B5: QI Abstract Presentations 23 rd March 2019 As part of our - - PowerPoint PPT Presentation

B5: QI Abstract Presentations

23rd March 2019

ME Forum 2019 Orientation

As part of our extensive program and with CPD hours awarded based

• n actual time spent learning, credit hours are offered based on

attendance per session, requiring delegates to attend a minimum of 80% of a session to qualify for the allocated CPD hours.

• Less than 80% attendance per session = 0 CPD hours
• 80% or higher attendance per session = full allotted CPD

hours Total CPD hours for the forum are awarded based on the sum of CPD hours earned from all individual sessions. Conflict of Interest The speaker(s) or presenter(s) in this session has/have no conflict of interest or disclosure in relation to this presentation.

Conflict of Interest

The speaker(s) or presenter(s) in this session has/have no conflict of interest or disclosure in relation to this presentation.

Learning Objectives

At the end of this session, participants will be able to:

• 1. Learn from presenters how they made the change, achieved success and
• vercome challenges.
• 2. Inspired through interaction with the speakers
• 3. Support the continuous improvement efforts in their organizations
• 4. Disseminate information and share experience

Reducing Elective General Surgery Cancellations

Hamad General Hospital

• Mr. Belal Salem,

Nursing Supervisor- Clinical Bed Management, RN, BSc.

Background and Introduction

Cancellations of planned surgical procedures have been a major and long- standing problem for healthcare organisations across the world. They represent a significant loss of revenue and waste of resources, have significant clinical, psychological, social and financial implications for patients and their families. The current paper investigates the reasons for day of surgery cancellations at HGH and proposes strategies to reduce their incidence. In 2017, the overall rate of cancellation of elective operations on the day of surgery ranging from 30%-32% of planned elective operations per month.

Aim and Measures

To reduce the percentage of cancellations for all elective General Surgical cases by 5% by the end of November 2018. Outcome Measure Percentage of Cancellation of Elective General Surgical cases Balance Measures Patient satisfaction Efficient utilization of OR slots Process Measure Standardize scheduling and tracking process for all pre-operative elective cases.

PDSAs / Change Ideas

q Working closely with STO to schedule the case according the OR slot. q Avoid the schedule of elective admission unless there is urgent indication q Balance the slot between day care and STO cases ( elective procedure) q Follow up with surgical team to adhere with agreed protocol and pathways of elective admission q Continue run the bed management service 24/7 with full capacity. q Develop preoperative committee to streamline the elective surgical admission pathway. q Protected surgical beds as per specialty. q Adapted JCI cohort study 2 in reviewing all STO slots and system to avoid any overbooking in the system. q Review and study all reasons for cancellation and develop an agreed action plans accordingly.

Run Chart

Conclusion

q Reduction of planned elective surgery cancellation to 15.65% compared to

• ur benchmark of 7.8%. Perioperative committee remain functioning with

frequent meetings and follow up for all the surgical challenges.

Next Steps and Sustainability

q Implementation of new STO process mapping in the new Surgical Specialty Center by the end of 2018 q Screening all cases and divert cases that can be done to another facility q Centralize the scheduling system through the STO for elective / Day case General Surgery q Keep scheduling the slots timing of procedure through the system (Cerner). q To maintain a real time operational data- dashboard and generating an efficient reports. q Perioperative committee remain functioning with frequent meetings and follow up for all the surgical challenges

Question and Answer

Developing a Sepsis Screening Tool for a Nurse Led Facility

Mobile Healthcare Service – Ambulance Service Group

Dan Reynald Borja, Miel Samson, Dr. James Laughton, Gary Kenward, Ronald Ancheta, Dr. Timothy Chetty,

• Dr. Nicole Anderson, Mohammed Jbeli

Background and Introduction

q The Patient Recovery Centre (PRC):

