Safer Patients Storyboard Template Kick off LS

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Critical Care Workstream L Langan, K Rooney
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Workstream Specific Breakout Sessions

• Content Area (morning session)
• Introduction to paediatric change package
• Share good examples from SPSP

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Organisational Transformation Requires.

• a vision and bold aims!
• Coupled with
• relentless execution of
• small, repeated tests of new ideas.

And why do we care about this?
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Why?
Because we are dealing with REAL PEOPLE! Not
just a bunch of facts and figures written in a
chart or logged into a database. It is not the
meningococcal in bed 8. Or, the child by the
window. But Real People with real concerns and
real issues. They deserve nothing less than our
full attention and respect.
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Real Life Person

• MF, 65 year old lady
• Lived alone, volunteer
• PMHx Obese, smoker, COPD
• Admitted on 6th Jan 09
• Exac of COPD, Type II Failure, Periarrest
• Predicted hospital mortality 17.5
• Initially quite uneventful

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Real Life Person

• Failed extubation 8th Jan
• 11th Jan VAP (PN2 E Coli)
• 10 days antibiotics
• 14th Jan Tracheostomy
• 17th Jan Hypokaleamic Fast AF
• New CVC subclavian artery further CVC
• Required vasopressor support

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Real Life Person

• Ventilated 24 days
• Discharged from ICU on 31st Jan
• ICU stay 26 days
• 26 x 1600 / day 41,600
• Includes VAP cost 7 x 1600 11,200
• Plus 10 days of antibiotics

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CVC BSI per 1000 CVC days (a rate)
Which translate to a Record 379 days!Building a
Safety Culture
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223 days without a VAP
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1.6 day reduction in ALOS
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Benefit / Saving

• 1 day in ICU costs 1,600.00 per day
• 360 admissions last year
• Cost saving 379 x 1.6 x 1,600.00
• 970,240.00
• 7 ICUs 6,791,680.00
• What could that buy to improve care?

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Possible in PICU as well
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Possible in PICU as well
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Critical Care Driver Diagram
Outcomes
Primary Drivers
Secondary Drivers
Reduce ventilator complications Reduce CVC
complications Prevent Infection cross
contamination Sepsis recognition and
treatment Child / family involvement in daily
goal setting Open communication between team,
child and family Joint end of life care
planning Child / young persons physical and
environmental comfort Reliable care planning,
communication and collaboration of a MDT Optimal
flow of children and young people through
critical care wards Infrastructure leadership
to deliver consistent, reliable evidence based
care Feedback from trigger tool mortality
reviews Staff with improvement skills
Appropriate, timely reliable evidence based
critical care therapies
Child and family centred-care
Improved Paediatric Care Outcomes (Reduced
Mortality, Infections, Other Adverse Events)
Effective and collaborative MDTs
Infrastructure and culture that promotes safety
and quality
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Secondary Drivers

• Reduce complications from ventilators
• Consider Non-Invasive ventilation
• Paediatric VAP prevention bundle
• DVT prophylaxis
• Sedation protocol
• Weaning protocol
• ARDS / ALI protocol
• Oral care protocol aspiration precautions
• Mobility protocol

• Reduce complications from central venous
  catheters (CVCs)
• Use CVC insertion maintenance bundles
• Prevent Healthcare Acquired Infections cross
  contamination
• PVC insertion maintenance Bundles
• Reliable Hand Hygiene

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Secondary Drivers

• Reliable infrastructure, care planning,
  communication collaboration of a
  multidisciplinary team
• Child/ family involvement in daily goal setting
• Institute multidisciplinary rounds
• Safety briefings
• Standardised clinical communication handovers
  (SBAR)
• Joint end of life care planning

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What is a bundle?

• Systematic method of measuring and improving
  clinical care processes
• 3-5 interventions when executed together result
  in better outcomes.
• Consistent application of best evidence
• Enhances communication.
• Simplifies complex processes
• Empowers staff

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Measurement

• Each individual element must be actioned
• OR excluded
• All or fail basis
• Aim is 100 overall compliance

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Adult Preventing VAP Care Bundle

• Sedation to be reviewed and , if appropriate,
  stopped each day
• All patients will be assessed for weaning and
  extubation each day
• Avoid the supine position, aiming to have the
  patient at at least 30 - 45 degrees head up
  (neonates 15 30 degrees)
• Use chlorhexidine as part of daily mouth care
• Use subglottic secretion drainage in patients
  likely to be ventilated for more than 48 hours.

