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Improving Quality & Patient Safety Evidence Based Order Sets An effective solution to the complex challenge of improving patient care and safety © Trillium Health Centre 2006 Experimental Design, Data Collection, Analysis Chris O’Connor MD, Neill KJ Adhikari MD CM MSc, Katharine DeCaire RN MN ACNP, Jan O Friedrich MD DPhil Order Set Committee Chris O’Connor, Katharine DeCaire, Zelia Campos, Bruce Tugwood, Pam Johnson, Allan Mills, Vera Jovanovic, Catherine Scaletta © Trillium Health Centre 2006 Outline Current Context: The Need for Order Sets Order Sets A Clinical Decision Support Tool Order Sets Improving Care at Trillium Order Set Advantages Order Set Challenges Trillium’s Order Set Innovation Open Source Order Set Project © Trillium Health Centre 2006 Current Context: The Need for Order Sets © Trillium Health Centre 2006 Modern Case Presentation 67 year old female Past Medical History: High Blood Pressure, Diabetes History of Present illness: Presents to Emergency Room with severe pneumonia. Patient is unable to breathe on her own and is intubated. She is transferred to the Intensive Care Unit for her medical care © Trillium Health Centre 2006 Modern Case Treatments Antibiotic treatment- fast Strict glycemic control Activated Protein C Communicate with and support patient family Early goal directed fluid therapy Proper sedation/pain relief DVT prophylaxis Correct electrolytes Early feeding Elevate the head of the bed Low tidal volume ventilation Bowel routine Steroids Mouth care Pepcid to prevent GI bleeding Ongoing investigations © Trillium Health Centre 2006 © Trillium Health Centre 2006 © Trillium Health Centre 2006 © Trillium Health Centre 2006 © Trillium Health Centre 2006 Context: Massive Gap Between the Possible and the Actual Quality Misuse, under use, overuse on a massive scale: Crossing the Quality Chasm 2001 Safety Medical error is common: Institute Of Medicine Report on Error 2000 Variation in Care Variability in care not explained by patient preferences or different disease patterns: British Medical Journal 2002; 325: 961-964 © Trillium Health Centre 2006 Context: The Canadian Adverse Events Study G. Ross Baker et al, CMAJ May 25 2004 170(11) The adverse event (AE) rate due to health care management was 7.5% The AE rate of preventable events was 2.8% The rate of deaths from preventable AEs was 0.66% This would mean between 9200 and 23750 deaths/yr in Canada © Trillium Health Centre 2006 Context: Gaps in the Care of Patients Admitted to Hospital with an Exacerbation of Chronic Obstructive Pulmonary Disease Edward Etchells et al, CMAJ April 27, 2004; 170 (9) 84% had at least 1 inpatient gap in care 15% patients with 3 or more gaps in their care, 15% an inpatient adverse event 2 of the 16 pts with adverse events died longer stays 16.4 v. 8.6 days if a pt had an adverse event Patients who had an inpatient adverse event had more gaps in their care 2.0 v. 1.3 gaps © Trillium Health Centre 2006 Where do we go from here? Traditional Methods to Change Clinician Behavior Written Materials/guidelines Audit and Feedback Academic Detailing Local Opinion Leaders Zero to moderate effectiveness at best Not scaleable Limited Scope Not durable © Trillium Health Centre 2006 Solution: Order Sets a Clinical Decision Support Tool A group of orders with a common functional purpose used by the physician to create orders. Integrates knowledge into the care delivery process “knowledge where the clinician needs it most” Organizes clinical knowledge so it is easy to remember, easy to use and has maximum benefit to the patient Contain evidence-based best practices Source of education Can be used in paper or computerized ordering systems © Trillium Health Centre 2006 © Trillium Health Centre 2006 © Trillium Health Centre 2006 © © Trillium Trillium Health Health Centre Centre 2006 2006 © Trillium Health Centre 2006 Order Sets: Key Benefits Safety Reduced transcription errors Reduced errors of omission Reduced errors in medication dosing Quality Improved compliance with evidence-based best practices Standardization of care Efficiency Decreased time to write and process orders Reduction in physician call-backs Reduction in missed orders Critical enabler for