critical care scn · process improvem ents (pdsa cycle); and monthly audit & ... through...

CRITICAL CARE SCNPROVINCIAL DELIRIUM INITIATIVE

C r i t i c a l

C a r e S C N

Alberta’s

Critical Care Community Edmonton & Calgary Pediatric ICUs:

• ACH PICU

• Stollery’s PICU

• Stollery’s PCICU

Edmonton Adult ICUs

• RAH GSICU

• UAH Burns

• UAH GSICU

• UAH Neruo

• MAZ CVICU

• Sturgeon ICU

• MIS ICU

• GNH ICU

North Zone:

• NLHRHC Fort McMurray ICU

• QEII Grande Prairie ICU

Central Zone:

• RDRHC ICU

South Zone:

• Chinook Lethbridge ICU

• Medicine Hat ICU

Calgary Zone:

• FMC ICU

• FMC CVICU

• PLC ICU

• PLC CCU

• RGH ICU

• SHC ICU

C r i t i c a l

C a r e S C N

C r i t i c a l

C a r e S C N

Partnering for Quality Health System

• Provincial scope• 22 ICUs• Multidisciplinary• Operational &

Medical leaders • Interdepartmental Partnership

• Inform future practice• Contribute to body of

evidence & research

C r i t i c a l

C a r e S C N

Transforming Information into

Action

Westfall, J. M., J. Mold, et al. (2007). Practice-Based Research--"Blue Highways" on the NIH Roadmap. JAMA 297(4): 403-406.Khoury, M. J., M. Gwinn, et al. (2007). The continuum of translation research in genomic medicine: how can we accelerate the appropriate

integration of human genome discoveries into health care and disease prevention? Genet Med 9(10): 665-74

The Breakthrough Series

Learning Collaborative

Initiate, Engage

Stakeholders& Plan

Innovation Collaborati

ve Learning

Session #1: Learn,

Level-set provincially

, Plan, Report Out

Collect & Report

Baseline Data

Site Implementation Team

Process Improvements (PDSA

Cycle); and monthly audit &

report of measures

Learning Session

#2: Learn, Share, Plan,

Report Out

Site Implemen

tation Team

Process Improvem

ents (PDSA

report of measures

Learning Session

#3: Learn, Share, Plan,

Report Out

Site Implementation Team

Process Improvements (PDSA

reporting of measures

Probable Learning Session

Transform ICU

Delirium Care

through continuous

quality improveme

Current State of the CC-SCN Provincial Delirium Initiative

Nov. 2016 Feb. 2017 Feb. – May 2017 May 2017 May – Sept. 2017 Sept/Oct 2017 Sept. – TBD 2017

C r i t i c a l

C a r e S C N

Building a Quality System

Evidence based

practice

Improvement

Methods

Analytics

Measure to Improve – a ‘framework’ required

Example of one indicator of ‘effectiveness’

Data Elements: Administrative Data (AHS/AHW) plus Clinical (Physician) Data

•DAD, CIHI, Statscan•Billing and Emergency Data

•Physician Clinic Data

Key Indicators:• Volume of patients/yr•% in defined risk groups•% admitted to hospital•% readmitted to hospital

Key Composite

Indicator (CI) •Risk-adjusted

outcome improvement/year

KEY INDICATOR

KEYCOMPOSITEINDICATOR

• Review your progress

• Evaluate your Plan

• Make adjustments

• Report & Share

C r i t i c a l

C a r e S C N

Information Value Chain

C r i t i c a l

C a r e S C N

The Process• Determine Key Performance Indicators (KPIs)

• Figure out how to operationalise them!

• What are the inclusions, what are the exclusions, what is the workflow?

C r i t i c a l

C a r e S C N

KPI Measures Template• Relationship to Quality

• Type of Indicator

• Proposed Data Sources

• Definitions

• Numerators

• Denominators

• Benchmark

• Risk Adjustment

• And many more fields!

C r i t i c a l

C a r e S C N

The Pain Dilemma• % of compliance with documented q4h pain

assessment o Number of assessments in a day?

o Timing between assessments?

o Hard cuts off and intervals?

