Reducing In-hospital Harm: Focus on prevention of sepsis and hospital acquired thrombosis Chris Hancock

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1 Join the conversation on Twitter n Tuesday 11 June 2013 Reducing In-hospital Harm: Focus on prevention of sepsis and hospital acquired thrombosis Chris Hancock Insert name of presentation on Master Slide

2 Insert name of presentation on Master Slide Wales Online

3 It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm (Florence Nightingale: Notes on Hospitals,1859)

4 Hospital Mortality and Harm There is a one in 300 chance of accidental death through errors in care. (Institute of Medicine, 2000) More than one in ten people admitted to hospital are harmed unintentionally by its care. (Vincent et al. 2001)

5 11859 adult preventable deaths in hospitals in England Horgan et al 2012

6 Despite over a decade of effort, there is little evidence that patient outcomes (broadly measured) have significantly improved, yet there has been some success (generally in efforts to reduce one type of harm, usually using one method of improvement). For example, efforts have focused on reducing blood stream infections, improving teamwork, or enhancing patient engagement Insert name of presentation on Master Slide

7 In the UK sepsis is estimated to be responsible for the deaths of 37,000 people every year and to cost the NHS 2.5 billion Daniels R. The incidence, mortality and economic burden of sepsis. (2009) In: NHS Evidence emergency and urgent care.

8 Hospital Acquired Thrombosis 25,000 to 32,000 deaths/yr from PE in the UK Immediate cause of death in 10 per cent of all patients who die in hospital Exceeded the combined total death from breast cancer, AIDS and traffic accidents Over 25 times greater than the annual deaths from MRSA More than 5 times the total of all hospital acquired infections Report by the House of Commons Health Committee, 2005 Insert name of presentation on Master Slide

9 Wales 2010 Approximately 900 deaths either due to or associated with HAT 47 deaths involving MRSA 614 from breast cancer 9 from AIDS 70% could be avoided if appropriate preventative measures are put in place Insert name of presentation on Master Slide

10 Acute Kidney Injury In Wales, approximately 1 in 14 patients admitted have AKI Up to 3,000 of patients dying in hospital will have AKI. (CMO Wales, 2013). In developed countries AKI is seen in 13-18% of all people admitted to hospital Costs to NHS estimated to be between 434 million million More than expenditure on breast cancer, or lung and skin cancer combined. Nice DRAFT Guidelines, 2013 Insert name of presentation on Master Slide

11 A: Time to Intervene - Key findings Assessment on admission was considered deficient in 47% of the cases under review. 38% of in-hospital cases of cardiac arrests (and subsequent resuscitation attempt) could have been avoided if patient care had been properly managed. 75% of cases displayed clear warning signs that the patient was deteriorating. Of these patients the signs were not recognised in 35%, not acted on in 56% and not communicated to senior doctors in 55% of cases.

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13 Number of patients in Wales HAI type Number of HAI* % of HAI Prevalence (%) of HAI by type UTI SSI GI infection Pneumonia BSI Skin and soft tissue infection LRT infection Eyes and ENT infection Systemic infection CRI-CVC Reproductive tract infection <0.1 Neonatal infection <0.1 CRI-PVC <0.1 Bone and joint infection <0.1 CNS infection <0.1 CVS infection <0.1 * Counts the number of HAI (i.e. Patients may have multiple HAI). Key: UTI urinary tract infection; SSI surgical site infection; GI gastrointestinal; BSI bloodstream infection; LRT lower respiratory tract; ENT ear - nose - throat; CRI-CVC catheter related infection (central venous catheter); CRI-PVC catheter related infection (peripheral vascular cannula); CNS central nervous system; CVS cardiovascular system. Acute Sector SSI (23.7%) UTI (16.7%) Pneumonia (12.3%) Non-Acute UTI (36.1%) Eyes & ENT (14.5%) SST (12.1%) ECDC point prevalence survey WALES results 2011

14 Medical Device Utilisation Number of patients surveyed Wales 2011 Number of patients with one or more devices in situ Device Number of devices in situ* % of device utilisation UC PVC CVC Intubation

15 Top 10 bacteraemias in Wales 2011

16 WAST Study in Withybush 10% had sepsis 1% had septic shock Insert name of presentation on Master Slide

17 Falls in hospital UK - 200,000 pa (NPSA, 2010) Wales - approx. 10,000 pa Pressure Ulcers UK - 15,000 pa (NPSA, 2010) Wales - approx. 750 pa Insert name of presentation on Master Slide

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19 How should we measure? What causes the most harm Vs What is it easiest to measure Insert name of presentation on Master Slide

