

88.5

7

5

7

6 6

5

8

0

2

4

6

8

10

12

14



Admissions to

ITU averted

55%

24%

20%

1%

Number of Admissions Averted

Possibly

Definetly

N0

<Not entered>



Hospital Mortality of

Follow-ups

• Acknowledge limitations of analysing such

data

• Pre-outreach (9months):

– 379pts left ITU alive, of whom 39pts died

prior to hospital d/c (10% mortality)

• Post-outreach (9months):

– 371pts left ITU alive, of whom 34pts died

prior to hospital d/c (9% mortality)Rapid Response to Acute Illness


Interview Quotations

• “…there is a stark contrast in the quality of care that critically

ill patients receive at night compared to the day; because

there aren‟t any critical care nurses…make Outreach 24hrs

and I have no doubt there will be a major improvement to

overall mortality and morbidity”

» (Surg SPR)

• “…we weren‟t realy sure what to expect initially, but they realy

have proven their worth with their input, suggestions, advice

and ability to work as part of the multi-disciplinary team…”

• (Ward Staff Nurse)



Interview Quotations

• “The obvious failures are the patients that Outreach aren‟t

informed about….” (ITU SPR)

• “…Friendly, approachable, knowledgeable, supportive yet

not intrusive, helpful. They share their skills readily and are

informative helping me to achieve targets by their approach

used to achieve comfort, dignity and general improvement in

patient care and outcome…. I hope their role continues

because they enhance my personal aims in providing

excellent care and I would like to say „thank you for being

there‟…”

(Ward Staff Nurse)



A Patient’s JourneyS- 36yr old male admitted 1/7 previously with hx of gastritis, diagnosed with pancreatitis on grounds of a raised amylase (790).

B- Recent redundancy and stresses, treated for symptoms of gastritis with GP 1/52 previously. Nil PMHx of note.

A- O/E pt in toilet passing coffee ground vomit. Encouraged pt to return to bed area for assessment. Pt in extremis:

R- Fluid challenge

Insert IDC

ABG following 1.5l fluid in 2hours (r/v acid-base)

Senior R/v (SPR in OT – will r/v in 1hour)

If acidosis improving with fluid, continue aggressive fluid resus

If acidosis worse despite filling for ITU R/v

Further venous access

Rpt U+Es in 4 hours – if ARF worse despite filling consider ITU R/v

R/v if further investigations re. abdo required



Anticoagulation :Re-engineering out-patient clinics

• Royal Glamorgan Hospital (RGH) INR clinics changed to pharmacist led, Point of Care Testing (POCT) in September 2008

• Implemented computer dosing and patient management system in RGH clinic

• Audit data demonstrates improvements:

• Developed standard primary care clinical protocols for POCT

• Future actions:

– To roll out POCT model across LHB, including primary care clinics

– Development of training program for both primary and secondary care practitioners

Previous Re-Engineered

INR INR

Service Service

DNA 10% 3.2%

Time In Range (TIR) 57% 73%

Documented Clinical Information 46% 100%

Medicines Management


AnticoagulationAll Cwm Taf Outpatient INR clinics

Cwm Taf – All

outpatient INR

clinics

% of patients

with INRs

>5 and >8

Cwm Taf out-patient INR clinics - total % patients with INR >5 & >8

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10

Month

% o

f o

ut-

pat

ien

ts

CT % patients >5

CT % patients >8

Linear (CT % patients >8)

Linear (CT % patients >5)



Anticoagulation: INR

Cwm Taf Total

% of INR tests >5

and >8

(inpatients &

outpatients)

Cwm Taf % INR tests >5 & >8

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

Apr -08

Jun0

8

Aug

08

Oct08

Dec0

8

Feb

09

Apr09

Jun0

9

Aug

09

Oct09

Jan-10

Mar-10

May

-10

Jul-1

0

Sep

-10

Nov-10

Jan-11

Mar-11

May

-11

% t

ests % INR tests

>5

% INR tests

>8

Linear (%

INR tests

>5)



8am- Patients arrive at

YCR and queue (no

appointment system)

Nurse collects yellow

books (YB)

Match up YB with

white card and attach

stickers

Patients called into

blood room for blood

test

Bloods transported to

RGH Pathology by taxi

Most patients leave the

clinic

YBs sent to receptionist

to “book in” to Pathology

system

YB to another

receptionist to book

into clinic on PAS

system Patients who stay to see

doctor wait in main

waiting room or call back

at 11am

Blood results entered

into Pathology system

10.30 - Doctor arrives,

nurse gets results and

doctor decides on dose of

warfarin

YB given to nurse in

consulting room where

prepared and receive

blood results (2 piles)

Dose and next

appointment written on

YB, put in envelope

and posted to patient

If patient needs a

change in dose that day

– telephoned after clinic

finished

Process map –

current INR service



Patient leaves with

all information

and next

appointment date

Patient arrives at

RGH just before

appointment time

Receptionist

books patient into

clinic on PAS

system

Patient waits to be

called in

Patient called in

clinic and finger

prick blood test,

result,

consultation and

new date given

Process map –

Re-designed POCT service



Patient Experience

How does service compare with previous

arrangements?

much better

better

no difference

worse



Patient Experience –Hospital or GP monitoring?