• 57 bedded, nurse-led step-down facility
• Patients needing ongoing clinical/social support following acute

episodes of hospitalization q Adapted UK Community Sepsis Screening tool

• Implement QEWS to improve the early recognition of deteriorating

patients

• Escalate ‘red flag sepsis’ patients promptly to a higher level of care
• Collaboration between MHS and Home Health Care Service (HHCS)

to test this unified community sepsis screening tool

Aim and Measures

To reduce the time between identification of sepsis symptoms to escalation to a higher level of care from 125 minutes to 30 minutes by June 2019 Measures q Time Zero to Time of Escalation q SP01 - Percent with reliable vital signs documented q SP02- Percent of Clinical Review, RRT, SIRS/ Severe Sepsis or equivalent alerts that were appropriately escalated q Clinical Review Time

PDSAs / Change Ideas

Charts

Results

q QEWS effectively introduced into the PRC in May 2018 q 100% compliance in recording vital signs on QEWS from September 2018 q Sepsis screening tool adapted for use and then adopted into PRC q Median escalation time (for suspected sepsis cases) decreased by 66.7% from 168.8 minutes to 56.3 minutes following introduction of Sepsis Screening Tool q All 8 cases identified as Red Flag sepsis received IV antibiotics in ED

Next Steps and Sustainability

q Test changes to improve:

• Escalation time to calling 999
• Improve flagging of sepsis patients sent to ED or Urgent Care

q Continue collaboration with Home Healthcare Service and extend to other Community services to align sepsis pathway across Qatar

Question and Answer

SUN: A Quality Improvement Journey: To Stop Unplanned ExtubatioN in NICU

Women’s Wellness & Research Center

Sashtha Girish, A/Quality Coordinator, NICU Bilal Kanth, Chief Respiratory Therapist, NICU Habeebah Fazlullah, Respiratory Therapist, NICU

Background and Introduction

Improving quality of care in NICU is imperative in healthcare. The ultimate goal of every intervention is to improve health & quality of life in all patients. An Unplanned Extubation (UEx) is a significant marker of poor quality of care. There was a trend of increase in events of UEx and this rate was quite alarming with no standardized tool in place, which could have closely monitored the rate and the associated reason(s) for the events neither we were able to compare with international level’s that how good nor how bad is

• ur clinical practice when it comes to managing and preventing the events of UEx.

So, we identified UEx as an area of improvement & maintaining UEx rate <1/100 vent days. We continued with RCA for each UEx & regular educational sessions are important aspects for our success. All infants admitted to NICU who requires invasive mechanical ventilation are being monitored as part of this QI project. By reducing UEx in NICU, we improved overall clinical outcomes, reduce length of stay, lowered costs & improved patient satisfaction. Effectively initiated in March 2018 with a tool that includes 24 data collection categories, close monitoring, and documentation & analysis by NICU team, “SUN” project continues to address the key measure of quality with the aim to sustain rate at <1 event/100 vent day.

Aim and Measures

To reduce the events of unplanned extubation (UEx) at NICU, WWRC from >1 event/100 ventilator days to <1 event/100 ventilator days (International Benchmark) by end of December 2018. Outcome Measure Percentage of reduction of number of adverse events related to unplanned extubation. Process Measure Percentage of compliance to Monitoring Tool with 24 categories. Balance Measure Percentage of increase in nasal related injuries due to more patients started or weaned earlier to non-invasive ventilation.

PDSAs / Change Ideas

q A chart as per latest NRP (Neonatal Resuscitation Program) for ETT (Endotracheal Tube) size and levels were introduced in all resuscitation areas from February 2018. q Introduction of awareness and monthly educational activity and starting to use the Monitoring Tool with 24 categories from March 2018. q Routine Check: security and level of ETT hourly with documentation from March 2018. q Encouraged using NIV (Non-Invasive Ventilation) and early weaning. q Education about patient care procedures was started from April 2018. q All ventilated babies have “High Alert Cards” on the bedside to make teams more vigilant and careful during their care to avoid UEx was implemented from May 2018. q Education sessions promoting Two-to-One care (TTOC) were emphasized to all team members and this was advocated by medical team for multifactorial benefits.

