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1
Mortality and harm reduction
in Cardiff and Vale UHB
25th November 2010
2
Driver Diagram
Reduce
Mortality,
Harm,
Variation
and
Waste
Ventilator bundle
Hospital Acquired
Infections
Central & Peripheral Line Insertion &
Maintenance Bundles
Blood stream infections
Clostridium Dificile Bundle
VTEs HAT assessment, prevention and
treatment
Clostridium Dificile
Surgical Errors WHO Checklist
Surgical site infections
Ventilator acquired Pneumonias
Catheter Associated UTI
Stroke care
Leadership for QI
WalkRounds/Patient Safety Fridays
Medicines Management
Reconciliation
High risk medications
Transforming Care
Heart Failure
SKIN Bundle
Falls Prevention
Mental Health
Sepsis/RRAILS
Mortality & Harm Reviews
First episode psychosis
Depression
Dementia
Early Warning Scores & Rapid
ResponseSSI Bundle
Urine Catheter insertion &
maintenance bundles
Pressure Ulcers
Pathways and Bundles
Build Skills Capacity & Capability
3
GTT Adverse Events RatesAdverse event rate per 1000 patient days
Cardiff and Vale University Health Board - UHW
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
Jul-06
Oct-06
Jan-07Apr-0
7Jul-0
7Oct-0
7Jan-08
Apr-08
Jul-08
Oct-08
Jan-09Apr-0
9Jul-0
9Oct-0
9Jan-10
Rate
Values Average (28.0)
Number of adverse events
Cardiff and Vale University Health Board - UHL
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
Oct-07
Dec-07
Feb-08
Apr-08
Jun-08
Aug-08
Oct-08
Dec-08
Feb-09
Apr-09
Jun-09
Aug-09
Oct-09
Dec-09
Feb-10
Num
ber
Values Average (4.1)
4
GTT – Number of triggers
Number of triggers
Cardiff and Vale University Health Board - UHL
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
Oct-07
Dec-07Feb-08
Apr-08
Jun-08
Aug-08Oct-0
8
Dec-08Feb-09
Apr-09
Jun-09
Aug-09Oct-0
9
Dec-09Feb-10
Num
ber
Values Average (43.6)
Number of triggers
Cardiff and Vale University Health Board - UHW
0.0
10.0
20.0
30.0
40.0
50.0
60.0
Jul-06
Oct-06
Jan-07Apr-0
7Jul-0
7Oct-0
7
Jan-08Apr-0
8Jul-0
8Oct-0
8
Jan-09Apr-0
9Jul-0
9Oct-0
9
Jan-10
Num
ber
Values Average (29.0)
Increased triggers have no
correlation with AE rates
5
Trigger Conversion Rate Monthly Conversion rate
Cardiff and Vale University Health Board - UHW
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
50.0
Jul-06
Oct-06
Jan-07
Apr-07
Jul-07
Oct-07
Jan-08
Apr-08
Jul-08
Oct-08
Jan-09
Apr-09
Jul-09
Oct-09
Jan-10
Perc
enta
ge
Values Average (18.0)
Monthly Conversion rate
Cardiff and Vale University Health Board - UHL
0.0
5.0
10.0
15.0
20.0
25.0
Oct-07
Dec-07
Feb-08
Apr-08
Jun-08
Aug-08
Oct-08
Dec-08
Feb-09
Apr-09
Jun-09
Aug-09
Oct-09
Dec-09
Feb-10
Perc
enta
ge
Values Average (9.0)
6
GTT – codes for UHWEvents by trigger code
Cardiff and Vale University Health Board - UHW from Jul 06 to
Mar 10
0
5
10
15
20
25
30
L12
G7
G4
G3
G2
G1
S1 L8 L13
L10
S2 L3 L14 L4 G
6G
5 L1 L2 L6 L7 M2
M4
S3 I2 L5 L11
M1
M5
Trigger code
Nu
mb
er
Wound infection
7
GTT Codes - UHLEvents by trigger code
Cardiff and Vale University Health Board - UHL from Oct 07 to
Mar 10
0
5
10
15
20
25
30
35
40
45
G7
G3
G4
L12
G2
L10
L13
G1
G6
S1 S2 L2 L3 M2 L1 G
8 L5 L6 L8 M1
M5
Trigger code
Nu
mb
er
Complication of procedure or treatment
8
Learning from GTT
• Similar event rates at both main sites
• More triggers at UHL than UHW average 40: 29
• Increase in triggers is due to increase in general care triggers detected at UHW
• Conversion rate is double at UHW that of UHL (18:9)
• L12 (wound infection) is the highest trigger at UHW
• G7 (complication of treatment) is the highest trigger at UHL
9
Next steps for GTT
• Better analysis of the data – identify
learning points
• Link the learning from GTT to the learning
from mortality reviews
