Tuesday 21 May 2013 14.00 15.30 Webex Improvement Clinic Webex - - PowerPoint PPT Presentation

Improving Care for Older People in Acute Care

Tuesday 21 May 2013 14.00 – 15.30 Webex Improvement Clinic

Webex Outcome

1. To link-up with test sites/local teams to hear about challenges and highlights 2. To provide an update on the Improving Care for Older People in Acute Care work stream, following improvement planning event on 28 March 2013 3. To share examples of good practice 4. To provide support for teams as they continue improvement journey

Agenda

14.00 Welcome & Introductions Webex Orientation 14.15 Improving care for older people in acute care update

• 28 March event feedback
• Qualitative work (focus groups and interviews)

14.20 Supporting your improvement journey – building on progress Annette Bartley (IHI Fellow) 14.40 Test site feedback – challenges, highlights, opportunities

• Pam Milliken, NHS Lanarkshire – Testing Think Frailty Triage Tool
• Laura Riach, NHS Greater Glasgow and Clyde – Approach to testing

the delirium bundle 15.00 Our experience of developing and testing a bundle - Adrian Hopper (Guys & St Thomas) 15.15 Discussion; Q & A session with Adrian 15.30 Close

Welcome & Introductions

• OPAC Team
• Experts on the webex – Annette Bartley (IHI

Fellow), Adrian Hopper (Guys & St Thomas)

• Team introductions (one person each team)

Penny Bond Michelle Miller Karen Goudie Jane Millar Kirstan Shields Joanne McDonald Hazel McIntosh Annemarie Long

Webex good practice

If you are in a group:

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taking place

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function, or call the contact number All users

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Some user tips

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NHS Board Delegate NHS Ayrshire & Arran Amanda Johnson NHS Fife Helen Skinner and Annette McArthur NHS Forth Valley Linda Wolff NHS Greater Glasgow & Clyde Christine Roberts, Laura Keel, David Craig, Christine McAlpine, Sandra Shields and Elaine Burt NHS Highland Caroline Parr and Ruth Mantle NHS Lanarkshire Maggie Hogg, Linda Guild and Joe Hands NHS Lothian James McWilliams and Louise Robertson NHS Shetland Jane Astles and Linda Leslie NHS Western Isles Frances Robertson Healthcare Improvement Scotland Irene Robertson, Jane Miller, Kirstan Shields, Annemarie Long, Hazel McIntosh, Michelle Miller and Penny Bond

Improving Care for Older People in Acute Care

Update

Flash report highlights

• Feedback from 28th March – improvement

planning & engagement event

• Change packages shared with teams
• Testing of delirium bundle and frailty triage

screening tool

• Improvement support visits
• OPAC session at PCHC event 31st May

Guest Speakers

• Annette Bartley, IHI Fellow
• Adrian Hopper, Associate Medical Director for

Patient Safety, Guy’s and St Thomas’ Hospital

Commitments from March 2013 – March 2014

Your Commitment (Teams) Our Commitment (HIS)

Attend and contribute to Learning Session 2 of Person Centred Health and Care Event (Special OPAC session

• n Frailty and Delirium 31 May 2013)

Attend OPAC Improvement Planning and Engagement Sessions in September 2013 and February 2014 to share results from testing, challenges and

• pportunities

Support teams at learning sessions, improvement planning and engagement events and improvement clinics, improvement support visits, share and spread good practice and enhance improvement skills. Provide monthly progress reports – last Friday of every month Provide feedback on progress reports and support for improvement where required. Share practice at learning sessions through presentations and story boards. Make connections locally with other improvement activity Provide a national platform for sharing of good practice, learning and celebrating success Identify opportunities to link improvement work with

• ther national improvement activity

Write case study of your experience and findings Produce a final report and publication from this work. Identify opportunities to showcase nationally and internationally.

