Presentation on theme: "Local Improvement Clinic"— Presentation transcript:
1 Local Improvement Clinic Dr Don BerwickPresident & CEO, IHIProf Bernard CrumpNHS Institute for Innovation & ImprovementDr Ross WilsonChair, Strategic Advisory Board International Forum
2 Kate Cotter, Jennifer Dempsey, Cheryl Baldwin Central Coast Health To Improve the Prescription of Osteoporosis Treatment in Post-Menopausal with a Hip or Vertebral FractureKate Cotter, Jennifer Dempsey, Cheryl BaldwinCentral Coast Health
3 Mission StatementTo Improve the prescription of osteoporosis treatment in post-menopausal with a hip or vertebral fractureTriple therapy osteoporosis treatmentincludes Calcium, Vitamin D and a Bisphosphonate.Improve prescription from 25% to 100% for all appropriate women in 3 monthsLonger term goal to reduce further osteoporotic fractures
4 Team members & roleProject team members with fundamental knowledge and who worked on the project:Kate Cotter: Ortho-geriatric registrarJennifer Dempsey: CNC MedicineCheryl Baldwin: CNC Ortho-geriatricConsultation with pharmacy department, orthopaedic clinical teams
5 Evidence for there being a problem worth solving Post-Menopausal Osteoporotic Fractures Are:CommonProven therapies to reduce further fracturesBUTEvidence-based guidelines are poorly implemented
6 A Common Problem - Australia IN AUSTRALIAIn 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.
7 Evidence for there being a problem worth solving Proven therapies to reduce further fracturesSupplementation 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
12 In Emergency Department Routine serum calcium measurement in all patients presenting to Emergency Department with a low impact fracture
13 Orthopaedic WardOrthogeriatric orientation provided to all RMO’s at start of new termEvery patient with a low impact fracture has osteoporosisEncourage charting of “Triple Therapy”Caltrate 1200mg dailyErgocalciferol 1,000 units dailyAlendronate 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)
14 Orthopaedic Ward Increase awareness at staffing level Participation in osteoporosis weekPoster in orthopaedic ward, orthopaedic outpatient clinic and emergency departmentIncorporating osteoporosis treatment into existing nursing pathway for fractured NOF
15 Orthopaedic Ward Increasing awareness at patient level Orthogeriatric team providing verbal and written information to patient about osteoporosis and its treatment
16 At DischargeCopy of dictated letter from Orthogeriatric Registrar listing diagnosis of osteoporosis and recommended treatment sent electronically to GP
17 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.
19 Run-chartPercentage of those NOT on treatment, who had treatment commenced
20 Central Northern Adelaide Health Service SHOWING RESTRAINTNigel DountonDoris KinnairdSam AlfredAdrian JacksonCentral Northern Adelaide Health Service
21 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.
22 Team MembersNigel Dounton – Mental Health Nurse ED Queen Elizabeth HospitalDoris Kinnaird - Mental Health Nurse ED Lyell McEwin HospitalSam Alfred – Consultant ED Royal Adelaide HospitalAdrian Jackson - Mental Health Nurse ED Royal Adelaide HospitalCentral Northern Adelaide Health Service
23 Guiding CommitteeDr Darryl Watson - General Manager Early Intervention and Acute Services Mental HealthDr James Hundertmark - Director Acute Service Mental Health QEH (CHAIR)Dr Geoff Hughes - Director Emergency Department Royal Adelaide HospitalNeville Phillips - Nursing Director Early Intervention and Acute Services Mental HealthSuzanne Heath - Manager Service Development Mental Health DirectorateAdrian Jackson - Project Officer, Early Intervention and Acute Services Mental HealthLynne James - Senior Program Planning Officer Acute Services Mental Health Directorate
24 Support Group Phil Coward –CNC ED Royal Adelaide Hospital Cynthia Papendick –ED Registrar Royal Adelaide HospitalMarcelle Thompson - Mental Health Educator Royal Adelaide HospitalLeigh White – Manager Security Royal Adelaide Hospital
25 Restraint as Overall % of Patient Numbers 2005 to 2006
26 High Order Flowchart Presentation to Emergency Department Admission into EDBehaviour EscalatesTreatment with Settling of BehaviourDischarge, Transfer or Admission
27 If Not Behaviourally Disturbed – Possible Waiting Room/Cubicle SAAS can Request Restraint Team Standby on ArrivalIf Not Behaviourally Disturbed – Possible Waiting Room/CubiclePatient’s Behaviour EscalatesDClerk for A9 and Old FilesEntering EDTriagedDIf Behaviourally Disturbed – Safe Room/ResusNursing/Medical Staff Arrive/PresentDIf Affected by Drug Alcohol – Longer Waiting Time to DetoxDIntervention Minimal Effect, Behaviour EscalatesSecurity CalledGuardDMonitoring Process – Observations for Restrained PatientAssessment Process To Determine Best TreatmentIf Restraint – 33# CallIf De-escalation is Not EffectiveMedication GivenAnd/or Seclusion Room And/or ShacklesBehaviour De-escalatesSecurity ArrivesIf De-escalation is EffectiveAttemptedDe-escalation Can Occur at Any PointDMedical Assessment Completed if NecessaryDDecision to Admit, Discharge etcDischarge from EDDestination Can Delay discharge From EDMore Formal Psychiatric AssessmentMed & Psych May Disagree Who is Responsible for PatientDD
28 Cause and Effect Diagram Patient FactorsPerceived NeglectCommunicationDrugsNicotineAnxietyPsych illnessThirstMedical illnessHungerEscalation Requiring RestraintMedicationSeclusion room locationPsych assessmentMedical assessmentHigh stimulusPre contact waitEnvironmentalInterventional Delays
30 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 patientPlace 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.
31 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
32 Restraint as Overall % of Patient Numbers Before & During Study Period Intervention 1Intervention 2%
33 Strategies for Sustaining Improvement Formalise the ED/Mental Health protocol for the assessment of the agitated patient to include both of the study interventionsRegular staff feedback on the process has already been instituted on a weekly basis and will continue until entrenchedThe RAH drug committee has been approached to ratify nurse initiation of the Lorazepam protocolAn ongoing review process screening for complications has been put in place
34 Strategies for Spreading Support has been secured from Mental Health and Emergency Medicine hierarchies to adopt the same approach on an area wide basisTeam members from various institutions will be instrumental in implementing the process within their own institutionsThe next meeting of the steering committee is scheduled for November.
35 Mission StatementAt Level 11 of Tan Tock Seng Hospital, the peripheral iv cannula phlebitis rate will be reduced by 50% in 3 months
36 Team Members & Roles 1. SNC Margaret Soon 2. NO Wong Siao Pin 3. SN Goh Mei Chern Staff from unit4. AN Widarni5. NE Prema Balan Teaching of staff6. NE Pua Lay Hoon7. Dr Benjamin Tan Dr covering L11
37 being a problem worth solving Evidence for therebeing a problem worth solvingPoint Prevalence Phlebitis rate done on May 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%
39 Intervention(s) - plan, protocol etc Compile, communicate & educatea. antibiotics information chart Speed of administration & proper dilutionb. Drugs not for IV administrationc. Flushing of line according to recommendationsd. Proper restraint of restless patients2. Audit compliance to recommendations & phlebitis rate