Clinical Audits: pathways to improvement · • Clinical audits have shown to be a pathway to improvement. • Use of data showing opportunities for improvement in patient management

Dr Debbie Hawkins Director MVH MAU

Mona Vale Hospital - MAU

Clinical Audits Pathway to Improvement

Dr Debbie Hawkins Director MAU, Mona Vale Hospital

October 2014

1


Mona Vale Hospital - MAU Background

2

• 8 bedded unit co-located on medical ward

• Achieved all 4 KPIs in 11 of last 14 months

• Majority of admissions Triage Category 2 or 3

• 28% of all ED admissions go through MAU

• >50% of all medical admissions go through MAU

• Average 20 patients per bed/month

• 96% occupancy in 2013/14

• Best performing MAU in NSW 2013


Mona Vale Hospital - MAU What makes a successful MAU?

3

• Shared organisational vision of the role of the MAU and how it delivers so effectively in terms of patient outcomes.

• Cohesive, multi-disciplinary team focussed on early

intervention and holistic care. • Close working relationships with Emergency Department and

other units - streamlines patients journey. • Clinical audits used to demonstrate opportunities for

improvement, in particular, clinical pathways which provide standardised best practice approach.


Mona Vale Hospital - MAU Some completed clinical audits

4

• Chest pain • Atrial fibrillation • STEMI • CTPAs • Pneumonia • Nursing home patients • Syncope • ICU admission from ED • Medical patient documentation

• Acute appendicitis – role of ultrasound

• Renal colic • Diverticulitis • UTI in children • Asthma • Bronchiolitis • Croup • Tonsillitis • Epistaxis


Mona Vale Hospital - MAU Why audits work

5

• Use of data demonstrating room for improvement in clinical management helps engage physicians in developing the solution – specifically pathways.

• Pathways are not then imposed, the data speaks for itself, building ownership in the outcomes.

• Combined audits involving ED and MAU data have allowed shared development of pathways – many of which start in the ED.

• Changes in practices as a result of audits leads to less clinical variation, improved patient management, less unnecessary interventions and decreased LOS.

• Audits are a conduit for improving the “core business” of the MAU.


Mona Vale Hospital - MAU Example 1 – Chest Pain

6

Purpose • To facilitate use of NSW Chest Pain pathway in ED • JMOs to become familiar with and use pathway

Looked at... • Are patients risk stratified in ED? • Is management in accordance with the stratification in ED and MAU?

Findings • 33% patients not stratified in ED • 25% receive suboptimal treatment • 100% are restratified in MAU • Good adherence to pathway for all MAU patients

Actions • NSW pathway incorporated into MAU notes • ED “paperless” so reluctant to use pathway. So:

o Laminated pathway prominently displayed o All Drs required to risk stratify at handover o JMOs (& senior ED staff) now conversant with pathway

Results LOS (days) 2011/12

1.3

2013/14

1.1

PEER

1.3


Mona Vale Hospital - MAU Example 2 - Pneumonia

7

Purpose • To determine whether patients are treated in accordance with CORB guidelines for management of pneumonia

Looked at... • Retrospective audit looking at patients admitted to medical ward with community acquired pneumonia

Findings • CORB score documented in 10% patients at admission • < 50% given correct antibiotic for CORB score • < 15% given correct oral antibiotic after original intravenous therapy • < 50% are treated with antibiotics for 7 days • 10% specified in discharge summary need for GP to repeat CXR

Actions • Results sent to ED staff and physicians • Pneumonia pathway developed emphasising role of CORB score in

determining antibiotic treatment


2.5

2013/14

1.7

PEER

3.2 Re-audit 4 months later

• CORB score documented in 40% of patients at admission • Appropriate antibiotics given in 70% of cases • Correct stepdown oral meds in 68% of cases


Mona Vale Hospital - MAU Other Examples

8

CTPAs • Led to introduction of PE algorithm for diagnosis of PE in ED. • 13% reduction in no CTPAs order (re-audit in process) • Pathway for management of PE on the ward just completed


2.1

2013/14

1.7

PEER

4.7

Syncope • Led to development of a syncope risk assessment tool for use in ED with recommendation all high risk patients admitted (mainly to MAU)

• Pathway developed Results LOS (days)

Uncomplicated

Complicated

2011/12

1.6 1.9

2013/14

1.3 1.7

PEER

1.7 5.2


Mona Vale Hospital - MAU Other Examples (cont.)

9

Atrial fibrillation

• Huge variability in pharmacological management of AF • Development of pathway with cardiologists • Used in ED & MAU • Considerably less clinical variation in approach • Appropriate rate v rhythm control


1.7

2013/14

1.2

PEER

2.1



0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

Average LOS, Days

Top 20 DRGs - 2013-14

MVH

Peers

MVH MAU vs Peers; LOS by DRG


Mona Vale Hospital - MAU IMPROVING PERFORMANCE Avg LOS in MAU for top 20 DRGs – 3yr comparison


Mona Vale Hospital - MAU IMPROVING PERFORMANCE 21% Increase in throughput 2011 -2014


Mona Vale Hospital - MAU IMPROVING PERFORMANCE Average total hours in ED for all MAU patients decreased by 43%


Mona Vale Hospital - MAU IMPROVING PERFORMANCE Avg LOS in MAU decreased by 41%


Mona Vale Hospital - MAU IMPROVING PERFORMANCE Ave LOS of MAU patients transferred to ward decreased by 35%


Mona Vale Hospital - MAU IMPROVING PERFORMANCE Readmission rates of MAU-home or MAU-ward-home discharges decreased by 12%


Mona Vale Hospital - MAU Summary

17

• Clinical audits have shown to be a pathway to improvement.

• Use of data showing opportunities for improvement in patient management increases clinician engagement and ownership of solutions.

• Allow introduction of a methodical approach to eliminate clinical variation with standardised, evidence based pathways.

• Cross fertilisation between ED and MAU.

• Several pathways implemented with good buy in, focussed on main DRGs – ie get good at the “core business” of MAU.

• Small improvements have significant impact on streamlining patient management and decreasing LOS (equates to > 1100 bed days in top 20 DRGs 2013/14).

• Don’t reinvent the wheel – there are good , evidence based guidelines out there which just need tailoring to your organisation.



18

Thank You

Clinical Audits: pathways to improvement · • Clinical audits have shown to be a pathway to improvement. • Use of data showing opportunities for improvement in patient management

Documents