C r i t i c a l

C a r e S C N

The Pain Solution

%Compliance =

100x[1-(cum_sum_4hr)/24]

• cum_sum_4hr = cumulative sum of time in 24 hr period where interval between measures exceeds 4 hrs

C r i t i c a l

C a r e S C N

Reporting - The house that

delirium builtD

MetaVision

TRACER

Other systems

C r i t i c a l

C a r e S C N

Optimisation and Evolution

“Perfection is the enemy of good”

C r i t i c a l

C a r e S C N

TRACER Web Reports

C r i t i c a l

C a r e S C N

TRACER Web Reports

C r i t i c a l

C a r e S C N

Ever Delirium - Percent of patient days where patient was delirious.

C r i t i c a l

C a r e S C N

C r i t i c a l

C a r e S C N

Mobilization – 3 x’s per 24

Goal = Daily mobilization

Pain Management

Sedation

Readiness

Workflow & routines

C r i t i c a l

C a r e S C N

Change Tools – Fishbone

DiagramCause and Effect Diagram

PEOPLE ENVIRONMENT

MATERIALS METHODS EQUIPMENT

Mobilization –

3 x’s per

24 hours

equipment not in place

Organized around ADL

Rehab discharge not

communicated to unit

Patients not functionally

ready to go home

Patient / Family readiness

Pt education documented

On white board re: WHY

Education on Mobilization

Room set up to support

Chair, assists available

Chair / Assist devices availableStaff & Family

Available to support

Ventilator

Assistance

C r i t i c a l

C a r e S C N

Change Tools – Driver

DiagramOUTCOME PRIMARY DRIVERS

SECONDARY

DRIVERS

IDEAS FOR

PROCESS CHANGE

Patient

Mobilization

Put mobilization

Times on

whiteboard

Entire team

Says “we need

To Mobilize

Get family

engaged

Coordination &

Communication

Mobilize &

Monitor

“READY”

to mobilize

Patient

“ABLE”

to mobilize

Pain Meds

Timed to event

Organized

Around Unit

workflow

e.g. Rounds

Education &

Understanding

Best practice

Medical &

Functional

Readiness

Hospital

Resources

CREATIVE COMMUNICATION

Provincial Data Delirium Initiative

Table 1. Characteristics of patients at General system units

(n=9772)

Ever Delirium

p value0 (n=5059) 1 (n=4713)

Male, n (%) 5622 2826 (50.27) 2796 (49.73) <.001

Age, yr, median (QR) 59 (45-69) 59 (45-69) 59 (59-69) .23

Admit type Urgent, n (%) 8481 4163 (49.09) 4318 (50.91) <.001

APACHEII score, median (QR) 22 (16-28) 19 (14-26) 24 (19-29) <.001

APACHEIII score, median (QR) 69 (51-92) 60 (45-83) 78 (6-98) <.001

52.78%

48.23%

Ever Delirium

No Yes

64.26 56.0250.14 49.02 46.88

40.32 40.28 38.69 36.6731.07

Deliri

Table 2. Characteristics of patients at General system unitsTotal

(n=9772

Delirium p

(n=5059)

<=24hrs

(n=2965)

>24 hrs

(n=1748)

Total n (%) 9772 5059

(51.77)

(30.34)

(17.89)

Male, n (%) 5622 2826

(55.88)

1742(58.75

(60.33)

Age, yr, median (QR) 59 (45-

59(45-69) 58(45-69) 59 (46-70) 0.38

Admit type Urgent, n

8481 4163(82.32) 2727(91.97

(91.02)

APACHEII score,

median (QR)

22 (16-

19(14-26) 23(19-29) 25 (20-30) <.00

APACHEIII score,

median (QR)

69 (51-

60(45-83) 76(58-96) 82 (63-

51.77%30.34

17.89%

Delirium

No <=24 hours >24 hours

28.129.7 28.8

22.119.3

18.116.7 15.6 15.6 14.6 14.4

<=24 hours

25.41 25.47

22.76 22.0420.94

17.62 16.93 16.84 16.05 15.56

13.2 12.98 12.2510.92

8.767.58

<=24 hours >24 hours

p<.001

No Delirium Delerium

p<.001

No Delirium Delirium

Figure 4. APACHE

p<.001020

p<.001

Delirium

Table 2. Outcomes for patients at General system units

totalEver Delirium

p value0 1

ICU outcome 0.04

Dead 1302 709 (14.01) 593 (12.58)

Hospital outcome 0.01

Dead 1842 904 (17.87) 938 (19.90)

ICU LOS, d,

median (IOR)

