improving productivity by focussing on quality of care - a programme of research at the hospital dr...
TRANSCRIPT
IMPROVING PRODUCTIVITY BY FOCUSSING ON QUALITY
OF CARE - A PROGRAMME OF
RESEARCHAT THE HOSPITAL
Dr Gill ClementsRoger KillenMarch 2006
“Patients do not die of their disease, they die of the
physiologic abnormalities of their disease”
Sir William Osler
PATIENT ASSESSMENT
• Blood pressure• Heart rate• Respiratory rate (oxygen levels)• Urinary output• Temperature• Conscious level
EARLY WARNING SCORES
• Measure of physiological illness• Marker of increased mortality risk• Linked to action
SPECIALIST CRITICAL OUTREACH TEAMS
• Hospital wide• Multidisciplinary• Ensure appropriate intensive care
unit (ICU) admissions• Provide training and education
NATIONAL CONFIDENTIAL ENQUIRY into PATIENT
OUTCOME and DEATH (NCEPOD) report 2005
• Inconsistent recognition of physiological instability
• Inconsistent action• Inappropriate intensive care unit
admissions• Inequality in early warning score
measurement and outreach team implementation
COCHRANE REVIEW OF THE EVIDENCE
• Many hospital deaths potentially predictable and possibly avoidable
• Clinical deterioration preceded by changes in physiological measurement
• Changes often misses, misinterpreted, mismanaged
• Delays in seeking advice, failure to recognise clinical urgency
SHREWSBURY AND TELFORD HOSPITAL
• Early warning scores across the 2 sites
• Critical outreach teams on both sites• Two busy ICUs• ALERT (acute life threatening events
recognition and treatment) training courses
• Hospital Standardised Mortality Ratios (HSMRs) low
• Desire to improve quality of care and productivity
• Enthusiastic team• Research opportunity• Hospital research money
RESEARCH PROGRAMME
Two projects:• implementing electronic decision support
tools• development of a more sophisticated
patient risk assessment toolIn partnership:
- Portsmouth and Birmingham Universities- Portsmouth Hospital- private limited company - The Learning Clinic
VitalPAC
• Improve accuracy and timeliness of observation data collected by nurses
• Automatic creation of early warning scores (EWS)
• Linked to decision support (bedside and remote)
• Reduce nurses work burden (remove paper)
• Wireless handheld computers
• Touch screen guides nurse through data input
• Calculates EWS • Protocols embedded• Personalised reminders
and order of observations• On line nurse training
PROGRESS SO FAR
• In use on 2 surgical assessment units
• Evaluation of improvement in quality and productivity
RESULTS
• Accuracy of scores improved from 63% to 90%
• Time to produce a score reduced from 37 seconds to 24 seconds
• Popular with staff
NEXT STEPS
• Remove paper• Add in access to blood results• Remote access for critical outreach
teams• Role out to medical assessment
units
VitalPAC+
• Development of a more sophisticated risk prediction/early warning score using data collected as a by product of clinical care (blood tests)
• Based on original work done in Portsmouth (Prytherch, Br J surg 2003)
Category Mortality risk (%)1 0 to 5
2 >5 to 7.5
3 > 7.5 to 10
4 > 10 to 12.5
5 > 12.5 to 15
6 >15 to 20
7 >20 to 25
8 >25 to 33
9 > 33 to 50
10 > 50 to 100
• Model replicated at Shrewsbury and Telford Hospital
• Model fits surgical and medical patients
• 90% emergency patients have routine bloods taken on admission
• Data in hospital systems
Percentage of low risk and high risk patients at SATH
over 5 yearsRisk category
1Risk category8, 9 and 10
2000 49 8
2001 45 8
2002 40 8
2003 42 10
2004 44 8
SO WHAT?
• Improvement in the quality of care• Improvement in productivity
QUALITY IMPROVEMENT
• Systematic implementation of accurate risk scoring of patients
• Systematic link to appropriate action• Effective, appropriate use of resources
(doctors, critical outreach nurses, ITU)• Audit tool Reduction in mortality and morbidity
PRODUCTIVITY IMPROVEMENT
• Stream emergency patients• Identify “appropriate” admissions –
emergency triage• Appropriate level of resources to
patients• Predict LOS• Predict risk of readmission
Any questions?