Local Improvement Clinic

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					Local Improvement
            Clinic


• Dr Don Berwick
  President & CEO, IHI

• Prof Bernard Crump
   – NHS Institute for Innovation &
     Improvement

• Dr Ross Wilson
  Chair, Strategic Advisory Board
  International Forum
    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




                                                2
          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 2005
                                   Wyong and Gosford Hospital
Percentage of patients




                         80%

                         60%                                      Calcium
                                                                  Vitamin D
                         40%
                                                                  Bisphosphonate
                         20%                                      Triple
                         0%
                                Jan         Feb        Mar
                                          Month
                     Flow Chart of Process
                                                                                   Presents to ED
                                                                                     & Fracture
                                                                                     Diagnosed




                   Admitted                                         Admitted
                                                                                               Admitted            Transferred to
                  Orthopaedic                                    General Medical                                                       Discharged
                                                                                             Geriatric Team      Peripheral Hospital
                     Team                                             Team




   Seen by                                                                 Transferred to                                               Follow-up
                                Transferred                                  Peripheral                                                Orthopaedic
 Orthogeriatric
                                 to Rehab                                    Hospital to            Discharged                         Outpatient
     Team                                                                 Await Placement                                                 Clinic




                                               Transferred to
                   Fracture                      Peripheral             Placed in Hostel
                   Repaired                      Hospital to                 Or NH
                                              Awail Placementi

                                                                                                                        Transferred
                                                                                                                         to Rehab



Transfer of Care
To Another Team                               Discharged
Cause and effect diagram
                 Causes of no treatment on discharge
  Environment                                    People



                                                          No education for the teams
           Patient discharged from multiple
           points
                                                            No designated responsibility
                Multiple people involved in
                discharge                                      Patient is not educated to ask for
                                                               treatment
                    Multiple transfers with poor
                    communication between facilities             Osteoporosis not considered in       No
                    and teams                                    treatment
                                                                                                      osteoprosis
                                                                                                      treatment
                                                                 Calcium not ordered                  on discharge
                   Biphosphonate not restarted on
                   discharge                                   After-hours RMO writing up discharge
                                                               summaries
                Biphosphonate not supplied by                No guidelines for discharge plan
                pharmacy
                                                           No pharmacy discharge education
          No script pads in ED and O/P
                                                          No documented discharge plans


   Equipment                                    Procedures
                                     Pareto Chart
                                     Pareto Chart of Osteoporosis
                                    60                                                                               100
                                    50                                                                               80
                                    40




                                                                                                                           Percent
Count




                                                                                                                     60
                                    30
                                                                                                                     40
                                    20
                                    10                                                                               20

                                      0                                                                              0
        Osteoporosis                                                   y                 s                      er
                                                   ed             ilit                                  ge
                                                er              ib                   MO              ar       th
                                           nsid              ns                 rR              isc
                                                                                                   h         O
                                                            o                 fo
                                      tc
                                         o                sp                n                rd
                                    no                 re                io                fo
                                                     d                 at               es
                                sis             a te               uc                lin
                             or
                               o               n                ed                  e
                           op              sig                o
                                                                              gu
                                                                                 id
                         te             de                  N
                                                                           o
                        s            No                                  N
                       O
                           Count                     21               17               9                8        6
                          Percent                  34.4             27.9            14.8             13.1      9.8
                          Cum %                    34.4             62.3            77.0             90.2    100.0
   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 Clinic
Attention: 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
           Percentage on Treatment at Discharge
80
70
60
50                                                 Calcium
40                                                 Vitamin D
                                                   Bisphos
30
                                                   Triple
20
10
0
     Jan   Feb   March April   May   June   July
                     Run-chart
     Percentage of those NOT on treatment, who had
     treatment commenced
70

60

50

40                                                     Ca
30                                                     Vit C
                                                       Bisphos
20

10

0
       Jan   Feb   March   April   May   June   July
SHOWING RESTRAINT

                Nigel Dounton
                Doris Kinnaird
                 Sam Alfred
               Adrian 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
3.00%




2.50%                                             2.48%                                 2.51%
                                                                          2.28% 2.28%                                   2.27%
                                                                                                                2.19%
2.00%
                                                                                                                                2.08%
                                                          1.98%                                                                     1.93%
                  1.81%                                           1.87%
          1.72%                   1.68%                                                                 1.67%
1.50%                                     1.51%
                          1.40%
                                                                                                1.25%
1.00%




