Linking Research, Audit, Quality Improvement and Evidence- Based Medicine Dr Chris Cairns 2010

Overview Definitions Example Questions / debate…….

Research is….. Clinical research determines the safety and effectiveness of…. –Medications –Devices –Diagnostic products –Treatment regimens Prevention, treatment, diagnosis, symptom relief.

EBM is…… Integration of….. –Best research evidence Bias Applicability Practicality –Clinical skills and experience –Patient values

Clinical Audit is….. “a process that seeks to improve patient care and outcomes through systemic review of care against explicit criteria” Research and EBM will give us these criteria…… Audit may tell us is research is relevant to our own practise…..

Clinical Audit……..!! “a quality improvement process that seeks to improve patient care and outcomes through systemic review of care against explicit criteria and the implementation of change”

Quality improvement is… Not quite so simple……. Improving patient care…..but how…..in what way….to what end…..??

Quality In ICU Safe: safety is a system property Efficient: avoid waste Patient Centered: care that is respectful and responsive to individual patient preferences and needs Equitable: care does not vary in quality Effective: evidence based and applied to all who could benefit Timely: reduce waits and delays for those who receive and give care IOM 6 Pillars of Quality

Quality improvement is……..!! “a quality improvement process that seeks to improve patient care and outcomes through systemic review of care against explicit criteria and the implementation of change” Audit for quality improvement with implementation of change Quality improvement using audit and implementation of change

Implementing Change Writing the EBM based protocol is easy… Converting this to a change in clinical practise which results in better patient outcomes is more difficult………..

Example VAP reduction: The Stirling Royal Infirmary Experience

VAP SHO project – high VAP rate “We need Surveillance / protocol / pathway / guide / bundle” Chris……..what’s the evidence for stuff?

Evidence “Lots” of evidence for individual components Little evidence for “bundle” impact but evolving

Evidence - SICSEBM Elevation of bed Daily sedation break Sub-glottic ETT Chlorhexidine oral care Weaning trial

Evidence Elevation of bed EBM site: One study (1+), 90 pts, NNT of 4-5 to prevent one VAP. Daily sedation break EBM site: One study (1+), 150 pts, vent days, 3.5 ICU days saved More recently – sedation break + weaning assessment.

Evidence - SICS Sub-glottic ETT: EBM site: one review, 4 studies, Grade A recommendation, NNT 12 to prevent one VAP. Chlorhexidine oral care: EBM site: one meta- analysis. NNT 14 to prevent one VAP.

Evidence - SICS Weaning trial: –In combination with sedation holiday (EBM site / JICS) One study (1+) 336 patients. Daily sedation holiday and weaning trial. NNT Death (1 yr) 7 Reduced ICU & hospital stay

Others – not in bundle NIV – avoiding intubation Kinetic beds – no evidence HME vs Heated Water Humidification – equally effective SDD????

Evidence for “Bundle” Sepsis experience VAP –? Evolving –SRI experience

SRI Experience – Nov 2005 VAP Prevention Bundle o positioning daily sedation holiday daily weaning assessment chlorhexidine mouthwash subglottic aspiration tube tubing management –appropriate humidification –avoidance of contamination

Additionally S/C enoxaparin pre-printed Ranitidine pre-printed Enteral feeding encouraged – if tolerated ranitidine cessation considered.

SRI experience At launch –Consultant buy in –Laminated charts by every bed space –Unit posters –Surveillance programme (Helix) –Ahead of the game nationally

Job done? What is the VAP rate? What is the bundle compliance? Hawe, Ellis, Cairns, Longmate ICM, 2009

Job done? What is the VAP rate? What is the bundle compliance? Hawe, Ellis, Cairns, Longmate ICM, 2009

g chart: statistical parameter is a geometric random variable denominator: number of ventilator days between episodes of VAP advantage of over more traditional methods is that it takes advantage of each observed infection yielding more plotted points at a faster rate, rather than waiting until the end of a specific time period and aggregating measurements. Upper control limit (3SDs) Upper warning line Centreline (mean)

FV VAP Bundle (* SICS Bundle) Postinterventions Chi-squared p value (Nov 2006 vs Oct 2007) Nov 2006May 2007Oct 2007 * Patient at 30 o -45 o 54%80%94% <0.001 Subglottic ETDT 72%92% <0.001 * Oral chlorhex 8%94%100% <0.001 Tubing/HMEF 98% 100% 0.31 * Daily weaning plan 52%72% * Sedation stop 72%86%82% 0.23 All elements 0%48%54% < Process

Problem? – Solution? Passive interventions don’t work Educational interventions to reduce VAP Structure, Process, Outcome

Active Implementation Education: workshops: definition, epidemiology, pathogenesis, risk factors, consequences of VAP, evidence-base for the bundle. Written material distributed. Over 90% of the unit’s medical and nursing staff had completed by April Repeat cycles of process and outcome measurement and feedback.

FV VAP Bundle (* SICS Bundle) BaselinePostinterventions Chi-squared p value (Nov 2006 vs Oct 2007) Nov 2006May 2007Oct 2007 * Patient at 30 o -45 o 54%80%94% <0.001 Subglottic ETDT 72%92% <0.001 * Oral chlorhex 8%94%100% <0.001 Tubing/HMEF 98% 100% 0.31 * Daily weaning plan 52%72% * Sedation stop 72%86%82% 0.23 All elements 0%48%54% < Sequential Process Measurements

Study Period

Passive Sept Feb 2007 Active March – Dec 2007 patients ventilated for > 48hrs Vent days episodes of VAP 4910 VAP/1000 vent days rd= % CI rr= % CI 0.16,0.96) Median LOS Mortality(112/374) 30%(49/215) 23% p=0.06

Lessons Passive implementation of the VAP prevention bundle failed. Compliance improved during an active multimodal implementation. This was associated with a significant reduction in the occurrence of VAP.

The Scottish Patient Safety Programme Title of the session & name of faculty Since then………………..

Post spsp improvements

VAP - Key Points Surveillance / constant feedback Education Process measurement / management Resources – without the above, bundles are “futile”

CVCrBSI Same principles SPSP target Lessons learnt in VAP applied to CVCrBSI

CVC

Summary Definitions Example Questions / debate…….

Debate How do we link these all together nationally? What should we me measuring? Is quality improvement part of the remit of SICSAG or……? Is quality improvement a sub-specialty?