computerized practitioner order entry © Trillium Health Centre 2006 Order Sets: Improving Care © Trillium Health Centre 2006 Order Set Adoption 80 70 60 50 % Use of Order Sets 40 30 20 10 0 Oct-Nov 2003 April-Dec Feb-Mar 2005 Dec-05 © Trillium Health Centre 2006 Data Collection Primary outcome DVT Prophylaxis Rates: Random Chart audit from three time periods October-November 2003 April – December 2004 February – March 2005 DVT prophylaxis rates in the Department of Medicine April 2003 to March 2005 Secondary Outcomes: Assess in second chart period Multiple Quality metrics assessed. © Trillium Health Centre 2006 DVT: The Preventable Epidemic DVT is the formation of blood clots in the legs DVT is very common in hospitalized patients DVT can cause death or serious disability There is excellent treatment to prevent DVT if patients get it Many studies have shown that many patients do not get this treatment which can save their lives “The disconnect between evidence and execution as it relates to DVT prevention amounts to a public health crisis” - S. GoldHaber, Associate Professor Harvard Medical School, 2003 The order sets contained a section with treatment to prevent DVT © Trillium Health Centre 2006 Impact of Order Set Use on DVT Prophylaxis Orders 45 40 35 30 % Orders w ith DVT Prophylaxis 25 Order Set No Order Set 20 15 10 5 0 Oct-Nov 2003 April-December 2004 Feb-March 2005 © Trillium Health Centre 2006 35% 30% Monthly DVT Prophylaxis Rates Improved Format + Content Order Sets Introduced 25% 20% 15% 10% 5% 0% rAp 03 ay M 03 4 5 3 4 3 4 4 5 4 3 3 3 4 4 4 3 4 3 4 04 -04 05 -0 -0 -0 -0 -0 ul-0 -0 -0 -0 n-0 ul-0 -0 -0 rrt-0 ov-0 ec-0 t-0 ov-0 ec-0 r b b n n n y p p g g a a c c p e e a J J Ju O Ja F M A Ju O Ja F M Se N D Se N D Au M Au © Trillium Health Centre 2006 Use of Low Molecular Weight Heparin 1000 LMWH Introduced into Medical Order Sets 900 800 Number of Doses 700 600 500 400 300 200 100 0 05 na J 05 be F ar M 05 rAp 05 ay M 05 05 nu J 5 l-0 Ju 05 gu A 05 pe S O 5 .0 ct N 5 .0 ov D 5 .0 ec 06 n. a J 06 b. e F 6 .0 ar M 6 r.0 p A © Trillium Health Centre 2006 50 LMWH Introduced Into Order Sets Monthly DVT Prophylaxis Rates (%) 45 40 35 30 25 LMWH Regular Heparin 20 15 10 5 0 05 na J 05 be F 5 -0 ar M 5 r-0 p A ay M 05 05 nu J 5 l-0 Ju 05 gu A 05 pe S O 05 ct. 05 v. o N 05 c. e D 06 n. a J 06 b. e F 6 .0 ar M 6 r.0 p A © Trillium Health Centre 2006 Impact of Order Set Use on Protocol Use 70 60 50 40 %Orders Order Set 30 No Order Set 20 10 0 Standardized Insulin Standardized Scale Potassium Protocol Standardized Diabetic Diet © Trillium Health Centre 2006 Impact of Order Set Use on Documentation 100 90 80 70 60 %Orders 50 Order Set No Order Set 40 30 20 10 0 Admitting Diagnosis Documented Allergies Documented Code Status Documented © Trillium Health Centre 2006 Order Set Impact on Order Content 90 80 70 60 50 %Orders Order Set 40 No Order Set 30 20 10 0 Zoplicone QHS PRN Lorazepam QHS PRN Ordering of PRN order for Allied Health Urea ECG Consult © Trillium Health Centre 2006 Impact of Order Sets on Order Process 100 90 80 70 60 %Orders 50 Order Set No Order Set 40 30 20 10 0 Numbering of pages Dating of Orders Timing of Orders Signing of Orders © Trillium Health Centre 2006 Management of DKA in ICU 100% 90% 80% 70% 60% 50% No order Set Order set 40% 30% 20% 10% 0% Code status Endocrine consult Urine C&S Urine R&M DVT Prophylaxis Standard ICU protocols © Trillium Health Centre 2006 ER/ICU Survey Results: Order Set Impact 40 35 Responses 30 25 Improved Process of Care Delivery 20 Improved Quality of Care Reduced Time to Use 15 Reduced Transcription Error Risk 10 5 0 Strongly Agree Agree Neutral Disagree © Trillium Health Centre 2006 The Order Set Advantage Addresses the challenges facing medicine today: Scalable Durable Broad Scope No significant process redesign to implement No significant education Work in line with ordering process augmenting physician knowledge Preserve autonomy © Trillium Health Centre 2006 The Order Set Challenge © Trillium Health Centre 2006 The Order Set Challenge Order Sets Must Be: Current Evidence Based and Best Practice Authoritative Easy to Use Comprehensive Reliable and safe Clinically Intelligent © Trillium Health Centre 2006 The Order Set Challenge Order Sets are Complex! Typical