Peter Toohey, Patient Safety Improvement Manager, UCLPartners
#QIinAKI #QIinSepsis @UCLPartnersPSP @pete_toohey
The UCLPartners Patient Safety Programme: Update
Patient Safety Priority Matrix
Together, Sepsis & AKI account for two thirds of potential mortality avoided from the top 8 interventions nationally
3
Intervention Potential Benefit –
Lives saved (per 100,00)
PYLL (per 100,00) <75
1 Implementation of NICE guideline on Acute Kidney Injury 19 (PYLL reduction all ages
estimated at 161)
2 Implementation of the Sepsis Six Care Bundle 18 -
3 Implementation of British Thoracic Society Care Bundle for community acquired pneumonia
6 83
4 Increased prescription of anti-thrombotics (warfarin) for patients with atrial fibrillation
4 28
5 Earlier stage of diagnosis of cancer 3 29
6 Intermittent Pneumatic Compression to prevent post stroke Deep Vein Thrombosis
2 14
7 Prevention of Venous Thromboembolism 2 -
8 Increased update of cardiac rehabilitation 1 10
Reconfiguration of hyper acute stroke services along the lines of London stroke services reconfiguration was also identified as a priority, although assessments of the relative benefits of national roll-out are complex
Source: NHS England
The IHI breakthrough series collaborative engine
UCLPartners Sepsis Collaborative Driver Diagram
Reliable identification & treatment of sepsis
in UCLP partner organisations
Outcome: Reduction in mortality
in pilot population
20% by March 2017
Recognise-Prompt identification of
patient with Sepsis
Evalutate-Follow-up review
Inform-Immediate referral to
doctor/nurse able to deliver treatment
Treat-Timely care delivery (e.g., iv
antibiotics within 1 hour)
AIM PRIMARY DRIVERS
Education and Awareness
Process measurement plan Review ≥10 patient records each month where patients’ ≥18 years old, on non-elective / emergency pathway, for active treatment; likely to have sepsis, e.g. blood cultures taken in first 24hours, or in ICD-10 codes A40/A41. Denominator is number of patients’ reviewer identifies with evidence of severe / ‘red flag’ / new definition sepsis – or septic shock – in the ED (or ward). Numerator values are numbers of patients with evidence for each of eight recommended indicators.
Culture of Safety & Quality Improvement
Patient & Family Centred Care
Reliable screening
Recheck after treatment Antimicrobial stewardship
Reliable referral process, communications & documentation
Reliable, timely treatment & source control
SECONDARY DRIVERS
Education Training
Executive sponsorship Clinicial leadership M.D.T. working Measurement
Patient involvement
1. All six vital signs recorded within 15 minutes of presentation (RR, SpO2, HR, BP, AVPU / GS, including New Confusion, temperature)
2. The word ‘sepsis’ written / highlighted / ticked in patient record within 1 hour of presentation
3. Documented iv antibiotics within 1 hour of presentation
4. Blood cultures obtained within hour
5. ≥500 mL iv fluid given within 1 hour of presentation (unless clear contra-indication)
6. Documented review within 3 hours after presentation (+/-30 mins.)
7. Evidence of escalation if not improved (no reduction in NEWS score / NEWS score still ≥5)
8. Documented review of antimicrobial therapy within 48 hours of presentation
KEY MEASURES
‘STOP AKI’- Driver Diagram
Reduce 30 day mortality following admission with AKI by 25% from baseline
value
To increase by 25% proportion of patients
who recover renal function (20% baseline creatinine) at 30 days
Improved patient experience and wellness
scores**
* Staff awareness and engagement campaign* Recruit AKI improvement team and MDT champions in acute admitting areas and ED* Staff training and education programme in admitting areas* Launch local guideline/pathway/’bundle’, AKI outreach team
Door to recognition of AKI less than 4 hours*
Door to Relief of obstruction less than 36 hours*
Door to fluids and/or antibiotics in
sepsis/hypoperfusion AKI less than 6 hours*
Door to cessation of nephrotoxins where drug toxicity contributory less
than 12 hours*
Training on fluid assessment in ED/AMU, rapid cannulation, nurse led-resuscitation, grab bags or sepsis trolley, antiobiotic guidance, senior review for fluid assessment
all AKI
Increase imaging capacity for ED/acute medicine patients with AKI, radiological prioritisation of AKI requests, use of CT KUB if limited US capacity, strengthen
pathways or outreach systems/telemdicine for urology or interventional radiology support
Staff education, incorporate AKI nephrotoxin screening in medicines reconciliation/nursing admission/medical admission/consultant ward round review, e-prescribing screening and decision support for AKI, early pharmacy review all AKI
patients
AIM PRIMARY DRIVERS(COLLABORATIVELY
AGREED)
EXAMPLE: SECONDARY DRIVERS (LOCALLY DESIGNED AND TESTED)
Door to therapy of renal disease for primary renal disease AKI less than 72
hours*
Blood test at triage, point of care creatinine, fast-track blood sample delivery,priority ED and acute medicine laboratory runs, install LIMS detection algorithm
with biochemistry phone out to teams, install LIMS detection algorithm with automated e-alert, AKI status in admission proforma (nursing or medical)
Staff education, urine dipstick all patients, fastrack and phoneback of all AKI diagnostic bloods, streamline specialist nephrology consultations, increase nephrology rounding or telemedicne, fastrack nephrology transfers with
appropriate escalation
** Primary and secondary drivers are currently being worked up with the AKI Patient Experience and Wellness Working Group.
The IHI breakthrough series collaborative engine
We are here
Key messages from the projects and learning sessions
Insights from the project
• Trusts giving or enabling dedicated time to do this project/participate is key
• Sharing and learning from the learning sessions and webinars is extremely positive (feedback from participating teams and individual team members)
High impact actions for leadership
• Share the data with your board, quality and safety committee
• Create visibility and acknowledge team’s efforts
• Ensure and maintain executive sponsorship
• Ensure the team have dedicated time where possible to work as a team with defined roles and members to support this work
Peter Toohey, Patient Safety Improvement Manager, UCLPartners
Thank you!
#QIinAKI #QIinSepsis @UCLPartnersPSP @pete_toohey