20 Sepsis Mortality and Harm Reviews

21 Welsh Risk Pool 2011/12 cash payments were: Claims reimbursed to members 52.6m WRP Managed Claims (former Health Authorities) 1.5m Periodical Payments 4.6m Total 58.7m 8/10 errors are down to poor systems rather than individuals Helen MacArthur, Head of Finance, Welsh Risk Pool and Legal and Risk Services

22 Number of patients 10/ 10/ 2 10/ 11/ 2 10/ 12/ 2 10/ 01/ 2 10/ 02/ 2 10/ 03/ 2 10/ 04/ 2 10/ 05/ 2 10/ 06/ 2 10/ 07/ 2 10/ 08/ 2 10/ 09/ 2 What Does Sepsis Look Like in Wales? Roughly 300/year 400 bedded DGH Measured by in hours Outreach service Number of patients with sepsis triggered from Oct 2011 to Oct All Wards Weeks

23 Percentage Percentage triggering with sepsis 70.0% UCL=67.2% 60.0% 50.0% 40.0% 30.0% _ X=35.5% 20.0% 10.0% 0.0% LCL=3.8% 01/10/ /12/ /02/ /04/ /06/ /08/ /10/ /12/ /02/2013 Month Insert name of presentation on Master Slide

24 Basic HAT rate process Obtain Radiology data Obtain PAS discharges Match Radiology to PAS to identify possible VTEs Filter for < 12 weeks post discharge to identify possible HATs Manual check of +ve VTE Divide +ves by discharges to get HAT rate

25 Number Numbers of deaths within 30 days by NEWS score at presentation Variable No DNAR DNAR Above 9 Insert name of presentation on Master Slide

26 Sepsis is a Tier 1 (development) Priority for Wales Proposed Measures (there is room for development) %DVT/PE occurring following admission or within 12 weeks of discharge Critical Care Severe Sepsis Mortality ICNARC Sepsis six compliance Nursing Dashboard Care Metrics Module/RRAILS Outcomes Database A new way of working Support for internal collaboratives 3 National Events in next year Monthly webexes We have insisted that there are no targets attached to this measure and so it should be able to be used as a measure for improvement rather than judgement especially as it is classified as a measure under development.

27 Cannot Improve Outcomes Without Reliable Processes Insert name of presentation on Master Slide

28 Sepsis is a Medical Emergency - in a similar way to Stroke and MI.

29 Reliably Doing the Right Thing Saves Lives Let s make it easier to do the right thing!

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32 How can we prevent overload and duplication? Beware of initiative fatigue Frontline staff should feel empowered to make changes BUT Must be supported and coordinated at more senior organisational and all Wales levels Insert name of presentation on Master Slide

33 All Wales Maternity DVT Assessment Insert name of presentation on Master Slide

34 National Early Warning Score (NEWS)

35 DRAFT Standardised Escalation and Response Bundles NEWS 3-5 Low Risk Inform Nurse in Charge Repeat Observations in 1 Hour Consider sepsis Consider removing catheter and PVCs Commence fluid balance chart Reagent strip urinalysis Blood glucose NEWS 6-8 Medium Risk NEWS >= 9 High Risk All of the actions above PLUS Assess, Intervene and Monitor (AIM) using the ABCDE approach Document in real time Use SBAR tool to inform appropriate team members Increase frequency of observations Additional monitoring if appropriate Use sepsis screening tool and start Sepsis Six bundle if appropriate AKI risk assessment U&E blood test All of the actions above PLUS Immediate call for Rapid Response

36 Define the escalation process who, when and how do we tell? Make highly visible posters, intranet etc. Standardise for all disciplines Integrate into training Replace not add to existing documentation

37 Define the response make expectations explicit? Does the response bundle = was this done yes/no? Are all response actions captured upon one document? When is time zero?

38 Establish standardised communication tools (eg. PSAG board, SBAR, safety briefing etc)

39 Apply human factors techniques to counteract the effect of human error Percentage of sepsis patients that receive sepsis six within one hour via bag Cwm Taf LHB. Sepsis Bag Database. from May 2012 to Sep May 2012 Jun 2012 Jul 2012 Aug 2012 Sep 2012 Months

40 Rehearse, train and prepare for worst case scenarios (eg. Simulation) All Wales ILS course Train as teams Train as close to the work place as possible

41 Insert name of presentation on Master Slide Is technology the answer?

42 Insert name of presentation on Master Slide Smartphone apps.

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45 Summary Organisations must identify the largest causes of harm and mortality. Measurement must be systematic, regular and shared widely You cannot improve outcomes unless you achieve reliable processes Use evidence to inform minimum standard Use human factors to develop reliable processes and efficient measurement Technology must be an aid and not dictate the agenda. Insert name of presentation on Master Slide

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