Local Improvement Clinic

• Dr Don BerwickPresident & CEO, IHI

• Prof Bernard Crump– NHS Institute for Innovation &

Improvement

• Dr Ross WilsonChair, Strategic Advisory Board International Forum

2

To Improve the Prescription of Osteoporosis Treatment in Post-

Menopausal with a Hip or Vertebral Fracture

Kate Cotter, Jennifer Dempsey, Cheryl Baldwin

Central Coast Health

Mission Statement

• To Improve the prescription of osteoporosis treatment in post-menopausal with a hip or vertebral fracture

• Triple therapy osteoporosis treatment– includes Calcium, Vitamin D and a

Bisphosphonate.

• Improve prescription from 25% to 100% for all appropriate women in 3 months

• Longer term goal to reduce further osteoporotic fractures

Team members & role

• Project team members with fundamental knowledge and who worked on the project: – Kate Cotter: Ortho-geriatric registrar– Jennifer Dempsey: CNC Medicine– Cheryl Baldwin: CNC Ortho-geriatric – Consultation with pharmacy department,

orthopaedic clinical teams

Evidence for there being a problem worth solving

Post-Menopausal Osteoporotic Fractures Are:

• Common

• Proven therapies to reduce further fractures

• BUT

• Evidence-based guidelines are poorly implemented

A Common Problem - Australia

IN AUSTRALIA• In 2001 2 million people were estimated to be

affected by osteoporosis, three-quarters of whom were women.

• 20,000 hip fractures per year, and this is estimated to increase by 40% each decade.

• Every 8.1 minutes someone in Australia is admitted to hospital with an osteoporotic fracture and this will increase to every 3.7 minutes by 2021 if nothing is done.

Evidence for there being a problem worth solving

Proven therapies to reduce further fractures• Supplementation with Calcium and

Vitamin D has been shown to reduce hip fractures by 43%

• National Osteoporosis Foundation Guidelines state that providing adequate daily Calcium and vitamin D is a safe and inexpensive ways to help reduce fracture risk

Results of Preliminary Audit

Prescription of Ca/Vit D/Bisphos Jan-Mar 2005Wyong and Gosford Hospital

0%

20%

40%

60%

80%

Jan Feb Mar

Month

Per

cent

age

of p

atie

nts

Calcium

Vitamin D

Bisphosphonate

Triple

Flow Chart of ProcessPresents to ED

& Fracture Diagnosed

Admitted Orthopaedic

Team

Admitted General Medical

Team

Admitted Geriatric Team

Transferred to Peripheral Hospital

Discharged

Follow-up OrthopaedicOutpatient

Clinic

FractureRepaired

Transferred to Rehab

Seen by Orthogeriatric

TeamDischarged

Transferred to Peripheral

Hospital to Await Placement

Placed in HostelOr NH

Transferred to Peripheral Hospital to

Awail Placementi

DischargedTransfer of CareTo Another Team

Transferred to Rehab

Cause and effect diagram

Noosteoprosistreatmenton discharge

Equipment

Environment

Procedures

People

Osteoporosis not considered intreatment

Patient is not educated to ask fortreatment

No designated responsibility

No education for the teams

Calcium not ordered

After-hours RMO writing up dischargesummaries

No guidelines for discharge plan

No pharmacy discharge education

No documented discharge plans

Multiple transfers with poorcommunication between facilitiesand teams

Multiple people involved indischarge

Patient discharged from multiplepoints

Biphosphonate not restarted ondischarge

Biphosphonate not supplied bypharmacy

No script pads in ED and O/P

Causes of no treatment on discharge

Pareto ChartCount

Perc

ent

Osteoporosis

Count14.8 13.1 9.8

Cum % 34.4 62.3 77.0 90.2 100.0

21 17 9 8 6Percent 34.4 27.9

60

50

40

30

20

10

0

100

80

60

40

20

0

Pareto Chart of Osteoporosis

In Emergency Department

• Routine serum calcium measurement in all patients presenting to Emergency Department with a low impact fracture

Orthopaedic Ward

• Orthogeriatric orientation provided to all RMO’s at start of new term– Every patient with a low impact fracture has

osteoporosis– Encourage charting of “Triple Therapy”

• Caltrate 1200mg daily• Ergocalciferol 1,000 units daily• Alendronate 70mg weekly (to commence on

discharge)

