Communications

1000 Lives Plus:

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Chris Hancock: Rapid Response to Acute Illness Programme Manager,

1000 Lives Plus

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A lack of communication

is killing our patients

• Dr Peter Pronovost

– Professor of

Anesthesiology and

Critical Care

Medicine, Johns

Hopkins University

School of Medicine

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Rollercoaster

Mortality

• 1 in 1.5 billion chance of being fatally

injured at an amusement park

• Injury rates for golf and deckchairs are

higher

– US Consumer Product Safety Commission

(2007)

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Healthcare Mortality

• More than one in ten people admitted to

hospital are harmed unintentionally by its

care.

• There is a one in 300 chance of accidental

death through errors in care.

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Patient Safety

3,283 patients dead through preventable error, another 7,000 suffer severe harm

Equivalent to 9 medium size aircraft (Boeing 737/Airbus A320) being written off with total loss of life every year……

…..in the UK!

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Why?

• How often during your episode of

healthcare should you receive the

agreed optimum care and treatment?

– Sometimes

– Most of the time

– Always

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Errors of Omission/

Adverse Events

The Defect Rate in technical quality of American health care is approximately:

45%McGlynn, et al: The quality of health care delivered to adults in the United

States. NEJM 2003; 348: 2635-2645 (June 26, 2003)

It’s what we don’t do that causes the harm

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Adverse Events

• Retrospective casenote review of 1006 admissions to a large NHS hospital.– Adverse events - 8.7%, of these:

• Disability > 6 months – 15%

• Contributed to death – 10%

– Adverse events are common, serious and potentially preventable

(Sari, Sheldon, Cracknell et al, Qual Saf Health Care 2007;16:434–439.)

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Who Comes to Work

to Do a Bad Job?

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The First Law of

Healthcare Improvement

“Every system is perfectly designed

to achieve exactly the results it gets.”

We all work within systems that make it

impossible NOT to harm and kill our

patientsSource: Don Berwick, IHI (Boston)

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1000 Lives Aimed to:

• Reduce avoidable mortality by 1000

• Reduce episodes of harm by 50,000

By improving the reliability and reducing the variation in the systems and processes that we use everyday.

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‘Count me in!’

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Aims of 1000 Lives

Plus

• All Welsh Healthcare Organisations

have pledged to:

– Engage with all the mandatory

interventions

– At least a 5% reduction in mortality and

harm over the next year

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So How do We

Improve the Reliability

of a Process/System?

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1000 Lives Approach

1. Concentrate on the Points Where These Adverse Events Occur

2. Create bundles of evidence based interventions

3. Measure compliance/reliability with these bundles

4. Decide what outcome will be affected by reliable implementation of these bundles and measure it

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Where do These

Adverse Events/

Ommissions Occur?• Transfer of information

• Handovers

• Hand offs

• Admissions

• Discharge

• Patient information

„Lack of communication is killing our patients‟ – Pronovost 2002

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Checklists

Yes No Clinical

Exclusion

DVT Prophylaxis √

GU Prophylaxis √

Head Elevation - 30° √ Signed

Sedation Hold √

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Care Bundle

Compliance• Having been adopted and implemented by all

Welsh ICUs the mean national aggregate

compliance for the period April 2007 – March

2008 by bundle was: -

– Ventilator care bundle - 97.82%.

– Central Venous Catheter Maintenance (CVCM)

care bundle - 97.11%.

– Central Venous Catheter Insertion (CVCI) care

bundle - 94.71%.

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HCAI mandatory surveillance programme Wales as

run by WHAIP team

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Days between a

CRBSI• Morriston Renal Dept – 286 days

• UHW CCD – 772 days

• YGC ITU – 121 days

• YGC Renal Dept. – 74 days

• NH ITU – 196 days

• Maelor ICU – 82 days

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Rapid Response to

Acute Illness• 11% of hospital deaths analysed were as a result of

unrecognized or untreated deterioration in their condition.

• National Patient Safety Agency, (2007) Safer care for the acutely ill patient: learning from serious incidents

• 21% of ICU admissions were avoidable.• NCEPOD, (2005) National Confidential Enquiry into Patient

Outcome and Death.

• Potential prevention of 1600 ICU admissions in Wales costing £12 million.

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2 Evidence Based

Bundles

• Rapid Response to Acute Illness (RRAI) Admission Bundle

• Within 2 hours of admission to acute care– Perform full set of physiological observations

– Plan for frequency of observations

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Transforming Care

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• Sepsis Six

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Hospital Acquired

Thrombosis (HAT)

• In Wales 1250 patient die in one year due to

a VTE event. The proportion of these which

are surgical patients is unknown.

• 20% of patients undergoing surgery

experience a DVT, for Wales over a year this

could equate to 82,400 preventable events.

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• a 300-bed hospital that lacks a systematic approach to VTE prevention can expect roughly 150 cases of hospital-acquired VTE.

• Approximately 50-75 of those cases will be potentially preventable through missed opportunities to provide appropriate prophylaxis.

• Approximately 5 of those patients will die from potentially preventable PE (Maynard & Stein 2007).

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Reducing Deaths

& Harm from

Hospital Acquired

Thrombosis

Assessment of

Risk

Prophylactic

Treatment

Patient

Involvement

Documented Risk

Assessment on admission

Documentation action

required

Patient Education

Patient Awareness of Risks

& Symptoms of HAT

Patient Involvement in Care

Mechanical Methods

Pharmacological Methods

Early Mobilisation

Reassessment of Risk every

48 hours / Change in

Condition

InterventionDriver

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WHO Safer Surgery

Checklist

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• Arguably the biggest

challenge for

communication is

internal rather than

external to the

organisation.

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Questions?