0.50%




0.00%
        May   June   July   August   Sept    O ct    Nov     Dec     Jan     Feb   March   April   May     June    July   August   Sept
High Order Flowchart

    Presentation to Emergency
           Department

         Admission into ED


        Behaviour Escalates


     Treatment with Settling of
           Behaviour

  Discharge, Transfer or Admission
                                                      D
                                                                                                                                     SAAS can
                      D
                                                                If Not Behaviourally             Patient’s Behaviour                  Request
                                             Clerk             Disturbed – Possible                   Escalates                    Restraint Team
                                             for A9            Waiting Room/Cubicle                                                 Standby on
  Entering ED                 Triaged       and Old                                                                                    Arrival
                                                                                            D
                                              Files
                                                                 If Behaviourally                     Nursing/Medical Staff
                          D
                                                                 Disturbed – Safe                        Arrive/Present
If Affected by Drug
 Alcohol – Longer                                                  Room/Resus                                                                 D
  Waiting Time to
                                  Intervention
       Detox                     Minimal Effect,
                                                                                                                         Security Called
                                   Behaviour                           Guard
                                                      D
                                   Escalates
Monitoring Process –
  Observations for                                                                        Assessment                    If Restraint – 33#
 Restrained Patient
                                                              If De-escalation is         Process To                           Call
                               Medication Given                  Not Effective           Determine Best
                               And/or Seclusion                                            Treatment
     Behaviour                                                                                                           Security Arrives
                                Room And/or
    De-escalates
                                  Shackles
                                                              If De-escalation is
                                                                   Effective
                                                                                                                      Attempted
    D                                                                                                             De-escalation Can
                                                                                                                  Occur at Any Point
  Medical Assessment                                                            D
     Completed if
      Necessary                           Decision to                   Discharge from
                                            Admit,                           ED
                                         Discharge etc
                                                                                                Destination Can
                                                                                                Delay discharge
        More Formal                                                                                From ED
                                                          Med & Psych May
         Psychiatric
                                                          Disagree Who is
        Assessment                                         Responsible for     D
                                  D                           Patient
           Cause and Effect Diagram
Patient Factors            Perceived Neglect

          Drugs                          Communication

             Anxiety                        Nicotine

                  Psych illness               Thirst


                                                                      Escalation
                       Medical illness            Hunger


                                                                      Requiring
                                                    Medication
                                                                      Restraint
                   Seclusion room                 Psych assessment
                   location
                                                 Medical assessment
          High stimulus                   Pre contact wait

 Environmental
                        Interventional Delays
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

                                                           Intervention 1             Intervention 2
 4
3.5                                   3.44
 3
                 2.89                                              2.9                    2.77
2.5
                               2.66                        2.64
 2      %1.98                                1.94 2.03
                        1.87
1.5                                                                         1.63
 1                                                                                 1.03          1.12
0.5
 0
                                                                                                        0.18
      Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Interv Interv Interv Interv Interv Interv Interv
                                                         A      A      A      B      B      B      B
        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.
Mission Statement


At Level 11 of Tan Tock Seng
Hospital,   the   peripheral   iv
cannula phlebitis rate will be
reduced by 50% in 3 months
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
90%

80%

70%

60%

50%

40%

30%

20%

10%

0%
        Speed of        Flushing not done    IV bolus against       Not diluted      Interm ittent   Restless Patient
      adm inistration                       recom m endation       according to     disconnection
                                                                recom m endations



                                                      Patient
                                                      Health Care Worker
           Intervention(s) - plan,
           protocol etc
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
Point Prevalence Phlebitis Rate

                             Phlebitis Rate

30.00%
          26.30%       25%
25.00%

20.00%
                                       14.60%
15.00%

10.00%

5.00%

0.00%                                                 0
         31-May-02   28-Nov-02     22-Jan-03    20-Jan-04
Strategies for Sustaining
(holding the gains)


 Involve all grades of HCWs within
  the department

 Ownership of the problem/issue

 Random point prevalence audit
  for comparison
    Strategies for Spreading


   Repeat hospital wide point
    prevalence study (20 Jan 04)

   Target at the next area with
    problems in peripheral phlebitis
Thank You

				
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