– If on a bisphosphonate at admission it must be charted on drug chart as “recommence on discharge”

– Importance of putting date of X-ray on discharge summary (required for special authority script)

Orthopaedic Ward

• Increase awareness at staffing level– Participation in osteoporosis week– Poster in orthopaedic ward, orthopaedic

outpatient clinic and emergency department

– Incorporating osteoporosis treatment into existing nursing pathway for fractured NOF

Orthopaedic Ward

• Increasing awareness at patient level– Orthogeriatric team providing verbal and

written information to patient about osteoporosis and its treatment

At Discharge

• Copy of dictated letter from Orthogeriatric Registrar listing diagnosis of osteoporosis and recommended treatment sent electronically to GP

Fracture ClinicAttention: All Fracture Clinic Staff Patient with minimal trauma fracture?The Bone Protection Project has been

implemented to ensure ALL patients presenting with a minimal trauma fracture are correctly managed and investigated for underlying osteoporosis.

ACTION:Please give the patient a G.P. referral letter.Use stamp provided to record letter given to

patient.

Run-chart

0

10

20

30

40

50

60

70

80

Jan Feb March April May June July

CalciumVitamin DBisphosTriple

Percentage on Treatment at Discharge

Run-chart

0

10

20

30

40

50

60

70

Jan Feb March April May June July

Ca

Vit C

Bisphos

Percentage of those NOT on treatment, who had treatment commenced

SHOWING RESTRAINT

Nigel DountonDoris Kinnaird

Sam AlfredAdrian Jackson

Central Northern Adelaide Health Service

Mission Statement

The Aim is to Reduce by 60% Within

Six Months the Use of Emergency Department Initiated Physical/Mechanical Restraint for Behaviourally Disturbed Patients.

Team Members

Nigel Dounton – Mental Health Nurse ED Queen Elizabeth Hospital

Doris Kinnaird - Mental Health Nurse ED Lyell McEwin Hospital

Sam Alfred – Consultant ED Royal Adelaide Hospital Adrian Jackson - Mental Health Nurse ED Royal

Adelaide Hospital

Central Northern Adelaide Health Service

Guiding Committee

Dr Darryl Watson - General Manager Early Intervention and Acute Services Mental Health

Dr James Hundertmark - Director Acute Service Mental Health QEH (CHAIR)

Dr Geoff Hughes - Director Emergency Department Royal Adelaide Hospital

Neville Phillips - Nursing Director Early Intervention and Acute Services Mental Health

Suzanne Heath - Manager Service Development Mental Health Directorate

Adrian Jackson - Project Officer, Early Intervention and Acute Services Mental Health

Lynne James - Senior Program Planning Officer Acute Services Mental Health Directorate

Restraint as Overall % of Patient Numbers 2005 to 2006

1.72%1.81%

1.40%

1.68%1.51%

2.48%

1.98%1.87%

2.28% 2.28%

2.51%

1.25%

1.67%

2.19%2.27%

2.08%1.93%

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

May June July August Sept O ct Nov Dec Jan Feb March April May June July August Sept

Presentation to Emergency Department

Admission into ED

Behaviour Escalates

Treatment with Settling of Behaviour

Discharge, Transfer or Admission

High Order Flowchart

Entering ED Triaged

Clerk for A9

and Old Files

If Not Behaviourally Disturbed – Possible

Waiting Room/Cubicle

If Behaviourally Disturbed – Safe

Room/Resus

Patient’s Behaviour Escalates

Nursing/Medical Staff Arrive/Present

Security Called

Security Arrives

If Restraint – 33# Call

Assessment Process To

Determine Best Treatment

Guard

Monitoring Process – Observations for

Restrained Patient

Behaviour De-escalates

Intervention Minimal Effect,

Behaviour Escalates

Medical Assessment Completed if Necessary

More Formal Psychiatric

Assessment

If Affected by Drug Alcohol – Longer Waiting Time to

Detox

Decision to Admit,

Discharge etc

Destination Can Delay discharge

From ED

If De-escalation is Not EffectiveMedication Given

And/or Seclusion Room And/or

ShacklesIf De-escalation is

Effective

Discharge from ED

Attempted De-escalation Can Occur at Any Point

SAAS can Request

Restraint Team Standby on

Arrival

D

D

D

D

D

Med & Psych May Disagree Who is Responsible for

PatientD

D

D

D

D

Cause and Effect Diagram

Patient Factors Perceived Neglect

EnvironmentalInterventional Delays

Escalation Requiring Restraint

Drugs

Anxiety

Psych illness

Medical illness

High stimulus

Seclusion room location

Hunger

Thirst

Nicotine

Communication

Pre contact wait

Medical assessment

Psych assessment

Medication

Pareto Chart

Intervention - plan, protocol etc Weeks 1 – 3 (Intervention A)

– Identify patients who are becoming agitated but are not yet violent or requiring restraint. (Early warning signs of agitation discussed with and printed out for staff)

– Offer fluids, sandwich etc and communicate with patient re issues of immediate concern.

