Stasis and VTE Is lack of order putting patients at risk? Professor Cliff Hughes AO 29March 2012
Safe Driving - NSW (435) 376 CF Hughes 29 th March 2012
NSW Heavy Vehicle Statistics 2011 General fatalities down 7% Heavy vehicles up 21% 61 fatalities* * Provisional CF Hughes 29 th March2012
NSW Heavy Vehicle Statistics 2012 Family of three killed! Driver had long history of fines and licence suspension Car did not have time to brake! Speed limiter* tampered with Major police investigation underway * Mandatory throughout Australia CF Hughes 29 th March2012
CF Hughes 29 th March 2012 Speeding
CF Hughes 29 th March 2012 Alcohol
CF Hughes 29 th 2012 NSW Statistics
Number of Notifications IIMS enthusiasm NSW Trend - IIMS Monthly Notifications 2006 2007 2008 2009 2010 2011 18000 16000 14000 12000 10000 8000 6000 4000 2000 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month CF Hughes, 29 th March 2012
CF Hughes, 29 th March 2012 The CEC A resource for improvement
2006/2007 Campaign Results Nurses 44.7% 44.9% 58.1% 59.2% 59.5% Doctors 24.9% 23.5% 53.0% 36.9% 34.5% Allied Health 32.0% 46.1% 48.7% 56.7% 39.5% Other Staff 34.5% 45.0% 61.8% 57.6% 48.9% Nurses Doctors Allied Health Other Staff
2006/2007 Campaign Results Nurses 65.5% 64.6% 74.5% 76.9% 71.2% Doctors 34.8% 38.1% 63.0% 54.9% 43.8% Allied Health 50.2% 58.4% 60.5% 69.7% 53.2% Other Staff 42.6% 54.2% 69.0% 64.2% 58.2% Nurses Doctors Allied Health Other Staff
Hand Hygiene Compliance National Benchmark: 70% (average 72.6) In NSW 17 hospitals below benchmark State average has improved 14.1% in Oct 2011 Now 75.9% Medical practitioners -61.9% (up 14%)* * National My Hospitals website
A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population Alex B. Haynes, M.D., M.P.H., Thomas G. Weiser, M.D., M.P.H., William R. Berry, M.D., M.P.H., Stuart R. Lipsitz, Sc.D., Abdel-Hadi S. Breizat, M.D., Ph.D., E. Patchen Dellinger, M.D., Teodoro Herbosa, M.D., Sudhir Joseph, M.S., Pascience L. Kibatala, M.D., Marie Carmela M. Lapitan, M.D., Alan F. Merry, M.B., Ch.B., F.A.N.Z.C.A., F.R.C.A., Krishna Moorthy, M.D., F.R.C.S., Richard K. Reznick, M.D., M.Ed., Bryce Taylor, M.D., and Atul A. Gawande, M.D., M.P.H. for the Safe Surgery Saves Lives Study Group N Engl J Med 2009; 360:491-499 January 29, 2009
Safe Surgery The rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward (P=0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist (P<0.001). CONCLUSIONS Implementation of the checklist was associated with concomitant reductions in the rates of death and complications among patients at least 16 years of age who were undergoing noncardiac surgery in a diverse group of hospitals. N Engl J Med 2009; 360:491-499 January 29, 2009
Stages of culture change* Understanding of the current culture Vision of where we should be Gap analysis Design a strategic plan articulates the vision Implement the plan Transition Follow up
Strategic Approaches* Establish a sense of urgency Create the guiding coalition Develop a vision and a strategy Communicate the change vision Empower the employees for broad based action Generate short wins Consolidate gains and produce more change Anchor new approaches in the culture * John P. Kotter Harvard CF Hughes 29 th march 2012
Safe Systems
Our Progress to Date - 2008 An overall 10% reduction in-patient red cell usage between 2007-2008 9168 units equates to a direct product cost of approximately $2,383,855 savings (based on AUD$260 per unit) Reduction in platelet waste Reduction in FFP How did we achieve this?