A Pie Chart Showing Patients' Preference for a GP- or RGH-

Provided Anticoagulation Clinic

GP

28%

RGH

35%

No Preference

37%



Patient Story

• Mrs M, age 52

• Warfarin for 6 years following heart valve

replacement

• Originally unstable INR, monitored in UHW,

then transferred to RGH out-patients

• Experience was of long waiting times, often

here all morning (“Warfarin day out”)

• INR was quite unstable, sometimes required

injections to stop it going too low.



Patient Story

• At first was apprehensive about change in service but quickly re-assured

• Biggest improvements are

– Much lower waiting times

– Immediate INR result

– Finger prick test (patient also has own machine)

– Keeps own Yellow Book and new dose given there and then



Patient Story

• Mrs M feels INR control is now much

better

• Attends clinic every 3-4 weeks

• Reassured that back up advice always

available from clinic staff if needed (feels

more “in control” herself)

• Discusses medication changes with

pharmacists in clinic



Patient Story

“I FEEL AS THOUGH I HAVE GOT MY

LIFE BACK – WARFARIN IS NOW A

PART OF IT”



Stroke

1st Hours Bundle

% compliance with First Hours bundle

Cwm Taf Stroke patients

from Jan 2010 to Apr 2011

0

10

20

30

40

50

60

70

80

90

100

Jan

2010

Feb

2010

Mar

2010

Apr

2010

May

2010

Jun

2010

Jul

2010

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Mar

2011

Apr

2011Months


First Days Bundle

• CT scan – 82%

• Weekend admissions. Since whiteboard has been in use on AMU, all patients have been compliant

% compliance with First Days bundle



0

10

20

30

40

50

60

70

80

90

100

Jan

2010

Feb

2010

Mar

2010

Apr

2010

May

2010

Jun

2010

Jul

2010

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Mar

2011

Apr

2011Months

Stroke


First 3 Days Bundle

% compliance with First 3 Days bundle



0

10

20

30

40

50

60

70

80

90

100

Jan

2010

Feb

2010

Mar

2010

Apr

2010

May

2010

Jun

2010

Jul

2010

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Mar

2011

Apr

2011Months

Stroke


First 7 Days Bundle

% compliance with First 7 Days bundle



0

10

20

30

40

50

60

70

80

90

100

Jan

2010

Feb

2010

Mar

2010

Apr

2010

May

2010

Jun

2010

Jul

2010

Aug

2010

Sep

2010

Oct

2010

Nov

2010

Dec

2010

Jan

2011

Feb

2011

Mar

2011

Apr

2011Months

Stroke


Mortality Cardiology RAMI Trend

0

20

40

60

80

100

120


2009/10 2010/11

2009/1

1

Cardiology Linear (Cardiology)

Reduce Mortality & Harm


Chronic Heart Failure

• Initial audit October 2010

• 1000 lives implementation January 2011

• Repeat audit February 2011

Heart Failure

• Collect information about:– Accuracy of documentation in

notes

– Referrals to heart failure service

– Prescribing of ACE/ARB and

betablockers

– Warfarin prescribing in AF

– Impact of prompt stickers


Methods

• Baseline Audit– 100 patients randomly selected with a discharge diagnosis of

heart failure (ICD coding 150.0 – 150.9)

• Repeat Audit– 41 consecutive discharges from cardiology ward (44%

documented heart failure)

Heart Failure


Results

Diagnosed Heart Failure Baseline Repeat

Echo 67% 100%

Referred to Heart

Failure nursing service

42% 78%

ACE Inhibitor 90% 89%

Betablocker 68% 67%

Warfarin for AF 74% 100%

Heart Failure


Work streams

• Executive Leads & Operational Leads Identified

• Work stream groups being established

• Baseline audits & scoping exercises being undertaken

• Enhanced Recovery After Surgery

• Mental Health

• Improving Maternity Services

• Reducing Falls in the Community


Key Contact Information

Dr David Cassidy – Assistant Medical Director for Governance & Quality Improvement

Kellie Jenkins-Forrester – Clinical Governance Manager

Patient Care & Safety Unit


Administration Block

Dewi Sant

Pontypridd

CF37 1LB

[email protected]

[email protected]

mailto:[email protected]




10th mortality and harm reduction in cwm taf health board...cwm taf health board insert name of...

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