ࡱ> po>H( `/ 0DTimes New Roman\) 0DSymbolew Roman\) 0 @ .  @n?" dd@  @@`` | B{%*  +    +3-:&xe())   0AA@quʚ;2Nʚ;g4BdBd6, 0ppp@ <4!d!dXk 08)<4ddddXk 08)<4BdBdXk 08)2 0___PPT10 pp___PPT9., , ? %q@pCOPD in-patient management : guideline development, implementation and follow-up in the acute hospital setting  qo o Don Campbell Caroline Brand Acknowledgements  Report Dr Caroline Brand and Ms Fiona Landgren Project Conception Dr Donald Campbell Dr Peter Greenberg Dr Harry Teichtahl Prof Anne Maree Kelly Prof Peter Cameron8(cr    +   Project Development and Research Design Dr Caroline Brand Ms Fiona Landgren Ms Jill Nosworthy Dr Don Campbell Data collection Ms Fiona Landgren Ms Ana Hutchinson Ms Catherine Jones Dr Caroline Brand Data analysis Dr Lachlan MacGregor Dr Caroline Brand fZZ'GK(B   &   ,  Clinical Practice Guidelines   Systematically developed statements developed to assist practitioner and patient decisions about appropriate health care for specific circumstances . What is known about: Implementation? Long-term impact? "#0(   pWhat did we do? What did we find? What difference did it make? Was it sustainable? What would we do differently?qqp What we set out to do  MGoal To improve the standard of care and health related quality of life for patients who have experienced an acute exacerbation of COPD requiring hospitalisation at Royal Melbourne (RMH) and Western Hospitals (WH). Aim Development and implementation of evidence-based clinical practice guidelines for the acute in-patient episode. "MN.   <.Project activities 1 Examine VIMD database 2 Prospective case-note audit (pre/post intervention) 3 CPG development pathway decision nodes evidence-based (consensus driven) Implementation Strategy multi-faceted, evidence-based``9" `9Z&   I  =/Project activities 2 5 Outcome measures Patient: Satisfaction HRQoL Institution: LOS Readmission rate 6 Process measures medication use, tests clinical indicators (ACHS for asthma, ?? For COPD)\LILI     L   'Guideline Implementation and Evaluation(( ' Time period: pre-implementation phase: 3/6/99 to 9/9/99 post-implementation phase: 7/11/99 to 31/3/00 Patients admitted: WH RMH pre-implementation 141 68 post- implementation 138 62 ,t( H      Demographic characteristics   WH RMH Parameter Pre Post Pre Post Av Age (yrs) 68 69 70 72 Males (% of total) 60 52 71 51 Current Smokers (% of total) 35 32 31 30 Ex Smokers (% of total) 63 62 56 57 Language Barrier(% of total) 11 11 25 10* Presentation to hospital 51 72 43 51 previous 12 months (% of total) Average duration of illness 4.1 5.7** 8.6 5.8 for presenting episode (in days) No of deaths (% total) 0 0 4 (6%) 3 (5%)JZQZ"Z+Z What happened?   Short-term impact evaluation ,$ LOS and Readmission rates    WH RMH Pre Post Pre Post (172) (173) (72) (70) Ave LOS (days) 7.1 7.1 8.4 4.5 ** (6,1-50) (5,1-37) (7,0-28) (4, 1-13) Unplanned re-admission 28 days post discharge 18 16 3 8 (% of total) (10%) (9%) (4%) (11%) x %! -V          Hours in ED     WH RMH Pre Post Pre Post (65) (65) (68) (63) Ave Time in ED (hrs) 9.4 8.8 8.7 12.4 * median 8.2 7.8 7.3 9.8 (range) (1-23) (2-34.2) (0.8-26.4) (2.7-34.6) VF 2F   -Test use at initial assessment   \Triage Category Pulse Ox (SpO2) ABG CXR FBE 1 X X X X 2 X X X X 3 X X X 4 X X X 5 X X X (X indicates test recommended) CXRs and ABGs- Reduced at RMH (unchanged at WH). ABG reduction significant at RMH (c2= 11.44, p < 0.001). Sputum m&c tests reduced at WH. Z]Z#Z D %E #       $Recommended ongoing therapy for COPD %$  WH RMH Pre Post Pre Post (65) (65) (68) (63) IV line inserted 85% 74% 93% 54% IV removed at 24 hours 24% 35% 25% 47%* Oral Antibiotics (wards) 89% 80% 80% 53%** IV Antibiotics (wards) 56% 35%* 60% 25%** Oral C steroids (wards) 91% 95% 85% 77% IV C steroids (wards) 64% 49% 20% 11% Ipratropium nebs (wards) 94% 88% 88% 74% MDI (+/- spacer) (wards) 88% 85% 57% 61%vc "  X     D%Recommended post discharge management &%  WH RMH Pre Post Pre Post (65) (65) (68) (63) Inhaler education 8% 42% 10% 8% Communication with GP 86% 68% 7% 8% (fax) Follow up arrangements (not recorded) 8% 6% 24% 11% Provision of a discharge pack >0Results  'Quality of life Disease specific QOL (SOLQ)- Coping reduced 28 days after discharge. Generic QOL (SF12) post implementation- MCS improved at both hospitals (NS). Satisfaction with care moderately high at both hospitals (low score for hospital reputation post implementation at one hospital ).))