May 13 21 May Webex Improvement Clinic 30-31 May People at the centre of health and Care : Learning Session 2 Last Friday Submit test data to michelle.miller3@nhs.net Jun 13 1-30 Test Site Visits – to arrange a visit from the OPAC team to discuss progress, highlights and challenges please contact michelle.miller3@nhs.net Last Friday Submit test data to michelle.miller3@nhs.net Jul 13 1-31 Test Site Visits – to arrange a visit from the OPAC team to discuss progress, highlights and challenges please contact michelle.miller3@nhs.net TBC Webex Improvement Clinic Last Friday Submit test data to michelle.miller3@nhs.net Aug 13 Last Friday Submit test data to michelle.miller3@nhs.net Sep 13 Date tbc Improving Planning and Engagement Event TBC Webex Improvement Clinic Last Friday Submit test data to michelle.miller3@nhs.net Oct 13 Last Friday Submit test data to michelle.miller3@nhs.net Nov 13 20-21 Nov People at the centre of health and Care : Learning Session 3 (provisional date) TBC Webex Improvement Clinic Last Friday Submit test data to michelle.miller3@nhs.net Dec 13 Last Friday Submit test data to michelle.miller3@nhs.net Jan 14 TBC Webex Improvement Clinic Last Friday Submit test data to michelle.miller3@nhs.net Feb 14 Date tbc Improving Planning and Engagement Event Last Friday Submit test data to michelle.miller3@nhs.net

OPAC KEY DATES 2013-14

Improving Care for Older People in Acute Care Maintaining Momentum

Annette Bartley RN BA (hon) MSc MPH Quality Improvement Consultant

Respect the Reality in Practice

5/22/2013

How great leaders inspire action

Simon Sinek

http://www.ted.com/talks/simon_sinek_how_great_leaders_inspire_action.html

Getting it right -First do no harm!

• Fundamental Safety Principles

–Prevention –Detection –Mitigation

Focus on patients

Relational Transactional Warm but chaotic Everything works Unpleasant and inefficient “Cold comfort farm” Efficient but impersonal Coordinated, integrated Warm, fed, watered “Battery chicks?”

–We must become masters of improvement –We must learn how to improve rapidly –We must learn to discern the difference between improvement and illusions of progress

Holding up the mirror

Of all changes I’ve observed, only about 5% were improvements, the rest, at best, were illusions of progress.

• W. Edwards Deming

Insanity: doing the same thing over and

• ver again and expecting different

results. Albert Einstein, (attributed) US (German-born) physicist (1879 - 1955)

Expectations

Setting a pace and momentum for this work

• Leadership
• Commitment
• Active participation
• Feedback
• Engagement

– http://www.ted.com/talks/drew_dudley_everyday_leadership.html

Expectations

• Empower frontline teams
• Enable local ownership
• Support teams and provide guidance
• Avoid the ABCD of external support

– Arrive – Belittle – Criticise – Depart

• Education and training
• Reporting progress

Maintaining momentum

• Focus on involving all the multi-disciplinary TEAM
• Be clear about your collective overall aim/s for this work
• Ensure you get baseline measures in place before you start

testing any changes

• Remember he/she that tests … wins
• Plan to test your changes using the PDSA methodology
• Systematically work through changes, building upon the

learning

• Never give up!!

Where are we now?

• Time to take stock
• What has been achieved to date?
• What plans do you have for maintaining momentum?
• What are your key challenges and barriers?
• Next steps?

Key Ingredients for Improvement

A Clear Aim – Measurement- Action

5/22/2013

The Model for Improvement

Hunches Theories Ideas Changes That Result in Improvement

A P S D A P S D

Very Small Scale Test Follow-up Tests Wide-Scale Tests

• f Change

Implementation of Change

What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement?

