1. IMPROVING PRODUCTIVITY BY FOCUSSING ON QUALITY OF CARE - A PROGRAMME OF RESEARCH AT THE HOSPITAL Dr Gill Clements Roger Killen March 2006

2. “Patients do not die of their disease, they die of the physiologic abnormalities of their disease” Sir William Osler

3. PATIENT ASSESSMENT Blood pressure Heart rate Respiratory rate (oxygen levels) Urinary output Temperature Conscious level

4. EARLY WARNING SCORES Measure of physiological illness Marker of increased mortality risk Linked to action

5. SPECIALIST CRITICAL OUTREACH TEAMS Hospital wide Multidisciplinary Ensure appropriate intensive care unit (ICU) admissions Provide training and education

6. 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

7. 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

8. 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

10. Desire to improve quality of care and productivity Enthusiastic team Research opportunity Hospital research money

11. RESEARCH PROGRAMME Two projects: implementing electronic decision support tools development of a more sophisticated patient risk assessment tool In partnership: - Portsmouth and Birmingham Universities - Portsmouth Hospital - private limited company - The Learning Clinic

12. 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)

13. Wireless handheld computers Touch screen guides nurse through data input Calculates EWS Protocols embedded Personalised reminders and order of observations On line nurse training

16. PROGRESS SO FAR In use on 2 surgical assessment units Evaluation of improvement in quality and productivity

17. RESULTS Accuracy of scores improved from 63% to 90% Time to produce a score reduced from 37 seconds to 24 seconds Popular with staff

18. NEXT STEPS Remove paper Add in access to blood results Remote access for critical outreach teams Role out to medical assessment units

19. 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)

20. CategoryMortality 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

21. 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

22. Percentage of low risk and high risk patients at SATH over 5 years Risk category 1 Risk category 8, 9 and 10 2000498 2001458 2002408 20034210 2004448

23. SO WHAT? Improvement in the quality of care Improvement in productivity

24. 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

25. PRODUCTIVITY IMPROVEMENT Stream emergency patients Identify “appropriate” admissions – emergency triage Appropriate level of resources to patients Predict LOS Predict risk of readmission

26. Any questions?