• Prioritise actions
10
RAMI• Weekly Deaths Review Group established
– Led by Medical Director, supported by Assistant Medical Directors (x2);
Assistant Director Patient Safety & Quality; Improvement Advisor and
Clinical Coding Manager, Clinical Coder in rotation to inform learning
• Data extracts generated weekly via Clinical Governance Data
Analyst from CHKS, patients whose RAMI suggests least likely
to die (RAMI less than 0.25)
• On average 18 of 45 weekly deaths case notes reviewed
• If triggers identified Medical Director generates letter for lead
Consultant to undertake case review and feedback
• Key learning to date
– Coding Quality improving
– Raising the profile and importance of clinical coding with clinicians and
making some operational changes to working arrangements to
strengthen coder / clinician interface.
11
12
CHANGES IN RISK ADJUSTED MORTALITY
60
65
70
75
80
85
90
95
100
105
110
MONTH
ORIGINAL RAMI*
UPDATED RAMI**
ORIGINAL RAMI* 89 104 77 89 88 86
UPDATED RAMI** 81 94 72 77 79
APR MAY JUN JUL AUG SEP
13
14
15
16
Leadership – WalkRounds• Patient Safety Fridays
introduced during 2009
• Involves c.two Exec and IM WalkRounds per week, over 80 completed
• Covers all of the organisation Initially became a „free for all‟
• Actions logged
• Key recurring themes are staffing and estates/ environments of care issues
• Various criteria applied to prioritise estates issues
• Planned ward refurbishment programme underway
• We also observe and share good practice
Next steps
• Better scheduling and direction of visits i.e more structure
• Maintain the focus on Q&S organisational priorities –Reduction in C.Diff; VTE Risk Assessment; SKIN Bundle; Rapid Response to Acute illness; Improved management/reduction in hospital falls
• Analysis of actions agreed, completed and monitored
• Outcomes reported and scrutinised at Board Level Quality & Safety Committee
• Process continues to be reviewed and is evolving
17
Patient StoriesStories provide Board with a window into the operational
working of the Health Board
• All Health Board Meetings now commence with a Patient Story
• True stories impact and engage the audience and helps reinforce accountability for ensuring high quality and safe patient care.
The Story is conveyed from the perspective of the Patient and their experience
Stories are a mix of good and not so good experiences
• Quality and Safety Committee meetings commence with a Patient Story from a Division. Divisional Q&S meetings are increasingly making use of Patient Stories
Stories capture the learning and is aligned to Fundamental of Care Standards or Standards for Health in Wales
• Ensuring action in response to stories is a priority for the UHB Stories capture the learning from the experience and outlines the action taken in
response to the patient feedback
Powerful method of ensuring the focus of Board
level meetings
18
Capacity and Capability
• Leading to Deliver programme for all new Directorate teams
• Establishing a „Faculty‟
• Staff Culture Survey – already commenced in Primary Care
• Model for Improvement incorporated in other programmes e.g. Care to Lead for ward sisters, Transforming Care, SKIN Bundle roll out and through attendance at 1000 Lives Plus learning events.
19
C-dificile actions
• C-dif group established
• UHB action plan in place
• All divisions have an action plan
• Antibiotic sticker developed to guide the process and make adherence more intuitive
• Organisation – wide antibiotic stewardship –cefuroxime and ciprofloxin prescribing ceased on 1st
June 2010
• Audit/measurement tool developed. First audit completed – awaiting results – great variation in practice at present.
