Working for healthier lungs The Whys and Whats of Care Bundles 23 November 2012

Working for healthier lungs NHS Service Improvement

Working for healthier lungs Quality Improvement Development of better care pathways is insufficient to improve quality of care. Pathways must be implemented effectively and be sustainable. Education on management and quality improvement methodology is not part of medical education

Working for healthier lungs Care Bundles Care bundles – Developed in USA – Not a checklist 3-5 items Evidence based Simple Necessary & sufficient Permits variance monitoring

Working for healthier lungs

Working for healthier lungs Analysed 30 day mortality amongst 134,000 patients admitted to 24 hospitals in the N.E. Pneumonia, heart failure, acute myocardial infarction Risk-adjusted mortality decreased significantly Absolute reduction of 1.3 % (95% CI: 0.4 to 2.1; P = 0.006) Equivalent to 890 fewer deaths (95% CI, 260 to 1500) over 18 months Largest reduction was for pneumonia: 1.9% (95% CI, 0.9 to 3.0; P<0.001) Non-significant reductions for AMI & heart failure

Working for healthier lungs N=94

Working for healthier lungs Driver diagrams A simple way of focusing improvement efforts by considering which actions and factors contribute most to achievement of the aim

Working for healthier lungs What do driver diagrams do? Encourage teams to expand their thinking Keep thinking linked to the overall aim Allow participants to see the logical links and completeness at every level of the plan Act as a communication tool for explaining a change strategy Recognise cause and effect relationships Support the development of measures

Working for healthier lungs Project Aim - COPD Primary outcome: – To reduce in-patient mortality from COPD Secondary Outcome – Reduce length of stay – Reduce total bed days – Reduce 28 day readmission rate (ICD‐10 diagnostic code of J41‐44)

Working for healthier lungs Driver Diagram for Improving Care at Admission for AECOPD

Working for healthier lungs Improve Care of AECOPD at Admission Recognise & respond to respiratory acidosis within 1 hour of admission ABG within 1 hour for those with oxygen sats <94% on air or controlled oxygen Assess suitability for NIV according to local guidelines & implement within 1 hour of admission Driver Diagram for Improving Care at Admission for AECOPD

Working for healthier lungs Improve Care of AECOPD at Admission Review by respiratory team within 24 hours Review may be conducted by a respiratory specialist nurse, doctor or physiotherapist Driver Diagram for Improving Care at Admission for AECOPD

Working for healthier lungs Improve Care of AECOPD at Discharge All patients should have respiratory medication and inhaler technique assessed prior to discharge All patients should receive a written plan for how to manage an AECOPD and a discharge “emergency” drugs pack All patients should be assessed for smoking status & willingness to quit (with referral discussed with all current smokers) All patients should be assessed for suitability for pulmonary rehabilitation & referred where appropriate Community follow up to be arranged within 2 weeks of discharge (or contact made with the patient by phone – where a local service exists) Driver Diagram for Discharge Care following AECOPD

Working for healthier lungs Project Aim - Pneumonia Primary outcome: – To reduce in-patient mortality from CAP Secondary Outcome – Reduce length of stay – Reduce total bed days – Reduce 28 day readmission rate ICD‐10 code J12‐18 (all sub‐categories excluding 18.0)

Working for healthier lungs

CAP Bundle Document

Working for healthier lungs A different approach

Working for healthier lungs Measurement Identify measures that fit each driver to show progress towards the aim Allows us to know if a change is an improvement

Working for healthier lungs CAP Bundle Document

Working for healthier lungs Change isn’t easy… For every complex human problem there is always one easy answer that is neat, plausible… …and wrong HL Mencken Find a faster way to fail, recover, and try again. If the problem you are trying to solve involves creating a magnum opus, you are solving the wrong problem Aza Raskin