3.1 (1.6-

2 (1.0- 3.7) 5.5 (2.9-

HOSP LOS, d,

median (IOR)

10 (4-

6 (2-15) 15 (7-33) <.001

14.0112.58

17.8719.90

No delirium Delirium

ICU In-hospital

p<.001

g in t

0 20 40 60Days

Ever delirium = No

Ever delirium = Yes

Kaplan-Meier Analysis of Delirium in the ICU Length of Stay

p<.001

0 30 60 90 120 150 180Days

Ever delirium = No

Ever delirium = Yes

Kaplan-Meier Analysis of Delirium in the Hospital Length of Stay

Table 2. Outcomes for patients at General system units

Delirium p

No <=24

>hours

ICU outcome

Dead 1302 709

(14.01)

(12.24)

(13.16)

Hospital outcome

Dead 1842 904

(17.87)

(18.58)

(22.14)

ICU LOS, d,

median (IOR)

3.1 (1.6

– 6.5)

2 (1-3.7) 4 (2.1-7.8) 8.1 (4.9-

HOSP LOS, d,

median (IOR)

10 (4 -

6 (2-15) 12 (5-29) 20 (11-39) <.001

14.0112.24 13.16

17.87 18.58

ICU In- hospital

p<.001

g in t

0 20 40 60Days

No Delirium

Delirium<= 24 hours

Delirium > 24 hours

Kaplan-Meier Analysis of Delirium in the ICU Length of Stay

p<.001

g in t

ospita

0 30 60 90 120 150 180Days

No delirium

Delirium <=24 hours

Delirium >24 hours

Kaplan-Meier Analysis of Delirium in the Hospital Length of Stay

day 1 day 2 day 3 day 4 day 5 day 6 day 7

Percentage

day 1 day 2 day 3 day 4 day 5 day 6 day 7

Patients

Timing of Development of

Delirium

Delirium Collaborative Data

C r i t i c a l

C a r e S C N

C r i t i c a l

C a r e S C N

C r i t i c a l

C a r e S C N

7.23% September screening compliance to 59.88% in April

C r i t i c a l

C a r e S C N

Provincial

C r i t i c a l

C a r e S C N

C r i t i c a l

C a r e S C N

C r i t i c a l

C a r e S C N

C r i t i c a l

C a r e S C N

C r i t i c a l

C a r e S C N

C r i t i c a l

C a r e S C N

C r i t i c a l

C a r e S C N

C r i t i c a l

C a r e S C N

Unit specific KPIs – Big

improvement performers!• Medicine Hat

o Ever Delirium –

• 58% @ baseline Jan-Apr 25%

• Royal Alex-o SBT eligibility assessed & documented

• 47% @ baseline April 83%

• South Health Campus- Calgaryo % of time pain & pain management discussed daily

C r i t i c a l

C a r e S C N

• Misericordia Hospitalo % of time eligible patients received 3 mobility events in 24hrs

• Chinook Regional Hospital-Lethbridgeo % of time RASS assessed and documented q4hr

• 12.28% @ baseline April 66%

• Foothills Hospital ICUo Significant pain

• 17.55% @ baseline April 11.98%

Unit specific KPIs – Big

improvement performers!

