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

Click On The Door You Wish To Open

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

• Click button to go directly to questions

• 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