Model for Improvement

Data over time

Making the connections

Risk Identification Communication of Risk status Risk Assessment Appropriate preventative strategy implemented Evaluation of outcome

PDSA PDSA PDSA PDSA

How will we know change is an improvement? Three Types of Measures

Outcome Measures: Voice of the customer or patient. How is the system performing? What is the result? Process Measures: Voice of the workings of the system. Are the parts/steps in the system performing as planned? Balancing Measures: Looking at a system from different directions/dimensions. What happened to the system as we improved the outcome and process measures? (e.g. unanticipated consequences, other factors influencing outcome)

To improve the identification and immediate management of delirium for people aged over 75 being admitted to acute care, by XX% by March 2014.

Immediate Treatment and Management of delirium Identification of Delirium

Education, leadership and culture

Aim Primary Drivers Secondary Drivers

Screening on admission to identify delirium

• Screening of patients over 75 years being admitted to acute care, to identify delirium,

using a screening tool (eg 4AT)

• Document diagnosis of delirium (where positive screening)
• Create a culture that supports family and carer involvement in care
• Promote the use of patient, family, carer feedback to improve care
• Ensure patient requirements are accurately reflected in the care plan

Improving Care for Older People in Acute Care: Think Delirium Driver Diagram

Immediate Treatment and Management of delirium (once delirium diagnosis has been made)

• Test the delirium care bundle within local context for usability
• Test the delirium care bundle to achieve compliance and reliability
• Reduce the time for implementation of care bundle
• Create a culture that supports family and carer involvement in care
• Avoid inappropriate inter and intra ward transfers
• Link to Scottish Delirium Association Pathway (or local pathway) for further

management

• Develop an infrastructure to support local testing of the delirium bundle using

improvement approaches

• Align work with other relevant work streams includingwider older peoplels

improvement work, person centred health and care, dementia strategy, Scottish Delirium Association Pathway and NHS Education for Scotland educational resources

• Optimise opportunities for spread
• Optimise opportunities to learn from and share good practice

Immediate Management of Delirium Care Bundle

Identify Delirium Using The 4AT Tool in patients over 75

Implement Bundle within 2 hours of 4AT positive Think about possible Triggers

Investigate and intervene to correct underlying cause (s) EWS (NEWS) &BM, AVPU, Fluid Balance Medications Explain Care to patient Take routine now Bloods FBC,U&Es, CRP LFTs,Mg & Ca + Culture URINE, BLOOD, Sputum Review MEDICATION …NEW, Withdrawn, Amount of Meds, remember Alcohol withdrawal Explain situation to patient , reassure and reassess. Speak to families and carers if possible for Hx

• f Change

Process Measure

Bundle element Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 TOTAL %

(Per element)

1. 2. 3. 4. 5. TOTAL %

(per patient)

To Conclude

“Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives.”

Thank You!

Questions?

abartley@ihi.org

Test Site Feedback Sharing experience and reflections

• NHS Lanarkshire
• NHS Greater Glasgow & Clyde
• Guys & St Thomas

Delirium and Dementia Guy’s and St Thomas FT

Adrian Hopper Associate Medical Director for Patient Safety

Delirium and Dementia Guy’s and St Thomas FT

• Identified as a priority
• Training card handed out for last 2 years
• Key task for the Liaison teams in Medicine

and Surgery

• National CQUIN for Dementia –

established DaD – delirium and dementia team

• Clinical lead Mark Kinirons
• Won CHKS award for dementia care

Delirium and Dementia Team

• Multiprofessional ( Nurse specialists,

Geriatrician , Psychiatrists )

• Single point of access for referrals
• Training
• Measurement
• Walk rounds

DELIRIUM INITIAL NURSE BUNDLE

FOR Cam + PATIENTS

DELIRIUM is An Emergency: Complete ALL 5 points

1 – ASSESSMENT

Full set of observations including PAR score & assess for causes If a fall – do / repeat STRATIFY CALL TO REVIEW WITHIN 60 MINS Doctor 0800-2030 Mon – Sun SNP 2030 – 0800 Mon - Sun

