Developing a care bundle for stroke Hazel Fraser Stroke Co-ordinator NHS Fife September 2011
Aim to cover Background Scottish Patient Safety Programme Care bundles PDSA Challenges faced Is it working?
Patient safety alliance (SPSA 2007) Scottish Patient safety Programme Systematically improve and reliably implement evidence based interventions 5 workstreams www.patientsafetyalliance.scot.nhs.uk Care bundles
Why use a bundle have audit?duplication data Patient specific rather then service Patient safety all or nothing Aim for process driven not person driven Nurses familiar with it.
Care Bundle Group of between 3 5 specific interventions/process of care that significantly improve patient outcome if done together rather than separately and patients would be managed consistently In need of improvement Achievable Measurable Collection of evidence based intervention Carried out within a defined time period On every occasion Completion of each element must be auditable with simple yes or no response All elements - All or nothing
Bundle elements
Where to start? Baseline data Motivate staff Change what needs to be changed Barriers/enablers Project plan Implement bundles Monitor progress and evaluate change Make change permanent - sustainability
SSCAS bundle analysis Scotland 31%, QMH 31% VHK 51%
Driver diagrams and Change packages Establish expected outcome Identify critical components Set out relevant evidence interventions Measurements using PDSA cycles learning Using the model for improvement Clarify process
Scottish patient Safety Programme Stroke care driver diagram and change package Outcomes Primary Drivers Secondary Drivers Provide appropriate access to reliable and timely care for stroke patients using evidence based therapies 1 Early response system in Emergency Care 2 Rapid recognition of signs & symptoms using recognised tool e.g. FAST in Emergency Care 3 Diagnostics confirmation using CT Scan on admission day 4 Use of prescribed conservative treatment if appropriate of Aspirin To meet all criteria as set out in SIGN 108/118/119 & NHS QIS stroke standards Create a highly effective collaborative and safety culture Ensure self management and family centred care 1 Triage into Stroke Unit on admission day 2 Emergency treatment 3 Interdisciplinary screening & assessments within 24 hours e.g. WSS,MUST,MME, SKINN,FEWS 1 Involve patient and family in care planning 2 Care conforms to care pathway 3 Reliable care delivery processes Develop an infrastructure that promotes quality care, improves service transformation and clinical delivery 1 Optimise flow and efficiency in assessment/admission/rehabilitation & discharge processes 2 Reliable MDT communication structure & goal orientated specialist care following stroke within 7 days 3 Supporting information systems 4 Balancing demand and capacity
When you combine the 3 questions with the PDSA cycle, you get the Model for Improvement The Improvement Guide, API
PLAN PLAN DO DO ACT ACT STUDY STUDY Implementing new procedures & systems - sustaining change PLAN PLAN ACT ACT DO DO STUDY STUDY Testing and refining ideas PLAN PLAN ACT ACT DO DO STUDY STUDY PLAN PLAN ACT ACT Accumulating information and knowledge DO DO STUDY STUDY PLAN PLAN ACT ACT DO DO STUDY STUDY PLAN PLAN ACT ACT DO DO STUDY STUDY Bright idea! Repeated use of the PDSA cycle
First Bundle Observation number Diagnosis of stroke on day of admission CT scan on day of admission Water swallow Screen (WSS) performed with outcome documented or contraindication to undertaking WSS documented Aspirin prescribed and administered if appropriate Patient admitted to stroke unit on day of admission SAMPLE Yes Yes Yes Yes Yes Yes No No No No No No N/A If any of the previous was not achieved, was an Incident Form raised Summary table of Stroke care Bundle findings Total Number Comments (if required) Number of patients with diagnosis of stroke on day of admission Number of patients with CT scan performed on day of admission Number of patients with documented WSS/ contraindication on admission Number of patients given aspirin appropriate to CT scan result Number of patients admitted to stroke unit on day of admission Total number of patients included in bundle
TOC Worksheet For Testing Changes (Acute Stroke: Cycle 1) Overall Aim/Goal: The plan of care follows each element on the stroke pathway at QMH and VHK (To achieve the aim/goal, a series of small tests of change is generally required.) Plan: Describe your first (or next) test of change Who? When? Where? One nurse will document that all elements were completed w/c 29 th November Ward 12 VHK Ward 9 QMH List the tasks that are needed to set up this test of change Who? When? Where? 1 decide which nurse will conduct the test 2 decide how and where to document any elements not achieved in the bundle 3 - decide how and where to communicate any elements not achieved in the bundle 4 w/c 29 th November Ward 12 VHK Ward 9 QMH Predict what will happen when the test is carried out 1 staff may not know that arrangements have been made with A&E, radiology, bed & management colleagues 2 - staff may not know how and where they have to document each element of the bundle for stroke diagnosis of CT scan, aspirin prescription &administration, and WSS. 3 - staff may not know how & who they have to communicate each element of the bundle for stroke diagnosis, CT scan, aspirin, and WSS. 4 Measures/anecdotes to determine if prediction was correct 1 nurse reports elements responses 2 nurse reports elements responses 3 nurse reports elements responses 4 - Do Describe what actually happened when you ran the test Study Describe the measured results and how they compared to the predictions Act Describe what modifications to the plan will be made for the next cycle from what you learned