&'+$&\/         ,  /   Long-term sustainability?   Two years later  &CPG-Two Year Evaluation . ` 1 Medical Record Audit (6 months post implementation) 2 Staff survey: awareness & use of CPG s Survey Intranet access and CPG quality Focus Groups & Key Informant InterviewsF*O" *OT    ' (, Summary Audit Some medical units may be protocol driven Specific drug recommendations accepted ? related to CPG use Poor uptake: process of care and non drug recommendations Uptake of CPG recommendations usually but not invariably relates to level of evidence|Q -WQ -Vn C    V-CPG - Staff Survey N=188 Medical 43.7% Nursing 29.0% Students 21.3% Age 20-49 (75.4%) Medical (57.9%) Surgical (22%) Senior staff 73% Gender F80:M57 (>39yrs F20:M52) 2`` 2$Staff Survey Summary- CPG use&    Barriers Difficult to locate Poor Index Too prescriptive No allowance for variation Not evidence based Lack of time Too general. w w x Facilitating Factors Represent best practice Evidence-based Easy to access Expedite decision making Concise Support treatment decisions Refresh memory.6(Intranet Survey Summary  Variable access to department home sites Inconsistency: layout, terminology and content Poor adherence to NHMRC guidelines for CPG construction"  8* Most health professionals favoured use of CPG/protocols Some staff expressed concern about  cookbook medicine Emphasis on use as guidelines not proscriptive documents Access and quality of guidelines is a major issue Occupational preferences identified- : nurses prefer protocols/pathways  nurses do not make decisions where there is ambiguity Departments are variably protocol driven: ED, ICU, Renal Medicolegal issues not a major concern High staff turnover limited corporate memory and training in use Y$  Y(:0F    9+    Contextual analysis  Staff turnover Relationship to quality program Interdisciplinary teams? (or professional isolation: multitude of teams) Information Technology support? Integrated care? Executive Leadership??`H0HH-Hd  H  '   Signposts for the future   Finding the imperatives that will drive systems integration in public sector health care Narrative to find simple rules Values and ethical frameworks Science of complexity Rewarding teamwork.\f\fP[   (  CKnowing what we now know, what would we do (differently) next time?DD C Leadership Build into Quality framework Communication Simple rules for providing quality care Patient-centred: involve from Day 1- meet needs Collaborative: build manager-clinician partnership Knowledge-based: CPG plus expertise Reward and recognition Team-play Communication \^^j'   0    / "? @   0` ` ̙33` 333MMM` ff3333f` f` f` 3>?" dd@,|?" dd@   " @ ` n?" dd@   @@``PR    @ ` ` p>> $(    6P} P  T Click to edit Master title style! !  0<   RClick to edit Master text styles Second level Third level Fourth level Fifth level!     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'2 *=patient management : .-@Times New Roman-. F2 3*guideline development, implementation and .-@Times New Roman-. 2 >follow.-@Times New Roman-.  2 >)-.-@Times New Roman-. 72 >+ up in the acute hospital setting.-@Times New Roman-. 2 J@ Don Campbell.-@Times New Roman-. 2 R?Caroline Brand.-@Times New Roman-. +2 j^Clinical Epidemiology & .-@Times New Roman-. 42 o^Health Service Evaluation Unit.-@Times New Roman-. 2 u^Melbourne Health.-՜.+,0     On-screen ShowMonash University֬ Times New RomanSymbolDefault DesignqCOPD in-patient management : guideline development, implementation and follow-up in the acute hospital setting AcknowledgementsClinical Practice GuidelinesSlide 4What we set out to doProject activitiesProject activities 2(Guideline Implementation and EvaluationDemographic characteristicsWhat happened?LOS and Readmission rates Hours in EDTest use at initial assessment%Recommended ongoing therapy for COPD&Recommended post discharge managementResultsLong-term sustainability?CPG-Two Year Evaluation Summary AuditCPG - Staff Survey N=188Staff Survey Summary- CPG useIntranet Survey Summary Slide 23 Slide 24Contextual analysisSignposts for the futureDKnowing what we now know, what would we do (differently) next time?  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