2 – INVESTIGATIONS to exclude causes

Drugs (anticholinergics, benzodiazepine and alcohol withdrawal)/ Dehydration Electrolyte imbalance Lots of pain Infection/Inflammation (post surgery) Respiratory failure (hypoxia, hypercapnia) Impaction of stool - do PR if needed Urine retention – do bladder scan if needed Metabolic disorder (liver/renal failure, hypoglycaemia)/Myocardial infarction

• 3. TREAT CAUSES & MONITOR PROGRESS
• Give reassurance and speak calmly and orientate patient
• Give Delirium PIL to patient and family – print from GTi PPG page
• Ensure can hear and see where possible
• Ensure adequate nutrition, fluids, pain control and bowels & bladder open
• Do not do unnecessary tasks

Promote mobility &N repeat STRATIFY

• Review Heightened Surveillance guidance for 1:1
• Monitor regularly - consider repeating CAM as indicated
• Do ECG if not done on this stay (important for drug treatment)

1 2

3

4

• 5. ESCALATE as appropriate

If hypoactive - if any care issues not solvable at ward level If Hyperactive - URGENT SENIOR/SNP REVIEW

5

• 4. Discuss ongoing management with Doctors +/- Family

DELIRIUM INITIAL MEDICAL BUNDLE

FOR Cam + PATIENTS

DELIRIUM is An Emergency: Complete ALL 5 points

• 1. ASSESSMENT

Full set of observations including PAR score incl. If a fall – do / repeat STRATIFY, Clinical examination including: Signs of infection, level of consciousness, AMT/MMSE, Review drug chart and previous interventions

• 2. INVESTIGATIONS to exclude causes

Drugs (anticholinergics, benzodiazepine and alcohol withdrawal)/Dehydration Electrolyte imbalance Lots of pain Infection/Inflammation (post surgery) Respiratory failure (hypoxia, hypercapnia) Impaction of stool Urine retention Metabolic disorder (liver/renal failure, hypoglycaemia)/Myocardial infarction

• 3. TREAT CAUSE & MONITOR PROGRESS
• Give reassurance and speak calmly and orientate patient
• Write up on PRN side - Haloperidol 0.5 – 1 mg or Lorazepam 0.5 – 1 mg for use after other interventions

have failed as indicated (check other drugs)

• Monitor – ensure Handover to doctors and request review as needed
• Alcohol & toxic / OD patients are managed differently

1 2

3

5 4

• 5. ESCALATE

IF HYPOACTIVE - if any care issues not solvable at ward level IF HYPERACTIVE - URGENT SENIOR/SNP REVIEW

• 4. Discuss ongoing management with Nurse in Charge +/- Family

Discussion

Q & A with Adrian Hopper

OPAC Next Steps – May 2013 – Sept 2013

May Jun

• Test site visits

July

• 7th – Prog Board
• 10th – Interviews with

patients and families (delirium)

• 21st – Webex

Improvement Clinic

• 30-31 PCHC Learning Event
• (OPAC session 31 May

11.00 – 13.00)

• Telephone catch-ups with

IAs supporting test sites

Aug Sep

• Improvement

Planning and Engagement Event

2013

Jan March April

Completed tasks:

• Improvement Planning Event 28 March 2013
• Change Packages and data collection tools disseminated for testing
• Twitter account established
• Community website updated
• Delirium - Staff Experience Focus Groups
• Test site visits
• WebEx

Improvement Clinic

• Test Site Visits

Programme Team contacts

• Penny Bond, Team Lead – penny.bond@nhs.net
• Michelle Miller, Improvement Advisor – michelle.miller3@nhs.net
• Karen Goudie, Clinical advisor– karen.goudie@nhs.net
• Jane Millar, Administrative Officer, jane.millar2@nhs.net
• Kirstan Shields, Project Co-ordinator kirstan.shields@nhs.net
• Joanne McDonald, QI Hub joanne.mcdonald@nhs.net @nhs.net
• Hazel McIntosh, Administrative Officer h.mcintosh@nhs.net
• Annemarie Long, Implementation & Improvement Facilitator

annemarie.long1@nhs.net