Adult ICUUrban vs Regional

C r i t i c a l

C a r e S C N

% of patient days with delirium

*Coronary Care units not included

Calgary Zone Edmonton Zone Regional Sites

Delirium Screening compliance is >85% for each

quarter

C r i t i c a l

C a r e S C N

*Coronary Care units not included

tAdult ICU

% of compliance with pain assessment

95% target

complianc

C r i t i c a l

C a r e S C N

f assessm

ignific

% of Assessment with

Significant pain

*Coronary Care units not

included

C r i t i c a l

C a r e S C N

Agitation & Sedation

Assessment

*Coronary Care units not

included

95% target

compliance

Calgary Zone

C r i t i c a l

C a r e S C N

Delirium

FMC CVICU FMC ICU PLC ICU SHC RGH

f patient

days w

Calgary Zone Delirium

quarter

C r i t i c a l

C a r e S C N

Pain Assessment

100.00

nce to q

assessm

Pain Assessment% of compliance time q4hr pain assessment

95% target compliance

C r i t i c a l

C a r e S C N

Significant Pain

f assessm

with s

ignific

Calgary Zone Significant Pain

C r i t i c a l

C a r e S C N

Agitation and Sedation

ince to q

assessm

Calgary ZoneAgitation and Sedation

Edmonton Zone

C r i t i c a l

C a r e S C N

Delirium

GNH MAZ CVICU MIS ICU RAH ICU SCH ICU UAH GSICU UAH Neuro

f patient

days w

Edmonton Zone Delirium

quarter

C r i t i c a l

C a r e S C N

Pain Assessment

100.00

GNH ICU MAZ CVICU MIS ICU RAH ICU SCH ICU UAH GSICU UAH Neuro

Edmonton Zone% compliance to q4hr pain assessment

C r i t i c a l

C a r e S C N

Significant Pain

Edmonton Zone Significant Pain

C r i t i c a l

C a r e S C N

assessm

Edmonton Zone Agitation and Sedation

Regional Hospitals

C r i t i c a l

C a r e S C N

Delirium

CRH QEII MHRH NLRH RDRH

f patient

with d

Regional HospitalsDelirium

C r i t i c a l

C a r e S C N

Pain Assessment

CRH ICU MHRH ICU RDRH ICU NLRH ICU QEII ICU

Regional Hospitals% of compliance q4hr pain assessment

C r i t i c a l

C a r e S C N

Significant Pain

MHRH ICU RDRH ICU NLRH ICU QEII ICU

f assessm

with s

ignific

Regional Sites Significant Pain

C r i t i c a l

C a r e S C N

CRH ICU MHRH ICU RDRH ICU NLRH ICU QEII ICU

nce to q

assessm

Regional SitesAgitation and Sedation

Pediatric ICU

C r i t i c a l

C a r e S C N

Delirium

Baseline Q3 (16/17) Q4 Q1(17/18) Baseline Q3 (16/17) Q4 Q1(17/18) Baseline Q3 (16/17) Q4 Q1(17/18)

ACH STOL PCICU STOL PICU

f patient

days w

Pediatric Hospitals% pf patient days with delirium

C r i t i c a l

C a r e S C N

Q3(16/17) Q4 Q1(17/18)

f patient

days w

ACH Delirium

Ever Delirium Screening Compliance

C r i t i c a l

C a r e S C N

Q3(16/17) Q4 Q1(17/18)

f patient

days w

Stollery PICU Delirium

C r i t i c a l

C a r e S C N

Q3(16/17) Q4 Q1(17/18)

f patient

days w

Stollery PCICU Delirium

C r i t i c a l

C a r e S C N

Pain Assessment

Baseline Feb March April May Baseline Feb March April May Baseline Feb March April May

ACH STOL PICU STOL PCICU

assessm

PediatricCompliance of pain assessment

C r i t i c a l

C a r e S C N

Significant Pain

Baseline Feb March April May Baseline Feb March April May Baseline Feb March April May

ACH STOL PICU STOL PCICU

f assessm

ignific

Pediatric Units Significant pain

C r i t i c a l C a r eS T R A T E G I CC L I N I C A LN E T W O R K

My Team Members:

Mazankowski CVICU

Todd M.

Deanna P.

Zee Y.

Daniel G.

Damaris G.O.

Megan P.

My Team Members:

Kristin Ferguson Kari Litzenberger

Dr. Chris Grant Allison Friesen

Regrets:

Dr. Andre Ferland

Chris Coltman

FMC CVICU

My Team Members:

Dr. Terry Hulme

Melissa Redlich (Manager)

Nicole Nigel (PT)

Kelsey Slemko (Clincian)

Rachel Lessoway (RN)

Monica Nguyen (RN)

Lyle Geldof (RT)

Chelsey McBride (RN)

Allie Barcomb (RN)

Steph McLeod (RN)

Kirstin Junchniewicz (RN)

ROCKYVIEW ICU

My Team Members:

Representation from ICU Management, QI

Lead, Nursing and RRT Educators, Nurse

Clinician, RRT Supervisor, PT, OT,

Pharmacy and bedside RNs and RRTs.

