Safer Patients Storyboard Template Kick off LS - Scottish Patient

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					Critical Care Workstream
L Langan, K Rooney
Workstream Specific
Breakout Sessions

Content Area (morning session):
•   Introduction to paediatric change
•   Share good examples from SPSP
         …a vision and bold aims!
                Coupled with
           relentless execution of
     small, repeated tests of new ideas.

       And why do we care
           about this?
 Because we are dealing with REAL PEOPLE!

Not just a bunch of facts and figures written in a
         chart or logged into a database.

    It is not “the meningococcal” in bed 8.
          Or, the “child” by the window.
  But Real People with real concerns and real
issues. They deserve nothing less than our full
               attention and respect.
Real Life Person

•   MF, 65 year old lady
•   Lived alone, volunteer
•   PMHx: Obese, smoker, COPD
•   Admitted on 6th Jan 09
•   Exac of COPD, Type II Failure, Periarrest
•   Predicted hospital mortality 17.5%
•   Initially quite uneventful
    Real Life Person

•   Failed extubation 8th Jan
•   11th Jan: VAP (PN2 – E Coli)
•   10 days antibiotics
•   14th Jan – Tracheostomy
•   17th Jan – Hypokaleamic – Fast AF
     – New CVC – subclavian artery – further CVC
     – Required vasopressor support
Real Life Person

 • Ventilated 24 days
 • Discharged from ICU on 31st Jan
 • ICU stay 26 days
    – 26 x £1600 / day = £41,600
    – Includes VAP cost = 7 x £1600 = £11,200
    – Plus 10 days of antibiotics
CVC BSI per 1000 CVC
days (a rate)

             Which translate to a Record
                      379 days!
              Building a Safety Culture
223 days without a VAP
1.6 day reduction in ALOS
Benefit / Saving

• 1 day in ICU costs £1,600.00 per day
• 360 admissions last year
• Cost saving    =     379 x 1.6 x £1,600.00
                 =     £970,240.00

• 7 ICU’s       =      £6,791,680.00
• What could that buy to improve care?
Possible in PICU as well
Possible in PICU as well
 Critical Care Driver Diagram
Outcomes               Primary Drivers        Secondary Drivers
                        Appropriate, timely   Reduce ventilator complications
                                              Reduce CVC complications
                        & reliable evidence
                                              Prevent Infection & cross contamination
                        based critical care   Sepsis recognition and treatment
                                              Child / family involvement in daily goal
                         Child and family
                                              Open communication between team,
Improved                  centred-care        child and family
Paediatric                                    Joint end of life care planning
                                              Child / young person’s physical and
  Care                                        environmental comfort
                        Effective and
Outcomes                collaborative
                                              Reliable care planning, communication
(Reduced Mortality,                           and collaboration of a MDT
 Infections, & Other    MDTs                  Optimal flow of children and young
  Adverse Events)                             people through critical care wards
                        Infrastructure and
                                              Infrastructure & leadership to deliver
                        culture that          consistent, reliable evidence based care
                        promotes safety       Feedback from trigger tool
                        and quality           & mortality reviews
                                              Staff with improvement skills
Secondary Drivers

• Reduce complications                • Reduce complications
  from ventilators                      from central venous
   – Consider Non-Invasive              catheters (CVCs)
     ventilation                         – Use CVC insertion &
   – Paediatric VAP prevention             maintenance bundles
     bundle                           • Prevent Healthcare
   – DVT prophylaxis                    Acquired Infections &
   – Sedation protocol                  cross contamination
   – Weaning protocol                    – PVC insertion &
   – ARDS / ALI protocol                   maintenance Bundles
   – Oral care protocol &                – Reliable Hand Hygiene
     aspiration precautions
   – Mobility protocol

Secondary Drivers

• Reliable infrastructure, care planning,
  communication & collaboration of a
  multidisciplinary team
   – Child/ family involvement in daily goal setting
   – Institute multidisciplinary rounds
   – Safety briefings
   – Standardised clinical communication &
     handovers (SBAR)
   – Joint end of life care planning

What is a bundle?

• Systematic method of measuring and
  improving clinical care processes
• 3-5 interventions when executed together
  result in better outcomes.
• Consistent application of best evidence
• Enhances communication.
• Simplifies complex processes
• Empowers staff

• Each individual element must be
• OR excluded
• All or fail basis
• Aim is 100% overall compliance
Adult Preventing VAP Care
• Sedation to be reviewed and , if appropriate,
  stopped each day
• All patients will be assessed for weaning and
  extubation each day
• Avoid the supine position, aiming to have the patient
  at at least 30 - 45 degrees head up (neonates 15 –
  30 degrees)
• Use chlorhexidine as part of daily mouth care
• Use subglottic secretion drainage in patients likely to
  be ventilated for more than 48 hours.
Paediatric Ventilator Care

• Head of bed elevation 30-45 degrees; (neonates
  15-30 degrees)
• Daily sedation vacations
• Daily assessment of weaning / readiness to
• Peptic Ulcer Prophylaxis
• DVT prophylaxis (unless contraindicated) for age
  appropriate children
• Comprehensive mouth care
Test of Change Form

  Use a form to
   organise and
     and tests!
Constructing an Aim
• Boundaries: the system to be improved (scope,
  patient population, processes to address,
  providers, beginning & end, etc.)
• Specific numerical goals for outcomes
   – Ambitious but achievable
• Includes timeframe (How good by when?)
• Provides guidance on sponsor, resources,
  strategies, barriers, interim & process goals

Example of an Aim
Overall, to reduce MRSA blood
stream infections
by 50% within 2 years.

