1. The STOP order Reducing the workload – the ‘STOP order’ Chris Hancock RRAILS Programme Manager, 1000 Lives Plus

2. The STOP order

4. Rollercoaster Mortality 1 in 1.5 billion chance of being fatally injured at an amusement park Injury rates for golf and deckchairs are higher –US Consumer Product Safety Commission (2007)

5. The STOP order Healthcare Mortality More than one in ten people admitted to hospital are harmed unintentionally by its care. There is a one in 300 chance of accidental death through errors in care.

6. The STOP order Errors of Omission/ Adverse Events The Defect Rate in technical quality of American health care is approximately: 45% McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-2645 (June 26, 2003) It’s what we don’t do that causes the harm

7. The STOP order Who Comes to Work to Do a Bad Job?

8. The STOP order The Gap Between Perception and Practice What We Think We Do Vs. What We Actually Do Mitchell Levy, Director, Surviving Sepsis Campaign

9. The STOP order The First Law of Healthcare Improvement “ Every system is perfectly designed to achieve exactly the results it gets.” Source: Don Berwick, IHI (Boston) The 1000 Lives method achieves better outcomes by improving the reliability of systems and processes that we use everyday.

10. The STOP order Care Bundles As it represents a reduction in errors of omission, compliance with the care bundle is a good proxy for reliability of that process.

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13. We already do that!

14. The STOP order HCAI mandatory surveillance programme Wales as run by WHAIP team

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16. NHS Wales Annual Quality Framework 2011/2012 Reduce harm and variation: It is unacceptable that the health care system should cause harm to patients, and as such, some basic quality deliverables have been set for delivery in 2011 /12, namely: eliminate pressure sores; adopt an explicit policy of zero tolerance for healthcare associated infections;

17. The STOP order 17 Why is the rate of CAUTI so low in Pakistan? Can’t afford many catheters Dr Nizam Damani Clinical Director: Infection Prevention and Control Craigavon Area Hospital, N.Ireland, UK

18. The STOP order Bangor reduction in use

19. The STOP order

20. Systematic Review and Meta-analysis Prolonged catheterization is the primary risk factor for catheter-associated urinary tract infection (CAUTI). Only interventional studies that used reminders to physicians or nurses that a urinary catheter was in use or stop orders to prompt catheter removal in hospitalized adults were included. A total of 6679 citations were identified; 118 articles were reviewed, and 14 articles met the selection criteria. The rate of CAUTI (episodes per 1000 catheter-days) was reduced by 52% (P !.001) with use of a reminder or stop order. The mean duration of catheterization decreased by 37%, resulting in 2.61 fewer days of catheterization per patient in the intervention versus control groups. Recatheterization rates were similar in control and intervention groups. –Meddings et al. 2010. Systematic Review and Meta-Analysis:Reminder Systems to Reduce Catheter-Associated Urinary Tract Infections and Urinary Catheter Use in Hospitalized Patients CID 2010:51 (1 September)

21. The STOP order Poor Communications is Killing our Patients More than half of the Root Cause Analysis Reports described erroneous verbal communication between staff members as root causes of or contributing factors of severe patient safety incidents. –Rabøl et al. (2011) Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals. BMJ Quality & Safety Online First, published on 5 January 2011 as 10.1136/bmjqs.2010.040238

22. The STOP order Visible Ward Management

23. The STOP order Measuring Care Bundle Compliance Audit Case Notes Obs Charts Nursing Notes Fluid charts Safety Briefing

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25. The Stop Order

26. The STOP order Data Collection Spreadsheet Number of catheter days – outcome measure Stop order compliance Denominators for care bundle compliance

27. The STOP order Putting it Into Practice Multidisciplinary Meeting to Agree- –Symbol for catheter on board –Criteria for inserting catheters –Criteria for keeping catheters in situ –Make visible – preferably next to PSAG board

28. The STOP order Summary High care bundle compliance is linked to improved outcomes Most important element is removal or non insertion This is about ward based systems Use high visibility ward management Make data collection as easy as possible

29. The STOP order Questions?

30. The STOP order Real-Time data Collection

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32. Standard Operating Procedures

33. The STOP order Auditable Guidelines

34. The STOP order Total Admissions Bundle 1. How many admissions have you had in this shift? 2. On the white board, how many admissions have recorded both:  MEWS Score AND  Frequency of observations? Recognition Bundle 3. How many patients are on the unit now? 4. During this shift how many of these patients have recorded on the white board both:  MEWS Score AND  Frequency of observations? Response Bundle 5. How many patients are ‘at risk’ (MEWS score higher than 3)? 6. How many ‘at risk’ patients have had an appropriate first response (start SBAR form)? Could they have sepsis? If yes please use the sepsis pathway tool. Sepsis Six Bundle 7. How many patients have been diagnosed as having sepsis? 8. How many of these have received the ‘sepsis six’ within 1 hour of diagnosis? Catheter Stop Order 9. How many patients have a catheter in situ? 10. How many catheters can be removed? 11. How many catheters need to be inserted? Have you considered all the alternatives?

35. The STOP order Society of Actuaries Report (2010) Seven percent of inpatient admissions resulted in some type of medical injury in 2008, and the average cost per error was about $13,000. 6.3 million medical injuries including 1.5 million injuries resulting from medical error in 2008. The errors collectively cost the U.S. health care system roughly $19.5 billion, resulted in more than 2,500 excess fatalities and 10 million excess days of work missed. The five most expensive errors accounted for about 55% of total error costs and were: –Pressure ulcers ($3.9 billion); –Postoperative infections ($3.7 billion); –Mechanical complications of devices, implants or grafts ($1.1 billion); –Postlaminectomy syndrome ($1.1 billion); and –Hemorrhage complications ($960 million). The three most expensive errors on a per-error basis were: postoperative shock ($93,682 per case); infection due to central venous catheter ($83,365); and infection following infusion, injection, transfusion or vaccination ($78,083).

36. The STOP order Cost of Avoidable Infections In cases associated with invasive surgery, attributable mean length of stay was 10.9 days, costs were $32 900, and mortality was 19.5% for sepsis; corresponding values for pneumonia were 14.0 days, $46 400, and 11.4%, respectively (P <.001). In cases not associated with invasive surgery, attributable mean length of stay, costs, and mortality were estimated to be 1.9 to 6.0 days, $5800 to $12 700, and 11.7% to 16.0% for sepsis and 3.7 to 9.7 days, $11 100 to $22 300, and 4.6% to 10.3% for pneumonia (P <.001). –Michael R. Eber, BSE; Ramanan Laxminarayan, PhD, MPH; Eli N. Perencevich, MD, MS; Anup Malani, PhD, JD (2010). Clinical and Economic Outcomes Attributable to Health Care–Associated Sepsis and Pneumonia. Arch Intern Med. 2010;170(4):347-353.

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