Local Improvement Clinic

1. Dr Don Berwick President & CEO, IHI Prof Bernard Crump NHS Institute for Innovation & Improvement Dr Ross Wilson Chair, Strategic Advisory Board International Forum Local Improvement Clinic

2. To Improve the Prescription of Osteoporosis Treatment in Post-Menopausal with a Hip or Vertebral Fracture Kate Cotter, Jennifer Dempsey, Cheryl Baldwin Central Coast Health

3. Mission Statement • To Improve the prescription of osteoporosis treatment in post-menopausal with a hip or vertebral fracture • Triple therapy osteoporosis treatment • includes Calcium, Vitamin D and a Bisphosphonate. • Improve prescription from 25% to 100% for all appropriate women in 3 months • Longer term goal to reduce further osteoporotic fractures

4. Team members & role • Project team members with fundamental knowledge and who worked on the project: • Kate Cotter: Ortho-geriatric registrar • Jennifer Dempsey: CNC Medicine • Cheryl Baldwin: CNC Ortho-geriatric • Consultation with pharmacy department, orthopaedic clinical teams

5. Evidence for there being a problem worth solving Post-Menopausal Osteoporotic Fractures Are: • Common • Proven therapies to reduce further fractures • BUT • Evidence-based guidelines are poorly implemented

6. A Common Problem - Australia IN AUSTRALIA • In 2001 2 million people were estimated to be affected by osteoporosis, three-quarters of whom were women. • 20,000 hip fractures per year, and this is estimated to increase by 40% each decade. • Every 8.1 minutes someone in Australia is admitted to hospital with an osteoporotic fracture and this will increase to every 3.7 minutes by 2021 if nothing is done.

7. Evidence for there being a problem worth solving Proven therapies to reduce further fractures • Supplementation with Calcium and Vitamin D has been shown to reduce hip fractures by 43% • National Osteoporosis Foundation Guidelines state that providing adequate daily Calcium and vitamin D is a safe and inexpensive ways to help reduce fracture risk

8. Results of Preliminary Audit

9. Flow Chart of Process Transferred to Rehab

10. Cause and effect diagram

11. Pareto Chart

12. In Emergency Department • Routine serum calcium measurement in all patients presenting to Emergency Department with a low impact fracture

13. Orthopaedic Ward • Orthogeriatric orientation provided to all RMO’s at start of new term • Every patient with a low impact fracture has osteoporosis • Encourage charting of “Triple Therapy” • Caltrate 1200mg daily • Ergocalciferol 1,000 units daily • Alendronate 70mg weekly (to commence on discharge) • If on a bisphosphonate at admission it must be charted on drug chart as “recommence on discharge” • Importance of putting date of X-ray on discharge summary (required for special authority script)

14. Orthopaedic Ward • Increase awareness at staffing level • Participation in osteoporosis week • Poster in orthopaedic ward, orthopaedic outpatient clinic and emergency department • Incorporating osteoporosis treatment into existing nursing pathway for fractured NOF

15. Orthopaedic Ward • Increasing awareness at patient level • Orthogeriatric team providing verbal and written information to patient about osteoporosis and its treatment

16. At Discharge • Copy of dictated letter from Orthogeriatric Registrar listing diagnosis of osteoporosis and recommended treatment sent electronically to GP

17. Fracture Clinic Attention: All Fracture Clinic Staff Patient with minimal trauma fracture? The Bone Protection Project has been implemented to ensure ALL patients presenting with a minimal trauma fracture are correctly managed and investigated for underlying osteoporosis. ACTION: Please give the patient a G.P. referral letter. Use stamp provided to record letter given to patient.

18. Run-chart Percentage on Treatment at Discharge

19. Run-chart Percentage of those NOT on treatment, who had treatment commenced

20. SHOWING RESTRAINT Nigel Dounton Doris Kinnaird Sam Alfred Adrian Jackson Central Northern Adelaide Health Service

21. Mission Statement • The Aim is to Reduce by 60% Within Six Months the Use of Emergency Department Initiated Physical/Mechanical Restraint for Behaviourally Disturbed Patients.

22. Team Members • Nigel Dounton – Mental Health Nurse ED Queen Elizabeth Hospital • Doris Kinnaird - Mental Health Nurse ED Lyell McEwin Hospital • Sam Alfred – Consultant ED Royal Adelaide Hospital • Adrian Jackson - Mental Health Nurse ED Royal Adelaide Hospital • Central Northern Adelaide Health Service

23. Guiding Committee • Dr Darryl Watson - General Manager Early Intervention and Acute Services Mental Health • Dr James Hundertmark - Director Acute Service Mental Health QEH (CHAIR) • Dr Geoff Hughes - Director Emergency Department Royal Adelaide Hospital • Neville Phillips - Nursing Director Early Intervention and Acute Services Mental Health • Suzanne Heath - Manager Service Development Mental Health Directorate • Adrian Jackson - Project Officer, Early Intervention and Acute Services Mental Health • Lynne James - Senior Program Planning Officer Acute Services Mental Health Directorate