20
Improvement is encouraging
This SPC Chart demonstrates that if we analysed the data (Oct 2010), we find a mean reduction from 70.9 to 39.5, that is a mean
reduction by 44%.
21
• Documentation of Antimicrobial prescription in the notes.
• Review of antimicrobial Prescriptions by Consultant
responsible for the patient within 72 hours
• Antimicrobial prescriptions for > 7 days must be resigned
and reasons indicated in the patient record.
• Compliance with UHB antimicrobial policy
22
Restrictive AB
formulary• Within Cardiff and Vale UHB antimicrobials are divided
into 3 main categories:
– A freely available across Secondary Care
– B freely available within specific units/ for specific indications (outside those units/indications treat as category C)
– C available only with agreement of Consultant Microbiologist (or other nominee)
23
24
25
WHO ChecklistProcedures where WHO Checklist was completed
0
500
1000
1500
2000
2500
Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10
month
nu
m b
er
of
pro
ced
ure
s
0.00
20.00
40.00
60.00
80.00
100.00
120.00
%
Number of
surgical
procedures
%
completion of
WHO
checklist
Data recording
processes unclear
Achieving reliability
26
Peri-Op normothermia% Procedures where peri-operative normothermia was
maintainted
0
500
1000
1500
2000
2500
Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10
month
Nu
mb
er o
f p
roce
du
res
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
% n
orm
oth
erm
ic
Number of
surgical
procedures
% patients
where
normothermia
was
maintained
27
Hospital Acquired Thrombosis
Organisational Priority
Executive sponsorship and establishment of
Working/Steering Group
Jan 2010 – Working Group outline
Feb 2010 – TaAG agreed
March 2010 – New terms of reference report to
Quality and Safety Committee
28
29
Thromboprophylaxis
• 21st October – UHB audit on assessment
and treatment by junior doctors.
• Presentation to Thrombosis Group 18th
November 2010.
• Audit outcome will help focus actions for
change.
30
PLASMAscreens
HAT
Promotion
Via
Patient Line
Patient Leaflets
31
The next phaseMeasure
• Re audit compliance with risk assessment tool and prescribing
• Rates of VTE
• Complications of thromboprophylaxis
Development of further protocols for VTE prevention
• Psychiatric patients
• Nursing home patients
Education and training
• Undergraduate programme
• Postgraduate programme
• Pharmacists
• GP‟s
32
Medicines reconciliation 1
Ongoing monthly data collection for all new admissions -
% patients with no reconciliation within 24 hours
Sequential days provide “virtual weeks” to highlight
impact of week-end service etc.
33
Medicines reconciliation 2
Primary care MUR‟s
targeted to patients with
identified reconciliation
issues post discharge. Pilot
project.
34
High risk drugs – anticoagulants -1
1. Ongoing run charts of reported INR‟s >5 and >8
2. MSc data analysis of anticoagulant associated major bleeds and impact of SPI2/1,000 lives (+)
Methodology may be transferable to other LHB‟s.