medical admission order set has 130 order elements in the set Interdisciplinary Multiproccess Integration with other care documents and activities Over 400 different order sets for a typical hospital Standardization, integration across systems is critical © Trillium Health Centre 2006 Current Status of Order Sets © Trillium Health Centre 2006 Current Status of Order Sets Lack of Recognition of Order Set Importance Order Set Design Often no standardized structure Structure is not modular Lack of integration with other processes/documents Order set life cycle not well established No dedicated Order Set Committee at most hospitals Most often P+T/MAC based process, occasionally process is distributed to the level of the health systems Best practices often not scaled across departments Lack of version control No measurement of metrics Each hospital has its own structure and approach to order sets © Trillium Health Centre 2006 Current Status of Order Sets No good library of content No standardization of format, content or processes between organizations Limited ability to share order set content between organizations Each Organization must create its own order set project Duplication of effort Reduced quality Slow implementation of best practices Consumption of limited hospital resources Organization may lack content expertise in all the subject areas need for order sets Organization may lack knowledge of order set best practices in design and order set lifecycle External resources for order sets currently are very limited © Trillium Health Centre 2006 Order Set Innovation © Trillium Health Centre 2006 Trillium’s Order Set Project 2001: Order set development begins in ICU Rapid Cycle improvement of order set design 2002: Order set development in other departments 2003: Standardized order set format established 2004: Current Order Set Committee established 2006: Standardized order sets in use in every Health System Over 250 order sets currently in use Admission order set use > 90% in most health systems © Trillium Health Centre 2006 Trillium Order Set Project Winner of the first Ministry of Health award for Innovation in Patient Safety and Quality Expanded Commitment to Order Set Development and Implementation Order Set Project now has six dedicated FTEs Goal of expanding content by over 400 order sets in the next year Preparation for CPOE. Order sets developed for use in current paper ordering environment and in CPOE system © Trillium Health Centre 2006 Trillium Order Set Innovation Excellence in Order Set Design 5 years of iterative improvement in order set design Integration of real world feedback Intelligent knowledge representation to increase usability and clinical impact Order Set Process Real time integration of authoritative content expertise into order sets Dedicated Interdisciplinary Order Set Committee 9 member committee that meets weekly Clearly established processes for all aspects of the order set lifecycle – initiation, development, approval implementation and maintenance Integration of order sets with other processes and documents © Trillium Health Centre 2006 Trillium Order Set Innovation Order Set Content Over 250 order sets developed Order sets used in every health system Content is interdisciplinary addressing all aspects of a patient’s care Web enabled searchable data base of all clinical decision support tools Interdisciplinary development teams Content experts own the content Order set committee provide process knowledge © Trillium Health Centre 2006 Open Source Order Sets Based on Trilliums award winning Order Set Project Dedicated to improving healthcare in Canada by facilitating the use of high quality, standardized evidence based order sets Partnering with other Health Care Organizations to standardize and improve the quality and safety of patient care Niagara Health System Open Source Order Sets Provide a complete order set solution Save organizations time, money and reduce demand on limited organizational resources Improve quality Local ownership and adaptation of tools © Trillium Health Centre 2006 Open Source Order Sets Standardized Order Set Design Standardized structure to order set content based on DAVID Rules of correct formatting at all levels of order set content