PDSAs / Change Ideas

q “CROWN Me” Project was introduced by physiotherapists for head positioning and turning which aided with reducing UEx. q Changing ETT security as required was begun in August 2018. q Education about a standardized taping and securing

• f

ETT was implemented and monitored from August 2018. q Use of appropriate sedation was started since October 2018. q Change of linen and bath to be done during the evening shift instead of mid- night and this was implemented in September 2018. q Physician’s written order as “Minimal Handling” for critically sick babies were implemented from September 2018. q Introduction of headgear to reduce rapid movements - Education & training going on (Nov 18 – Jan 19) - To be implemented in April 2019.

Run Chart

Run Chart

Conclusion

q We achieved the primary goal of having the rate below the international benchmark <1/100 ventilator days. Since the education, constant RCA analysis, participation & willingness of the staff to promote improved patient care and outcomes we didn’t have any UEx in Sept 2018. q We have reduced complication of traumatic extubation, failed extubation & multiple intubations. q The active use of NIV has promoted better patient outcomes due to reduced rate of BPD and shorter ICU stays. We had a higher census of patients successfully weaned from NIV. q Patients are discharged with fewer complications not related to UEx and mechanical ventilation.

Next Steps and Sustainability

q Auditing/RCA every month to asses the compliance of the monitoring tools and standards. q Hands-on training done (Nov 18 – Jan 19), now planning to introduce further education about headgear to reduce rapid movements of the baby. q Education for RTs about x-ray interpretation to determine appropriate ETT levels. q The long term plan is to continue this project while simultaneously dropping the unit baseline by 25% consecutively each year until the end of year 2020 to reach a rate of UEx < 0.56/100 ventilated days.

Question and Answer

Improving patient safety by reducing catheter associated urinary tract infection

National Center for Cancer Care and Research

Mary Maheswari

Head Nurse - SPCU

Background and Introduction

q In 2016 NCCCR has high rate of CAUTI 7.2 (N=11) compared to 1.8% NHSN Benchmark. q An increased rate of CAUTI infection is a major concern. This can lead to the following :

• Increased risk of sepsis
• Mortality and Morbidity
• Increased length of stay
• Decreased patient satisfaction
• Added Cost

Aim and Measures

To reduce NCCCR rate of CAUTI 2.86 in 2017 to 1.43 by December 2018. Outcome Measure Rate of CAUTI infection per month Process Measure Percentage of compliance with the completion of CAUTI care bundles.

PDSAs / Change Ideas

q Piloted the monitoring tool for Weekly audits q Formulation of multidisciplinary focus group. q Staff selection as champions q Refreshment Education & Re-demonstration to old staffs and Validation & Education to new staffs. q Patient and Family engagement. q Environmental Rounds / visit Patients with the Quality Team. q Policy Review. q Audit for Bundle compliance q Sharing information among health care provider q Timely reporting of supplies challenges

Run Chart

Conclusion

q Leadership involvement and Staff recognition and acknowledgement for their hard work and commitment to Patient Safety. q Patient and family engagement. q In comparison with 2016 CAUTI rate of 6 (n=11), the CAUTI project team in collaboration with key stake holders and strong leadership support; achieved 1.0 annual rate ( 80% CAUTI rate reduction N=2) in 2018.Exceeding our target of 50% reduction. q In terms of financial impact NCCCR CAUTI reduction initiatives were able to save total of *$29,556. *Data Source: NCCCR NDNQI Scorecard 2016 to 2018. (J Hosp Med. 2013 Sep; 8(9): 519–522.)

Next Steps and Sustainability

q Develop educational leaflets. q Sustain target and spread the learning to the other units. q Senior leadership to be informed about progress to ensure ongoing support. q Continuous staff involvement on the initiatives of infection control program along with training to sustain the process.