TOC Worksheet for Testing Changes (Acute Stroke: Cycle 4) 16 th May 2011 Overall Aim/Goal: The plan of care follows each element on the stroke pathway at QMH and VHK (To achieve the aim/goal, a series of small tests of change is generally required.) Plan: Describe your first (or next) test of change Who? When? Where? Further amendments to v8 care bundle elements and reporting to staff of monthly monitoring data and introduce instruction guide DR/IM June 2011 VHK QMH List the tasks that are needed to set up this test of change Who? When? Where? 1 Add criteria into Admission/CT/Aspirin elements and use instruction guide 2 Inform all staff of changes in using the guide to complete the bundle 3- Data to be reported as monthly, as well as weekly to the wards 4 - Variances to be recorded as signposts 5 - DR SM, DR + teams IM May/June 2011 VHK 12 QMH 9 Predict what will happen when the test is carried out 1 Flow and efficiency will improve 2 Bundle measures and reporting will show improvement on CT/WSS/Aspirin/ASU 3 Bundle measures will show any variances in care pathway 4 - Measures/anecdotes to determine if prediction was correct 1 improved performance CT/WSS/Aspirin/ASU 2 improved patient flow M&M/bed management in access, LoS 3 care pathway compliance & variance reduction 4 - improved staff & patient experience Do Describe what actually happened when you ran the test Care bundle elements continue to show variances and lack of clarification on understanding by staff on criteria for completing Study Describe the measured results and how they compared to the predictions Result showed changes on patient flow into each area, increased & low sustainable performance in that admitted patients did meet 3/5 bundle elements CT/WSS/Aspirin/ASU, measures revealed small change because of raised awareness in telephone number and increase understanding on how to complete a bundle Act Describe what modifications to the plan will be made for the next cycle from what you learned Continue as before with promoting contact number in A&E/AMAU working with bed management and modify the guidance document and ensure that all staff have clarity on how to complete a bundle to increase consistency
Our experience 5 cycles of change so far 10 th version of document Barriers time, priority Inconsistency of data collection and completion Clarification, clarification, clarification
Current bundle Summary table of Stroke Care Bundle findings Total Number Comments (if required) Number of patients with suspected diagnosis of stroke on day of admission dated, timed & documented Number of patients with CT scan performed on day of admission, day 0 Number of patients with CT scan performed on day 1 of admission Number of patients with documented WSS or contraindication on admission Number of patients given aspirin appropriate to CT scan result by end of day 1 Number of patients appropriately admitted to stroke unit on day 0 or by end of day 1 Total number of patients included in bundle Total number of patients with bundle achieved Observation number Admission date of patient with suspected diagnosis of stroke/tia (dd/mm/yy) CT scan on day of admission CT scan on day 1 or admission Water swallow Screen (WSS) performed with outcome documented or contraindication to undertaking WSS documented Aspirin 300mg prescribed and administered if appropriate on day 0 or day 1 Patient admitted to stroke unit on day 0 or day 1 or admission / / Yes Yes Yes Yes Yes No No No No 1. Delay in prescription 2. Allergy present 3. Haemorrhagic stroke 4. Use of parenteral anticoagulants or therapeutic wafarin, clopidogrel or dipyridamole 5. Non stroke diagnosis No 1. Discharged home 2. MHDU 3. No capacity 4. Non stroke diagnosis COMMENTS;
Summary table of Stroke Care Bundle findings Newer feedback w/c 04/07/11 w/c 11/07/11 w/c 18/07/11 No of patients with CT scan performed on day of admission 6 3 2 6 w/c 25/07/11 No of patients with CT scan performed on day 1 of admission 11 3 4 10 No of patients with documented WSS or contraindication on admission 10 4 4 9 No of patients given aspirin appropriate to CT result by end of day 1 8 2 3 7 No of patients appropriately admitted to stroke unit by end of day 1 8 4 3 8 Total number of patients included in bundle 11 4 4 10 Total number of patients with bundle achieved 9 3 4 7 Total number of patients with bundle achieved Ward 12, Victoria Hospital Goal Line=95% 100% 100% 90% 82% 80% 70% 75% 70% 60% % 50% 40% 30% 20% 10% 0% 04-Jul 11-Jul 18-Jul 25-Jul week commencing
Reason for not achieving 100%: w/c 4 July 1 d/c home TIA follow up, 1 non-stroke diagnosis & 1 no capacity w/c 18 July 1 MHDU - thrombolysed w/c 25 July 1 d/c home & 1 no capacity Number of patients admitted to stroke unit on day 0 or day 1 of admission Ward 12, Victoria Hospital Goal Line=95% 100% 100% 90% 80% 73% 75% 80% 70% 60% % 50% 40% 30% 20% 10% 0% 04-Jul 11-Jul 18-Jul 25-Jul week commencing
Fife wide same day ASU red line NHS QIS standard
Fife wide next day ASU red line HEAT target 2013, dotted target 2012
Fife wide wsst
Fife wide CT
Fife wide Aspirin
2011 6m.SSCAS bundle analysis
What we ve learnt Too much time between change and action Too much time between meetings Lack of leadership -?MCN led, CNS led Lack of clarity Lack of understanding of usefulness of data therefore poor buy in initially Stick with it
www.wales.nhs.uk/strokecarebundles 1000 lives 1 st hours, First day, First 3 days, First 7days www.nhmrc.gov.au/nics NHS north west Care Bundles Stroke 90:10 programme Maxine Power, North West Improvement alliance. 9 bundles Progress in Improving stroke care:a good practice guide http://www.advancingqualityalliance.nhs.uk
Welsh bundles
Any Questions? Hazel.Fraser@nhs.net