1. Measurement and Reporting 15.10.08 Presenter: Chris Hancock

2. Measurement and Reporting

3. “The normal range for resp rate is 40-60 bpm” “This guys BP has normally been 70/40 for two days – what’s the panic?” “We can’t give him more oxygen – he’s got COPD” “There is no point phoning the Doctor – they never come” “Don’t rush when nurses phone – they get hysterical easily” “I only accept referrals from other consultants” He’s been going off for hours but no one will do anything” “We use the masks with the holes in so patients can use a straw to drink”

4. Measurement and Reporting

5. NCEPOD (2005) Case note review of 469 of 560 deaths –42% suboptimal management after hospital admission –11-16% deficiencies in resuscitation and physiological management –66% were grossly unstable for more than 12 hours before referral Improving care of the acutely ill patient requires improving process control & reliability

6. Measurement and Reporting In Wales 8000 annual level 3 admissions 40% of admissions that receive poor care show a mortality increase of about 20% Mortality is approximately 640 per year Conservative estimate and does not include those patients who deteriorate and die prior to ICU admission.

7. Measurement and Reporting “If you fly on a plane, you have a one in 10M chance of being killed. If you go into hospital, you have a one in 300 chance – and not from the illness you went in with.” Sir Richard Branson Vice President of the Patient’s association

8. Measurement and Reporting 1000 Lives Campaign The aims of the 1000 Lives Campaign are to prevent 1000 deaths and 50,000 episodes of harm in the two years to March 2010 All Trusts and LHBs ICC – spread of bundles beyond ICU RRAI – NICE CG 50 and Sepsis care bundles

9. Measurement and Reporting WCCIP Mean national aggregate compliance for the period April 2007 – March 2008 by bundle was: - –Ventilator care bundle - 97.82%. –Central Venous Catheter Maintenance (CVCM) care bundle - 97.11%. –Central Venous Catheter Insertion (CVCI) care bundle - 94.71%. Many units reported zero CRBSI for several months or are routinely reporting time between infections. Improvements in outcomes include reduction in pharmacy costs, reductions in ALVT and a reduction in mortality.

10. Measurement and Reporting Ventilator bundle – 97.82%

11. Measurement and Reporting CVC maintenance bundle (CVCM) - 97.11%

12. Measurement and Reporting The WCCIP Database Areas outside the ICU Measurement for improvement rather than judgement 1000 Lives requires only monthly prevalence Critical Care Strategic Framework Handover of database

13. Care Bundle Compliance Ventilator in other ICUs CVCM and CVCI in OT, A&E, CCU etc 2 Sepsis bundles and sepsis 6

14. Measurement and Reporting Resources Monthly conference call –ICC – 1 st Wednesday –RRAI – 2 nd Wednesday Events –Sepsis – 23 rd Oct –North Network – 4 th Dec –National - January Extranet workgroups

15. Measurement and Reporting

16. Key Contacts Gwent – Kate Hooton Cwm Taf – Robert Williams Velindre – Lisa Miller C+V – Mike Spencer

17. Measurement and Reporting

18. Lessons from WCCIP and SPI The intervention must be owned by the people who are implementing it The same people must “own” the audit process Recognise local expertise

19. Measurement and Reporting PDSA Rapid feedback Accuracy is not the most important factor Wide circulation Put in prominent place (back of toilet door) Act upon it

20. Measurement and Reporting Make it relevant and easy to do Congruent with SSC, WHAIP etc ALoS, ALVT, DToC –Already part of CCMDS –Reporting delay 1 – 3 months

21. Measurement and Reporting Severe Sepsis Bundles Mortality rates are very high – around 30 – 50%. Globally, sepsis kills about half a million people a year: as many as myocardial infarction. –Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock 2008. Crit Care Med. 2008; 36(1): 296-327 In Wales this possibly equates to the deaths of between 700-1100 people in ICU annually. But we don’t know

22. Measurement and Reporting Sepsis Bundles Management Bundle evidence weakened Most effective treatments are simple interventions such as giving oxygen, large volumes of intravenous fluids and antibiotics. –Rivers E et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345: 1368-1377 No need to do both the Resus bundle and sepsis 6

23. Measurement and Reporting

24. Severe Sepsis Outcomes? Surviving Sepsis Campaign Database Developing a Sepsis Trigger Tool

25. Measurement and Reporting Mandatory Measure Cardiac Arrest Call Rate –Universally used –Background noise constant –Rate rather than number

26. Measurement and Reporting RRAI Measures No. of calls for medium and high risk –2 hospitals measuring this as no of outreach calls –Dependant on system DNAR –Number of DNARs increases as CACR decreases –1 hospital records the number of times that outreach intervention results in DNAR –1 Trust centrally records all DNAR orders

27. Measurement and Reporting

29. Qualitative review of treatment prior to deterioration –Linked to critical incident reporting –Provides feedback to frontline staff

31. Measurement and Reporting Questions

32. Conclusion Ventilator associated pneumonia (VAP) rate Central venous catheter-related bloodstream infection (CRBSI) rate Days between a CRBSI Percentage compliance with ventilator bundle Percentage compliance with CVC insertion bundle Percentage compliance with CVC maintenance bundle Percentage compliance with sepsis management bundle Percentage compliance with sepsis resuscitation bundle Percentage compliance with ‘sepsis six’ ALOS on mechanical ventilation ICU ALOS Monthly rate of delayed transfers of care Percent compliance with hand hygiene Percentage achievement of daily goals Number of cardiac arrest calls Number of calls for rapid response to medium and high risk acute illness Qualitative review and feedback on outcomes of cardiac arrest and rapid response calls. Number of do not attempt resuscitation (DNAR) orders