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Paediatric Ventilator Care Bundle

• Head of bed elevation 30-45 degrees (neonates
  15-30 degrees)
• Daily sedation vacations
• Daily assessment of weaning / readiness to
  extubate
• Peptic Ulcer Prophylaxis
• DVT prophylaxis (unless contraindicated) for age
  appropriate children
• Comprehensive mouth care

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Test of Change Form

• Use a form to organise and standardise your
  documentation and tests!

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Constructing an Aim Statement

• Boundaries the system to be improved (scope,
  patient population, processes to address,
  providers, beginning end, etc.)
• Specific numerical goals for outcomes
• Ambitious but achievable
• Includes timeframe (How good by when?)
• Provides guidance on sponsor, resources,
  strategies, barriers, interim process goals

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Overall, to reduce MRSA blood stream infections
by 50 within 2 years.
Example of an Aim Statement
How good? By When?
Hope is not a plan!
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Check Points in Developing anAim Statement

• AIM Content
• Explicit over arching description
• Specific actions or focus
• Goals
• AIM Characteristics
• Measurable (How good?)
• Time specific (By when?)
• Define participants and customers

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Aim Provide appropriate, reliable and timely
care to critically ill children using
evidence-based therapies by June 2013
Secondary Drivers Secondary Drivers Secondary Drivers Secondary Drivers Secondary Drivers
Complications from Ventilators
Complications from CVCs
Hospital Acquired Infections
Sepsis Recognition and Treatment
Change Concept 2
Change Concept 3
Change Concept 4
Change Concept 1
Change Concept 1
Change Concept 2
Change Concept 3
Change Concept 4
Change Concept 1
Change Concept 2
Change Concept 3
Change Concept 4
Change Concept 1
Change Concept 2
Change Concept 3
Change Concept 4
Source R Lloyd
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Aim Reduce Complications from CVCs by 50 by
June 2013
Central Line Insertion Bundle
CVC Maintenance Bundle
Standardise Process Line Carts and Dressing Kits
Partner with Accident and Emergency, Operating
Theatres Oncology for Standardisation

Lead 1
Lead 2
Lead 1
Lead 3
Source R Lloyd
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Aim Design a Reliable Process for CVC
Maintenance Bundle by September 2010
Daily Checking and Need for CVC
Dressing in Tact and Changed w/i 7 Days
CVC Hub Decontamination
Hand Hygiene Prior to Access
Chlorhexidine Gluconate

Lead A
Lead A
Lead B
Lead C
Lead B
Source R Lloyd
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What are your aims?
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Launch then lunch
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Critical Care Workstream L Langan, K Rooney
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Workstream Specific Breakout Sessions

• Content Area (afternoon session)
• Reaffirm methodology, conduct PDSA exercise,
  run through first tests
• Share testing experience and identify plan of
  action

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To Be Considered a Real Test

• Test was planned, including a plan for collecting
  data
• Plan was carried out and data were collected
• Time was set aside to analyse data and study the
  results
• Action was based on what was learned

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The Value of Failed Tests

• I did not fail one thousand times I found one
  thousand ways how not to make a light bulb.
• Thomas Edison

Source R Lloyd
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Keys and Barriers to Success

• Keys

• Barriers

• PDSA cycles
• Small, rapid cycle
• Seek usefulness not perfection -stickers
• Improve as fast as you test
• Multidisciplinary approach
• Early adopters
• having made a difference
• Leadership
• Evidenced based
• Measurement over time
• Outcome process measures
• Run charts - feedback
• Monthly review

• Resistance to change
• not invented here
• already doing this
• this weeks gimmick
• Culture behaviour
• Educate, educate
• Clinician engagement
• scepticism
• Resources
• Data collection
• Person dependence
• Sustainable process

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Cause Effect Diagram
Education
CVC Insertion
Surveillance
Lack of CVC RN
Insertion site
Type of CVC
Insertion Guidelines
Lack of timely lab results
Aseptic technique
Maintenance guidelines
Lack of database
Nursing Education
Skin prep
Insertion technique
Competency
CVC Infection
Nursing Assessment
Flushing
Daily need review
Hubs
Documentation
Hand Hygiene
Inappropriate access
Dressing
CVC maintenance
CVC use
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Any questions?