Linking Research, Audit, Quality Improvement and Evidence-

Based Medicine

Dr Chris Cairns

2010

Overview

• Definitions

• Example

• Questions / debate…….

Research is…..

• Clinical research determines the safety and effectiveness of….– Medications– Devices– Diagnostic products– Treatment regimens

• Prevention, treatment, diagnosis, symptom relief.

EBM is……

• Integration of…..– Best research evidence

• Bias• Applicability• Practicality

– Clinical skills and experience

– Patient values

Clinical Audit is…..

• “a process that seeks to improve patient care and outcomes through systemic review of care against explicit criteria”

• Research and EBM will give us these criteria……

• Audit may tell us is research is relevant to our own practise…..

Clinical Audit……..!!

• “a quality improvement process that seeks to improve patient care and outcomes through systemic review of care against explicit criteria and the implementation of change”

Quality improvement is…

• Not quite so simple…….

• Improving patient care…..but how…..in what way….to what end…..??

IOM 6 Pillars of Quality

Quality improvement is……..!!• “a quality improvement process that seeks to

improve patient care and outcomes through systemic review of care against explicit criteria and the implementation of change”

• Audit for quality improvement with implementation of change

• Quality improvement using audit and implementation of change

Implementing Change

• Writing the EBM based protocol is easy…

• Converting this to a change in clinical practise which results in better patient outcomes is more difficult………..

Example

VAP reduction:

The Stirling Royal Infirmary Experience

VAP

• SHO project – high VAP rate

• “We need Surveillance / protocol / pathway / guide / bundle”

• Chris……..what’s the evidence for stuff?

Evidence

• “Lots” of evidence for individual components

• Little evidence for “bundle” impact but evolving

Evidence - SICSEBM

• Elevation of bed

• Daily sedation break

• Sub-glottic ETT

• Chlorhexidine oral care

• Weaning trial

Others – not in bundle

• NIV – avoiding intubation

• Kinetic beds – no evidence

• HME vs Heated Water Humidification – equally effective

• SDD????

Evidence for “Bundle”

• Sepsis experience

• VAP – ? Evolving– SRI experience

SRI Experience – Nov 2005

• VAP Prevention Bundle • 30 - 45o positioning• daily sedation holiday• daily weaning

assessment

• chlorhexidine mouthwash • subglottic aspiration tube • tubing management

– appropriate humidification– avoidance of contamination

Additionally

• S/C enoxaparin pre-printed

• Ranitidine pre-printed

• Enteral feeding encouraged – if tolerated ranitidine cessation considered.

SRI experience

• At launch– Consultant buy in – Laminated charts by every bed space– Unit posters– Surveillance programme (Helix)

– Ahead of the game nationally

Job done?

• What is the VAP rate?

• What is the bundle compliance?

• Hawe, Ellis, Cairns, Longmate ICM, 2009

Job done?

• What is the VAP rate?

• What is the bundle compliance?

• Hawe, Ellis, Cairns, Longmate ICM, 2009

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•g chart: statistical parameter is a geometric random variable denominator: number of ventilator days between episodes of VAP•advantage of over more traditional methods is that it takes advantage of each observed infection yielding more plotted points at a faster rate, rather than waiting until the end of a specific time period and aggregating measurements.

Upper control limit (3SDs)

Upper warning line

Centreline (mean)

FV VAP Bundle

(*SICS Bundle)

Postinterventions Chi-squared p value(Nov 2006 vs Oct 2007)

Nov 2006 May 2007 Oct 2007

* Patient at 30o-45o 54% 80% 94% <0.001

Subglottic ETDT 72% 92% 92% <0.001

* Oral chlorhex8% 94% 100% <0.001

Tubing/HMEF 98% 98% 100% 0.31

* Daily weaning plan52% 72% 72% 0.039

* Sedation stop72% 86% 82% 0.23

All elements 0% 48% 54% <0.0001

Process

Problem? – Solution?

• Passive interventions don’t work

• Educational interventions to reduce VAP

• Structure, Process, Outcome

Active Implementation

• Education: workshops: definition, epidemiology, pathogenesis, risk factors, consequences of VAP, evidence-base for the bundle. Written material distributed.

• Over 90% of the unit’s medical and nursing staff had completed by April 2007.

• Repeat cycles of process and outcome measurement and feedback.

FV VAP Bundle

(*SICS Bundle)

Baseline Postinterventions Chi-squared p value(Nov 2006 vs Oct 2007)

Nov 2006 May 2007 Oct 2007

* Patient at 30o-45o 54% 80% 94% <0.001

Subglottic ETDT 72% 92% 92% <0.001

* Oral chlorhex8% 94% 100% <0.001

Tubing/HMEF 98% 98% 100% 0.31

* Daily weaning plan52% 72% 72% 0.039

* Sedation stop72% 86% 82% 0.23

All elements 0% 48% 54% <0.0001

Sequential Process Measurements

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Study Period

Passive

Sept 2005 - Feb 2007

Active

March – Dec 2007

patients ventilated for > 48hrs

374 215

Vent days 2556 1327

episodes of VAP

49 10

VAP/1000 vent days

19.17 7.5rd=11.6 99% CI 2.3-21.0rr=0.39 99% CI 0.16,0.96)

Median LOS 4.5 5.0

Mortality (112/374) 30% (49/215) 23% p=0.06

Lessons

• Passive implementation of the VAP prevention bundle failed.

• Compliance improved during an active multimodal implementation.

• This was associated with a significant reduction in the occurrence of VAP.

The Scottish Patient Safety Programme

Title of the session & name of faculty

Since then………………..

VAP: % All Bundle Compliance

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78

96 100

010

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Month 08

%

Post spsp improvements

Calendar days between VAP acquisition Sep 2005 - J un 2009

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calendar days between UCL CL UWL

Passive intervention period Active intervention & compliance feedback

Scottish Patient Safety Programme

VAP Incidence: Bundle Compliance

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Patient Safety Programme begins

Tw ice daily w ean screen sticker added to 24hr chart

VAP bundle prompts added to daily goals sheet.

Active period: Bundle implementation,

audit & education

Continuous measurement initiated

VAP - Pt constantly pulling at trachy, poorly compliant with head up & mouthwash

VAP - Long term pt vent for more than 150 days

VAP - poorly compliant pt, refusing to sit up refusing chlohex. Handling trachy and tubing. Not clear cut!

HELICS surveillance

VAP - Key Points

• Surveillance / constant feedback

• Education

• Process measurement / management

• Resources – without the above, bundles are “futile”

CVCrBSI

• Same principles

• SPSP target

• Lessons learnt in VAP applied to CVCrBSI

CRBSI g chart Sept 2005 - May 2009

(last acquisition 09/12/2007)

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CVC

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CRBSI Prevention% Bundle compliance

CRBSI Rate Compared to CVC Insertion Bundle Compliance

Insertion Pack introduced

CVC Maintenance bundle -prompt added to 24 hr chart

Establishment of team of nurses to take ow nership of CVC inserion & maintenance bundles and measurement

Continuous measurement begins

Insertion bundle questions added to Wardw atcher

Insertion bundle sticker developed for pt notes

Online educational resource devloped for CVC insertion bundle and maintenance bundle

CRBSI - Line migrated & TPN leaking from line site, line not removed immediately.

HELICS surveillance begins

Summary

• Definitions

• Example

• Questions / debate…….

Debate

• How do we link these all together nationally?

• What should we me measuring?

• Is quality improvement part of the remit of SICSAG or……?

• Is quality improvement a sub-specialty?

www.sicsebm.org.uk