35
High risk drugs – anticoagulants 2
3. Audit of causes for INR’s >5 and treatment given• Majority of high INR‟s on established therapy,
• Only half of “counselled” patients could recall important aspects,
• Multi factorial or new/worsening disease state most common reason,
• 12% around time of initiation,
• 18% following new medication,
• Advice on treatment only followed about 50% of time
4. Survey on communication with primary care
• Newer style form preferred
• Information received by more than one route 51%
• Fax route preferable 65%
• Information always arrives in good time 19%
• Information sometimes arrives in good time 78%
• Forms always filled in correctly 38%
• Forms sometimes filled in correctly 54%
• Obvious contact for queries 81%
• Discharge at weekends and before patient apparently stable raised as concerns
36
High risk drugs - Insulins
Insulin prescription
administration chart in
use with patient safety
issues from MSc FMEA
“Hypo pack” introduced
on wards following new
national guidance –
supported by training of
medical and nursing staff
37
Acute Stroke Services Action Plan
• Executive-led multi-disciplinary steering group to drive improvements
• Enhanced medical and nursing establishment to support service
development
• Ring-fenced specialist beds on UHW ward C7 acute stroke unit
• Revised bed management protocols to ensure timely transfer of acute
admissions to unit (24 hour compliance has increased from less than 10%
to over 80% since May this year)
• High levels of compliance with WAG intelligent targets for acute stroke
services, delivering a range of evidence-based clinical interventions across
3 hour, 24 hour, 3 day and 7 day care bundles
• High levels of clinical and managerial ownership and commitment has been
critical to achieving service improvements
38
Stroke Thrombolysis Action Plan
• Strong evidence base for delivery of thrombolysis for acute stroke patients within 3 hours of symptom onset
• Successful implementation requires rapid specialist assessment, diagnostics and careful monitoring post-treatment
• Monday – Friday service established in 2008 following development of protocols
• 24/7 service commenced in September 2010 within Cardiff and Vale, using specialist stroke physician rota
• WAG programme to rollout across Wales, using regional consultant rotas and telemedicine technology
• Door to needle time of less than one hour now being achieved
• Regular service audit / review to eliminate delays and ensure best practice
• Ongoing public awareness and inter-service co-operation is key to ensuring prompt attention and treatment to save lives and reduce disability
39
TIA Action Plan
• Key role of TIA service as stroke secondary prevention
• Multi-disciplinary task and finish group to drive service improvements, with close primary care liaison
• Establishment of integrated cross-site service to eliminate variation, with one point of referral
• Establishment of daily clinics, with rapid access philosophy
• Urgent cases now seen in clinic within 48 hours
• Revised diagnostic support to achieve „one stop shop‟
• Revised out of hours protocol to reinforce 7 day philosophy
• Urgent surgery referrals actioned within two weeks
• New database from November to assess service quality and timeliness against new target standards
40
Stroke Services – Conclusions
• Stroke service improvements started from a very low base in 2007
• Central and local commitment to improvements as a priority
• A lot has already been achieved, particularly stroke being seen as a true medical emergency
• More remains to be done, against a very challenging financial background
• But stroke is now getting the priority and commitment that it deserves, and stroke patients have a greatly improved service
41
IPC Bundles
• Central Lines – spreading beyond critical care.
• Urine Catheter bundles tested.
• Group established to roll out
• PVC bundles tested in critical care. Team developed for testing bundle outside critical care.
• Ventilator bundle well established.
42
Pressure ulcers - SKIN
Bundle
• Tested and implemented on critical care
• C&V Faculty established to deliver education, training and mentoring
• Roll out plan via C&V mini collaborative approach including community nursing and nursing homes
43
hunches,
theories &
ideas
changes that result
in improvement
Pressure Ulcers –Testing and
Implementing SKIN Bundle
Plan
SKIN bundle
used with one
patient
All patients in the
intensive care
area
SKIN bundle used for all
patients in the CCU
PDSA cycles
enabled
•Refinement of the
SKIN bundle visual aid
•Feedback on
compliance rates
•Targeted education
•Measure outcomes
using safety cross
44
SKIN bundle and safety cross
to prevent pressure ulcer
acquisition in critical care
University Hospital Llandough
45
Project aim
• To ensure that all patients at risk of developing pressure ulcers were identified.
• To reliably implement prevention strategies identified in the Prevention and Treatment of Pressure Ulcers Guide (NIHCE 2005).