Foothills Medical Centre ICU

My Team Members:

Alberta Children’s Hospital PICU

My Team Members:

PAWD-E Patrol: Alice Chan, Shannon Duncan, Dominic Cave, Laurance Lequier, Gonzalo Guerra, Lorraine Hodson, Christine MacDonald, Tamara Liber, Whitney Gendall, Just Kiew, Lara Sreibers Cindy Scouten, Archie Enano, Adele Benest, Sarah Bieganek,

Stollery Pediatric Critical Care

Jon Pryznyk - RRT Supervisor

Kari Taylor - CNE

Dr. Juan Posadas – Medical Director

Michelle Parsons - PT

Stephanie Oviatt - PT

Charissa Elton-Lacasse - NP

Myrriah Huyton - RN

Meaghan Wood - RRT

Jana Smith - NC

Rachel Taylor – Manager

Karolina Zjadewicz – QI Lead

Jeanna Morrissey – Delirium Practice Lead

Team Members:

South Health Campus ICU

(Insert team picture here)Our Multi disciplinary team includes: Management , Physician , Nursing , Pharmacy , PT , OT and Social Work

Robert , Carmen, Mike, Fay Twyla, Gillian, Jennifer, Krista Angela ,Geoff , Jennifer , Roxanne , Sandy , Kirby , Deanna , Phil , Jann , Kelly

RDRH ICU

Here is our team ready to combat delirium

Core Team Members:

Erica Kam

Heather Emmerzael

Heidi Cunningham

Laurie Sembaliuk

Melissa Ziober

Dr. Pierre Villeneuve

Grey Nuns Hospital Intensive Care Unit

My Team Members:

Dr. Ella Rokosh Kim Scherr

Wanda Power Gwen Bileski

Phuong Tien Michelle Campbell

Jill McLauchlin Olga Muradov

Melissa Black Alice (Sin Hang) Chan

Angie Grewal Eric Lau

Rhonda Schmidt Leanne Ellis

Trish O’Toole

Misericordia Community Hospital ICU

UAH Neuro. ICU

Team Members:

Dr. Gabriel Suen – ICU MD

Shirley Baumgartner – PCM

Glenda Corrigal – UM

Nancy Coyne – CNE

Sophia Lepore – RN

Beverly Lefebvre - RT

Kristine Hayday - PT

(Sturgeon Community Hospital- ICU)

C r i t i c a l C a r e S C N

MHRH I-rounds board

C r i t i c a l C a r e S C N

REPORT DATE: 2017-05-04 Delirium Report

2017-MarPatients Screened for Delirium: 3 patients out of 3

(100%)Patients with RASS Assessment: 3 (100%)Patients with ICDSC Assessment: 3 (100%)

2017-AprPatients Screened for Delirium: 1 patients out of 2

(50%)Patients with RASS Assessment: 1 (50%)Patients with ICDSC Assessment: 1 (50%)

ANNUAL REPORT: 2017Patients Screened for Delirium: 103 patients out of 117

(88%)Patients with RASS Assessment: 83 (71%)Patients with ICDSC Assessment: 85 (73%)-20170504

My Team Members:Kristen Davis

Joanne ShepherdJacinta Ziegler

Michelle PicardMarissa Storie

Cindy O’FlahertySandra Beida

Lacee TaylorAngie Dort

Dr. Gerald Nikoleychuk

QE II Regional Hospital ICU/CCU

Dr. Mike Meier Samantha Taylor

Salima Ismail Christopher Tham

Kelly Robinsons Laverne Gallagher

Jessica Hullman Renee Nason

Paula Roberts Karen Lee Brown

Jill Bech Lori Yurkiw

Lily Zhang

U of AGSICU/Burns

My Team Members:

Dr. E. Janzen

Riley Epp, RN

Spencer Bisley, RRT

Victor Kemble, RN

Alison Martin, RN

Stephanie Quan, RRT

Kathy Sassa, CNE

Jo Taylor, Unit Manager

Lethbridge Chinook Regional Hospital ICU

Scott Groves, RN

My Team Members

Pam Lund, RN (ICU Manager)

Katie Kirschner, RN

Lee Junlajeam, RT

Yejide Adeniji, PT

NLRH- Fort McMurray

My Team Members:

PLC ICU

Judy RRT supervisor

JasonNursing Attendant

TorieClinical Nurse Educator

MaureenPhysiotherapist

IlaUnit Manager

BrittanyNurse Clinician

My Team Members:

Fran Gallant – Nurse Clinician

Sue Kujundzic – Nurse Clinician

Sammar Hussein - RN

Roy Poules - CNE

Maria Brix – Unit Manager

Jenny Mazuryk - Manager

Peter Lougheed Centre CCU

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