24. Restraint as Overall % of Patient Numbers 2005 to 2006

25. High Order Flowchart Presentation to Emergency Department Admission into ED Behaviour Escalates Treatment with Settling of Behaviour Discharge, Transfer or Admission

26. Entering ED Triaged D SAAS can Request Restraint Team Standby on Arrival If Not Behaviourally Disturbed – Possible Waiting Room/Cubicle Patient’s Behaviour Escalates D Clerk for A9 and Old Files D If Behaviourally Disturbed – Safe Room/Resus Nursing/Medical Staff Arrive/Present D If Affected by Drug Alcohol – Longer Waiting Time to Detox D Intervention Minimal Effect, Behaviour Escalates Security Called Guard D Monitoring Process – Observations for Restrained Patient AssessmentProcess To Determine Best Treatment If Restraint – 33# Call If De-escalation is Not Effective Medication Given And/or Seclusion Room And/or Shackles Behaviour De-escalates Security Arrives If De-escalation is Effective Attempted De-escalation Can Occur at Any Point D Medical Assessment Completed if Necessary D Decision to Admit, Discharge etc Discharge from ED Destination Can Delay discharge From ED More Formal Psychiatric Assessment Med & Psych May Disagree Who is Responsible for Patient D D

27. Cause and Effect Diagram Patient Factors Perceived Neglect Communication Drugs Nicotine Anxiety Psych illness Thirst Medical illness Hunger Escalation Requiring Restraint Medication Seclusion room location Psych assessment Medical assessment High stimulus Pre contact wait Environmental Interventional Delays

28. Pareto Chart

29. Intervention - plan, protocol etc • Weeks 1 – 3 (Intervention A) • Identify patients who are becoming agitated but are not yet violent or requiring restraint. (Early warning signs of agitation discussed with and printed out for staff) • Offer fluids, sandwich etc and communicate with patient re issues of immediate concern. • Outline normal processes involved in ED assessment to patient • Place patient label in one of the study book located at Triage and Area A & B. • Weeks 4 – 7 (Intervention B) • Early administration of Lorazepam 1mg, generally initiated by nursing staff. If necessary repeat dosing with input from medical staff. • Place patient label in one of the study books as previously described.

30. Data sheet with results in the three key areas • The initiation of intervention was recorded in a ‘study book’ placed at three locations in the ED. The patients ‘identifying label’ was stuck in the book and a brief note recorded next to their name. • Data on urgent restraint callouts was collected by the security firm responsible, and compiled by the Royal Adelaide Hospital Safety and Quality Unit. • Results in three key areas are: • There were no additional costs above those of usual treatment as medication costs and consumables are already budgeted for. • The consumer representative on the steering council was unavailable. There were no complaints voiced by patients in the ED. Staff were universally supportive at weekly review sessions. • No adverse events related to the interventions were identified during review of case notes for enrolled patients

31. Restraint as Overall % of Patient Numbers Before & During Study Period Intervention 1 Intervention 2 %

32. Strategies for Sustaining Improvement • Formalise the ED/Mental Health protocol for the assessment of the agitated patient to include both of the study interventions • Regular staff feedback on the process has already been instituted on a weekly basis and will continue until entrenched • The RAH drug committee has been approached to ratify nurse initiation of the Lorazepam protocol • An ongoing review process screening for complications has been put in place

33. Strategies for Spreading • Support has been secured from Mental Health and Emergency Medicine hierarchies to adopt the same approach on an area wide basis • Team members from various institutions will be instrumental in implementing the process within their own institutions • The next meeting of the steering committee is scheduled for November.

34. Mission Statement At Level 11 of Tan Tock Seng Hospital, the peripheral iv cannula phlebitis rate will be reduced by 50% in 3 months

35. Team Members & Roles 1. SNC Margaret Soon 2. NO Wong Siao Pin 3. SN Goh Mei ChernStaff from unit 4. AN Widarni 5. NE Prema BalanTeaching of staff 6. NE Pua Lay Hoon 7. Dr Benjamin TanDr covering L11

36. Evidence for there being a problem worth solving Point Prevalence Phlebitis rate done on May 31 2002 is 26.3%. • International average = 15% • Institutional average = 11.8% • National average = 8.3% Repeated point prevalence rate in the unit on 28 Nov 2002 is 25%

37. Pareto Chart

38. Intervention(s) - plan, protocol etc • Compile, communicate & educate a. antibiotics information chartSpeed of administration & proper dilution b. Drugs not for IV administration c. Flushing of line according to recommendations d. Proper restraint of restless patients 2. Audit compliance to recommendations & phlebitis rate

39. Point Prevalence Phlebitis Rate

40. Strategies for Sustaining(holding the gains) • Involve all grades of HCWs within the department • Ownership of the problem/issue • Random point prevalence audit for comparison

41. Strategies for Spreading • Repeat hospital wide point prevalence study (20 Jan 04) • Target at the next area with problems in peripheral phlebitis

42. Thank You