Question and Answer

“Time to Say NO to Restraint: A Nurses Responsibility”

Heart Hospital - CTICU

Miki Varghese

Staff Nurse, Heart Hospital

Background and Introduction

“Restraints must never be used as a substitute for good nursing care or staff convenience. Restrained patients require more care and increased documentation.” (American Nurses Today, 2015). All cardiac surgical patients received in Cardiothoracic Intensive Care Unit (CTICU) post operatively were on physical and chemical restraints throughout 2014.

Aim and Measures

q To reduce the percentage of the use of physical restraints for cardiac surgery patients from 100 % to 50% by June 2015 and from 50% to 0% by December 2015. q To sustain the zero percentage of the use of physical restraints for cardiac surgery patients.

PDSAs / Change Ideas

q Staff education q Collaboration with the patient and family q Patient assessment for agitation and delirium by following the RASS scale q Dissemination of results through email and QI visual board. q Data Collection & Analysis

Change is hard! Teamwork is crucial MDT involvement is essential

Run Chart – Outcome Measure

Run Chart – Process Measure

Run Chart – Balance Measure

Conclusion

q Restraint generally means some method of restricting another's freedom of movement. Is using restraint good or bad? It depends on what it is being used for, when it is being used for, for whom, who is using it, for how long, and under what conditions. q Significant reduction of 50% use of physical restraints was achieved by the mid of 2015. q Accomplished zero percent use of physical restraint by end of 2015. q Sustained the same rate in 2016 and 2017. q In 2018 we had physical restraints used for seven patients, the cause remains to be agitation. q Our target is to achieve zero percent compliance in use of physical restraints.

Next Steps and Sustainability

q Continue education and monitoring. q To maintain zero percent physical restraint. q Continue sedation vacation while using chemical restraint. q To implement weaning and sedation protocol. q To implement delirium project. q To continue to sustain current achievements through implementing standard practice continuous monitoring and achieve the target of zero

Question and Answer

Improving Hospital Discharge Before Target Time at the NICU

Al Wakra Hospital

Ghadeer Mustafa

Director of Nursing

Background and Introduction

q Delays in the discharge of hospital patients cause a backlog for new admissions from the Emergency Departments (ED) and transfers from other Units q To ensure an effective use of the inpatient bed capacity; Al Wakra Hospital set the timely discharge as one of the hospital key priorities for 2017-2018 q The NICU discharge target time is 2 pm for and the hospital’s target is 60% q In Jan-June 2017, the percentage of patients discharged before the target time in NICU was inconsistent and ranging around 56%. Late discharges causes pending admissions in labor room and obstetric operating rooms which negatively impact the patient’s health condition

Aim and Measures

q To achieve 60% of patients discharged before 2 PM by end of June 2018, then to achieve 60% of patients discharges before 1pm by end of June 2019 Outcome Measure Percentage of patients discharged before 2 pm Process Measure Percentage of MDR completed before 11 am Balancing Measure Number of patients re-admitted within 28 days of discharge

PDSAs / Change Ideas

Run Chart – Outcome Measure

Run Chart – Process Measure

Run Chart – Balancing Measure

Conclusion

q By re-designing the discharge process, we were able to achieve more than the set target in shorter time than expected. The commitment, dedication and support of the whole multidisciplinary team cultivates a sense of responsibility for everyone which makes huge difference.

Sustainability

q Run chart revealed sustainability in achieving the target and ready to spread the change q Aligned our improvement to the Triple aim approach underpins the National Health Strategy of 2018– 2022, focused on better health, better care and better value. q Aligned our project to AWH strategic priority for 2017-2018 which is the timely discharge q Fully engage the frontline staff and stakeholders involved in holding the gains q Small tests of change and scale it up with wide range of conditions q Spreading the word about the project’s progress and success q Engage the leadership

Next Steps

q To meet the target for discharge before 1 pm q Spreading the change

Question and Answer

Thank you.