– Outline normal processes involved in ED assessment to patient– Place patient label in one of the study book located at Triage and Area A

& B.

Weeks 4 – 7 (Intervention B)– Early administration of Lorazepam 1mg, generally initiated by nursing

staff. If necessary repeat dosing with input from medical staff.– Place patient label in one of the study books as previously described.

Data sheet with results in the three key areas

The initiation of intervention was recorded in a ‘study book’ placed at three locations in the ED. The patients ‘identifying label’ was stuck in the book and a brief note recorded next to their name.

Data on urgent restraint callouts was collected by the security firm responsible, and compiled by the Royal Adelaide Hospital Safety and Quality Unit.

Results in three key areas are: – There were no additional costs above those of usual treatment as

medication costs and consumables are already budgeted for.– The consumer representative on the steering council was

unavailable. There were no complaints voiced by patients in the ED. Staff were universally supportive at weekly review sessions.

– No adverse events related to the interventions were identified during review of case notes for enrolled patients

Restraint as Overall % of Patient Numbers Before & During Study Period

1.98

2.89

1.87

2.66

3.44

1.94 2.03

2.642.9

1.63

1.03

2.77

1.12

0.180

0.5

1

1.5

2

2.5

3

3.5

4

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 IntervA

IntervA

IntervA

IntervB

IntervB

IntervB

IntervB

Intervention 1 Intervention 2

%

Strategies for Sustaining Improvement

Formalise the ED/Mental Health protocol for the assessment of the agitated patient to include both of the study interventions– Regular staff feedback on the process has already been

instituted on a weekly basis and will continue until entrenched

– The RAH drug committee has been approached to ratify nurse initiation of the Lorazepam protocol

– An ongoing review process screening for complications has been put in place

Strategies for Spreading

Support has been secured from Mental Health and Emergency Medicine hierarchies to adopt the same approach on an area wide basis

Team members from various institutions will be instrumental in implementing the process within their own institutions

The next meeting of the steering committee is scheduled for November.

At Level 11 of Tan Tock Seng

Hospital, the peripheral iv

cannula phlebitis rate will be

reduced by 50% in 3 months

Mission Statement

Team Members & Roles

1. SNC Margaret Soon

2. NO Wong Siao Pin

3. SN Goh Mei Chern Staff from unit

4. AN Widarni

5. NE Prema Balan Teaching of staff

6. NE Pua Lay Hoon

7. Dr Benjamin Tan Dr covering L11

Evidence for there being a problem worth solving

Point Prevalence Phlebitis rate done on

May 31 2002 is 26.3%.

•International average = 15%

• Institutional average =

11.8%

• National average = 8.3%

Repeated point prevalence rate in the

unit on 28 Nov 2002 is 25%

Pareto Chart

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Speed ofadministration

Flushing not done IV bolus againstrecommendation

Not dilutedaccording to

recommendations

Intermittentdisconnection

Restless Patient

Patient

Health Care Worker

1. Compile, communicate & educate a. antibiotics information chart Speed of administration & proper dilution

b. Drugs not for IV administration

c. Flushing of line according to

recommendations d. Proper restraint of restless patients

2. Audit compliance to recommendations & phlebitis rate

Intervention(s) - plan, protocol etc

Point Prevalence Phlebitis Rate

Phlebitis Rate

0

26.30% 25%

14.60%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

31-May-02 28-Nov-02 22-Jan-03 20-Jan-04

Involve all grades of HCWs

within the department

Ownership of the

problem/issue

Random point prevalence

audit for comparison

Strategies for Sustaining(holding the gains)

Strategies for Spreading

Repeat hospital wide point

prevalence study (20 Jan 04)

Target at the next area with

problems in peripheral

phlebitis

Thank

You