Benefit > Risk Risk > Benefit Haemoglobin g/l 4 5 6 7 0 0 0 0 8 0 9 0 100 110 120 130 140 Within this region individual patient factors determine transfusion threshold
Diagnostics Data Red Cell audit in March 2007 Data linkage- Red Cell Utilisation Database Qualitative Research Market research into prescribing behaviours of senior clinicians Literature Review- emerging evidence
Red Cell Audit Results 2007 12.7% pts anaemic - had surgery with Hb s under 105g/L 4% received transfusion with Hb s over 100g/L 95% had post-op transfusion with Hb s over 70g/L Standard dose 2 units
Relative Use Database Metropolitan Hospitals
Blood Myths & the Evidence
Overall % of Reduction in Red Cell usage in NSW Teaching Hospitals for in Patients 2007-2008 2006-2007 performance Teaching Hospital % improvement by hospital to previous year* Highest Relative use A -19% B -24% Intermediate C -5% D 2% E 2% Lowest F -14% G -8% *Overall hospital activity increased during 2007-2008
www.thetransfusionquestion.com.au
Individual Value Post Op Pre transfusion Hb for orthopaedics and cardiac surgery 08/09 150 125 1 2 2008 Feb March 1 April 1 1 1 1 Oct 08-Feb 09 May 2009 100 75 UCL=105.6 _ X=80.6 50 LCL=55.7 1 29 58 87 116 145 174 Observation 203 232 261
NSW Central Line Associated Bacteraemia ICU Project AR Burrell, M-L McLaws, A Pantle, M Murgo, E Calabria
Financial costs of CLAB US estimates 15 680 lives and $1.3 billion medical costs could be saved annually by reducing the number of CLABS* United States House of Representatives Committee on Oversight and Government Reform Staff Report September 2008, Survey of State Hospital Association: Practices to prevent hospital associated bloodstream infections The US Agency for Healthcare Research and Quality recently committed $3 million over 3 years to help reduce the incidence of CLAB Health Care Advisory Board, Daily Briefing, 10 February 2008
NSW CLAB-ICU Top down/bottom up project NSW Intensive Care Coordination & Monitoring Unit and Clinical Excellence Commission Methodology modelled on the work of Pronovost et al. The project promoted a standardised insertion technique including: Hand washing Full barrier precautions during insertion Cleaning skin with chlorhexidine Avoiding femoral site if possible Removing unnecessary catheters Also included a retrospective review of all incidents entered into the NSW Incident monitoring system
Guideline and checklist
Results Data on 10,890 line insertions Concurrent incident review: Retained/lost guidewires Arterial puncture Multiple passes Inadequately secured lines Inadequate position check prior to use Lack of access to ultrasound equipment Policy breaches Training & supervision common themes Safety Alert for guidewires issued Training framework developed
Minimum practical requirement and assessment Observe minimum of 1 insertion Perform minimum of 3 supervised insertions at each site Perform minimum of 5 independent insertions Theory assessment Practical assessment Final signoff Continuingl earning
Checklist Compliance all ICUs July 07 Dec 08 Competency assessed 48.3% (22.9% no, 28.8% missing) Hat, mask, eyewear 79.9% Hands washed 2 mins 91.6% Sterile gown/gloves 95.9% Alcoholic chlorhexidine prep allowed to 95.8% dry Entire patient draped 93.4% Sterile technique maintained 95.6% No multiple passes 80.9% Confirm position radiologically 74.3% Other method to confirm placement 43.6% (44.7% no, 11.7% missing)
Impact of compliance Non compliance with the clinician bundle : relative risk of CLAB was RR 1.62 (95% CI 1.1-2.4, p=0.0178) For central lines RR 1.99 (95% CI 1.2-3.2, p=0.0037) For PICC RR 5.08 (95% CI 1.03-25, p=0.059) Dialysis catheters no difference If compliant with both clinician bundle and patient bundle then risk of CLAB was RR 0.6 (95%CI 0.4-0.9, p=0.0103)
The Quality Journey Culture Comparison Compliance How we define good To meet all required targets To be better than others, locally or nationally To be the best we can possibly be Source of motivation to deliver From outside Imposed From outside Top-down From inside Internal, personal Duration Episodic Episodic Ongoing
Broken Windows! 1. The Bronx 10 minutes 24 hours 2. Palo Alto 1 week 3. Add a sledge hammer! Minutes a few hours! *Zimbardo cited in Wilson JQ Kelling GL
Fig. 1. K. Keizer et al., Science 322, 1681-1685 (2008) Published by AAAS
Fig. 2. K. Keizer et al., Science 322, 1681-1685 (2008) Published by AAAS
Leadership Capabilities Profound Strategy Purposeful Direction Purposeful Behaviour Profound Knowledge Adapted from Gerald V Miller Miller, G.V. The Leadership Dimensions Survey // Gordon J. (ed.) (2003) Pfeiffer s Classic Activities for Developing Leaders. (pp. 409 435). Reproduced with permission
Leadership Dimensions Leader: creates meaning defines clear outcomes addresses human impact of changes manages resources Profound Strategy Leader: models the vision matches words and deeds monitors / supports changes Constancy of Purpose Congruence of Activity Purposeful Direction Purposeful Behaviour Competency of Outcome Compatibility of Values Leader: understands systems communicates effectively builds team Leader: promotes interdependence over independence reviews staff performance models ethical behaviour Leadership Capabilities Leadership Dimensions Profound Knowledge Source: Gerald V. Miller Leadership Dimensions 3
Leadership Skills Quality assurance and risk management Financial management Strategic planning Strategic flexibility Human impact of change Org impact of change Resources available Clear outcomes defined Clear response to change Constancy of purpose Profound Strategy Full commitment seen in action Monitor the change Support the change Model the vision Walk the talk Congruity of activity Business knowledge Change management CPI Clinical redesign Organisation d.ment Audit Performance mgt. Staff selection and d.ment Purposeful Direction LEADERSHIP Purposeful Behaviour Self development Decision-making Conflict management Communication Negotiation Professional development 360 reviews Competency of Outcome Ability to systems think Give and receive feedback Communication Promote activity Team building Human side of mgt Leadership Capability Leadership Dimension Skills required Profound Knowledge Clinical governance strategies Health system knowledge Information management IT systems Healthcare reform strategies Health law Compatibility of Values Promote interdependence Assist staff to thrive Staff reviewed and reinforced Ethical behaviour
CF Hughes 29 th 2012 NSW Statistics
Building Better Systems VTE or not VTE Coming to a screen near you www.debatingvte.com.au
CF Hughes 29 th March 2012 Fatigue