• To reduce the number of hospital acquired pressure ulcers by 50% of the baseline by 2010
46
Methodology
• Baseline audit of practice
• Introduction of the „safety cross‟ to record and understand pressure sore acquisition
• Introduction of the „SKIN bundle‟ to ensure consistent delivery of evidence based care
• Measure compliance and patient outcomes
• Focused and targeted education
47
SAFETY CALENDAR MONTH: May
Date of last Pressure Ulcer
7 8 11 1213 14 17 1819 20 23 24
3129 30
246
101622
2628
1521
2527
13
9
5
17
Ward acquired: 18th May
Admitted with: 21st May X
No new case
identified
Admitted with
New case
identified 21
Recording pressure ulcers using the
Safety Cross
48
Safety cross
• Is visible – it demonstrates that we are committed
to measuring and improving our care
• It doesn‟t replace the safety reporting system - it
enables us to more efficiently comply
• Prevents staff becoming desensitised to unsafe
practices
• Enables analysis of all pressure ulcer acquisition
49
Delivering reliable care –
the SKIN bundle
• A bundle is a set of evidence based practices that when performed collectively and reliably improve patient outcomes
• SKIN bundle
– Surface selection
– Keep turning and moving
– Manage Incontinence and moisture
– Monitor Nutrition and fluid intake
50
SKIN bundle
Waterlow
At risk? *Yes/No
D/T N/T
Surface Mattress Repose boots TEDs/Heel check
Keep moving Position change ___________ hrly
Incontinence Yes/No Barrier cream
Consider f lexiseal
Nutrition
WASSP > 7 High Risk
NG/ TPN/ Food chart
Using a visual reminder we daily:-
• Evaluate and document risk
assessments
• Ensure all patients receive the
most appropriate care e.g.
monitor food intake
• Document deviations from best
practice, e.g. when patients do
not consent to interventions
• Audit practice – monitor what we
are doing well and how we can
improve
51
Results – Compliance with the SKIN bundle
Achieving reliability
Spreading too soon
Testing sticker compliance
52
Results – days between pressure ulcers
0
20
40
60
80
100
120
14010
May
09
18 M
ay 0
9
01 J
un 0
9
10 J
ul 0
9
14 J
ul 0
9
28 A
ug 0
9
13 S
ep 0
9
04 O
ct 0
9
03 N
ov 0
9
24 F
eb 1
0
30 A
pr 1
0
28 J
un 1
0
15 S
ep 1
0
Day
s b
etw
een
eve
nts
Values Median (38.0)Lower (0.0) Upper (122.8)
At the beginning of this project we had a unit acquired pressure ulcer (grade 2 – 3)
every 12 days we have increased days between damage to 38 days (median) and
have not had any pressure damage for 55 days
113 days between
53
Team work
54
Community Nursing -
Pressure Damage
2009/10
• 315,000 visits made to patients
• 40,000 Referrals made to
the service
• Caseload of 5600
• Pressure ulcer incidence of 5.6%
55
Opportunity/Challenges for community nursing
• To reduce incidence of Pressure damage
• Improve patient experience and quality of
patient care
• Promote self care and patient empowerment
• Identify stakeholders
• Identify and evidence any constraints
in system
• Ensure timely access to equipment
• Develop documentation to support SKIN
Bundle methodology
56
St Albans Care HomePressure Damage – Our Story by Ruth Young, Matron
St Albans is an independent, privately owned care home based in Cardiff.
It has 40 beds comprising of nursing, continuing health care and complex care needs.
Our clients……
57
Our Pressure Damage History Much like many care homes, our pressuredamage story was a difficult one to tell with…
• Numerous cases of pressure damage of allgrades;
• The most severe cases proceeding to POVAs,Inquests and litigation;
• Staff struggling to cope with the stress ofinvestigations;
• Uncomfortable clients and distressed relatives.
58
The Need For Change
Change was needed so that we could be confident that we were delivering the best care possible to our clients and we focused on the following:
• Documentation (implemented Daily Skin Check Chart for Carersand Prevention/Detection Treatment Regime and regular audit of these);
• Culture/Staff Responsibility (Skin Champions identified to oversee the quality of documentation/consistency of grading and to instigate care regimes);
• Product Availability (ensured all clients had access to Airflow mattresses).
59
The Next Chapter
As a result of these changes, we are now proudly able to say that we are a care home free from avoidable pressure damage with a committed team confident in this knowledge.
We are the first care home to be part of the SKIN Bundle work and have shared our experience and knowledge to produce the tools to help others get where we are today.