     How good? By When?
       Hope is not a plan!
Check Points in Developing an
Aim Statement
      AIM Content
        • Explicit over arching
        • Specific actions or focus
        • Goals

      AIM Characteristics
        • Measurable (How good?)
        • Time specific (By when?)
        • Define participants and
Aim: Provide appropriate, reliable and timely care to
critically ill children using evidence-based therapies by
June 2013

                             Secondary Drivers
Complications                       Change       Change    Change
from Ventilators   Concept          Concept      Concept   Concept
                      1                2            3         4

Complications      Change
from CVCs             1                2            3         4

Hospital           Change           Change       Change    Change
Acquired           Concept          Concept      Concept   Concept
                      1                2            3         4

Sepsis             Change           Change       Change    Change
Recognition and    Concept          Concept      Concept   Concept
                      1                2            3         4

                             Source: R Lloyd
     Aim: Reduce Complications from CVCs
     by 50% by June 2013

                        A P                 A P                    A P                 A P
                         S D                 S D                    S D                 S D

                D S                  D S                   D S                D S
                P A                  P A                   P A                P A

         A                    A                     A                  A
            P                    P                     P                  P
        S                    S                     S                  S
           D                    D                     D                  D

 A P                  A P                  A P                 A P
  S D                  S D                  S D                 S D

Central Line      Standardise           CVC                Partner with Accident and
Insertion         Process:              Maintenance        Emergency, Operating
Bundle            Line Carts and        Bundle             Theatres & Oncology for
                  Dressing Kits                            Standardisation
Lead 1            Lead 1                   Lead 2          Lead 3
                                     Source: R Lloyd
   Aim: Design a Reliable Process for
   CVC Maintenance Bundle by
   September 2010
                        A P            A P            A P            A P           A P
                         S D            S D            S D            S D           S D

                D S             D S            D S            D S            D S
                P A             P A            P A            P A            P A

         A               A              A              A              A
            P               P              P              P              P
        S               S              S              S              S
           D               D              D              D              D

 A P             A P            A P            A P            A P
  S D             S D            S D            S D            S D

Daily           Dressing in     CVC Hub         Chlorhexidine Hand Hygiene
Checking and    Tact and        Decontamination Gluconate     Prior to
Need for CVC    Changed w/i 7                                 Access
Lead A          Lead A           Lead B        Lead B         Lead C

                                Source: R Lloyd
What are your aims?

Launch then lunch

Critical Care Workstream
L Langan, K Rooney
Workstream Specific
Breakout Sessions

Content Area (afternoon session):
•   Reaffirm methodology, conduct
    PDSA exercise, run through first
•   Share testing experience and
    identify plan of action
To Be Considered a
Real Test

• Test was planned, including a plan for
  collecting data
• Plan was carried out and data were collected
• Time was set aside to analyse data and study
  the results
• Action was based on what was learned
The Value of “Failed”

“I did not fail one thousand
times; I found one
thousand ways how not to
make a light bulb.”
              Thomas Edison

Source: R Lloyd

Keys and Barriers
to Success
             Keys                               Barriers
•   PDSA cycles                      •   Resistance to change
     • Small, rapid cycle                 • ‘ not invented here’
     • Seek usefulness not                • ‘already doing this’
        perfection -stickers
     • Improve as fast as you test        • ‘this week’s gimmick’
•   Multidisciplinary approach       •   Culture & behaviour
     • Early adopters                     • Educate, educate
     • ‘having made a difference’    •   Clinician engagement
•   Leadership                            • scepticism
•   Evidenced based                  •   Resources
•   Measurement over time                 • Data collection
     • Outcome & process measures    •   Person dependence
     • Run charts - feedback              • Sustainable process
     • Monthly review
   Cause & Effect Diagram
Education            CVC Insertion               Surveillance
                                                                 Lack of CVC RN
Insertion       Type of CVC           Insertion site
Guidelines                                                        Lack of timely lab results
                 Maintenance           Aseptic technique
Nursing          guidelines                                             Lack of database
                                            Skin prep
Education       Insertion technique
                           Daily need
                           review                                Hubs

Documentation                     Hand
                                  Hygiene              Inappropriate
                       Dressing                        access
       CVC                        CVC use
Any questions?


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