Clear syntax of order set content Designed to anticipate CPOE Modular Format Best practices are contained in functional groups Facilitates the spreading of best practices across different order sets and across health systems Over 300 modules including many high value best practice modules such as deep vein thrombosis prophylaxis, bowel care, pain control, electrolyte management Order Set Lifecycle Order Set Committee Interdisciplinary membership Robust methodology for development, approval, implementation and maintenance © Trillium Health Centre 2006 Open Source Order Sets Large Library of Developed Content Over 250 order sets and clinical protocols Comprehensive interdisciplinary content Incorporation of real world experience Will grow to over 600 order sets in the next year Order Set Web Page Web accessible data base to store library of order set content Order sets clearly organized, searchable by many different criteria and relationships between order sets and clinical protocols clearly established Order Set Project Support On-site and remote support including physician, nursing, pharmacy Goal is rapid knowledge transfer © Trillium Health Centre 2006 Order Set Project Outline Establish an Order Set Committee Best practices around order set lifecycle Catalogue and upgrade legacy order set content Convert to standardized modular format Integrate new best practice content as appropriate Standardization of best practices across the organization Approval of new and upgraded order sets by the Order Set Committee Develop and Implement Order Sets Utilization of library of best practice content Adapt Open Source Order Sets to local health system needs New sets developed by content experts at Grey Bruce Comprehensive communication plan to facilitate adoption © Trillium Health Centre 2006 Order Set Project Outline Store order sets on an intranet accessible database Collection of data for metrics The measurement of improved outcomes is an important part of an order set project Order sets can have a dramatic impact on easily measured quality metrics in a very short time period Open Source Order Sets will work with you to select the key metrics that can be used to evaluate your project Number of order sets in use Order set adoption Adherence to best practices Before/after, cross-sectional analysis © Trillium Health Centre 2006 Benefits Save time Save money Improve the quality and safety of patient care Large improvements of easily measured metrics in short periods of time Improve order set design Increase order set use by physicians Increase the clinical impact of order set use Increase the standardization of best practices across the healthcare system Increase the knowledge base that can be used for order set development Hospitals are no longer developing order set content in isolation Improve the coordination of order sets with other order sets, documents and processes Improved coordination of health care delivery in Ontario © Trillium Health Centre 2006 Future The forces driving the need for order sets are accelerating Medical knowledge is increasing Complexity of treatments is increasing Effectiveness of treatments is increasing Care is delivered by large interdisciplinary teams Computerized Physician Order Entry requires order sets Recognition that effective orders must achieve many objectives simultaneously Quality Safety Workflow Resource utilization © Trillium Health Centre 2006 Why We Are Doing This? © Trillium Health Centre 2006 Why We Are Doing This? Share our award winning project with others Collaborate with other healthcare organizations Build a community of shared knowledge Potential to transform healthcare To standardize best practices across organizations To facilitate clinicians practice To improve the quality and safety of patient care we provide to all patients Save Lives © Trillium Health Centre 2006 Why We Are Doing This? Order Sets Save Lives Order Sets Deliver Better Care Order Sets Improve Efficiency © Trillium Health Centre 2006 “Standardize and automate that which is routine about a patient’s care so the clinician can focus on what is unique about each patient” © Trillium Health Centre 2006 Thank You! Chris O’Connor M.D. FRCPC Katharine De Caire ACNP © Trillium Health Centre 2006