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?