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AEGIS Automated Early warning Generation Information System A Quality Improvement Journey ONIG Presentation October AEGIS Automated Early warning Generation Information System A Quality Improvement Journey ONIG Presentation October 2015

The Problem – Current ICU Admission State v 25% of all patients admitted to The Problem – Current ICU Admission State v 25% of all patients admitted to the ICU are from the in patient wards v 80% of these patients had vital abnormalities that included 3 or more SIRS criteria v Ward admissions to ICU had a mortality rate of 30 -40% vs ED admission mortality rate of 15% and post-op mortality rate of 5% Results of an internal retrospective chart review of 365 patients admitted to Osler’s ICUs & data retrieved through the CCSO CCIS database 2

The Problem - Delayed Response & Failure to Rescue v 50% of ward patients The Problem - Delayed Response & Failure to Rescue v 50% of ward patients admitted to Osler’s ICU had not had a prior CCRT consult v Delayed CCRT notification of greater than 8 hours from onset of calling criteria v In-hospital cardiac arrest Ø 80% non-shockable rhythms Ø 13% hospital survival rate Ø 6% 1 year survival rate 3

“What is being done” Finding the Right Solution “Where it is being done” Decision “What is being done” Finding the Right Solution “Where it is being done” Decision Point # 1 – is it the right solution ? ? ? 4

Literature Review v “Physiological track and trigger warning systems” (EWS) have been developed for Literature Review v “Physiological track and trigger warning systems” (EWS) have been developed for use outside critical care areas v These system have been found to assist in the timely recognition of deteriorating patients. v Use periodic observation of basic vital signs together with predetermined criteria. v They should be used as an adjunct to clinical judgment. v They have been found to be supportive to novice and beginner level nurses and to assist in assessment skill building. 5

Environmental Survey v The NEWS score is the largest national EWS effort to date. Environmental Survey v The NEWS score is the largest national EWS effort to date. v still remains problematic in the UK due to its lack of universal implementation ability (it has exclusion criteria) and it has yet to have its retrospective validation study published. v Despite, poor validation there are now many expensive “out of the box” software applications developed that utilize either a “MEWS” or “NEWS” scoring system. 6

“Out of the Box” Scoring Systems v Scoring systems have been found to have “Out of the Box” Scoring Systems v Scoring systems have been found to have poor discriminatory value as a score requires interpretation The MEWs Scoring System Decision Point # 2 – could we design a more specific set of triggers? ? 7

Project Feasibility – Right Time & Right Resources Completed a supportive project infrastructure review Project Feasibility – Right Time & Right Resources Completed a supportive project infrastructure review 1. Organizational aptitude § Business case § Stakeholder commitment 2. Organizational capacity § Fiscal health § Human resource abilities & capacity § Technical systems abilities & capacity Decision Point # 3 – is it the right time ? ? Decision Point # 4 – do we have the right resources ? ? ? 8

Project Aim To reduce the time to early recognition of patient deterioration and thereby Project Aim To reduce the time to early recognition of patient deterioration and thereby increase the response time to prevent failure to rescue on the inpatient wards through the implementation of a home grown “track & trigger” system. 9

Regional Chief Technology Officer Program Director of Critical Care Services Project Sponsors & Project Regional Chief Technology Officer Program Director of Critical Care Services Project Sponsors & Project Teams Project Technical Design Team CW Critical Care LHIN Lead (Physician Lead) Clinical Analyst(s, ) Information Services Telecommunications & Devices Lead Project Clinical Design & Pilot CW Critical Care LHIN Lead (Physician Lead) Clinical Quality Critical Care Lead Clinical Analyst(s, ) Information Services Pilot Inpatient Ward Clinical Resource Nurses Corporate Project Implementation CW Critical Care LHIN Lead (Physician Lead) Clinical Quality Critical Care Lead (Clinical Lead) Clinical Champion (Clinical Co Lead) Corporate Project Manager Clinical Analyst(s, ) Information Services 10

Project Measurements Process Measures Frequency of alerts Time to CCRT call from 1 st Project Measurements Process Measures Frequency of alerts Time to CCRT call from 1 st calling criteria met Balancing Measures Frequency of CCRT New Consults Inpatient Ward Staff Satisfaction with new processes Outcome Measures Inpatient ward Code Blue events rate (# of CODE Blue events/1000 inpatient ward admits) Inpatient ward unplanned transfers to ICU rate ( # of ICU transfer/1000 inpatient ward admits) Inpatient ward mortality rates ( # of inpatient ward deaths/1000 inpatient ward admits) 11

Technical Design Vital Signs & Laboratory Values in Meditech (EMR) Meditech Version 5. 67 Technical Design Vital Signs & Laboratory Values in Meditech (EMR) Meditech Version 5. 67 AEGIS algorithms programmed in IATRICS a middle ware product. When algorithms are identified IATRICS sends a preprogrammed alert message. Alert Message sent to wireless handheld device i. POD ® 12

All Inpatient Wards Clinical Algorithm Design • SIRS Criteria (HR, Temp. , WBC) • All Inpatient Wards Clinical Algorithm Design • SIRS Criteria (HR, Temp. , WBC) • Shock Index (HR/SBP) Additional Added Inpatient Ward Specific Algorithms Respirology § High & Low Respiratory Rate Neurology § Elevated Systolic Blood Pressure § AVPU Cardiology § High & Low HR Surgical (Post Op) § Low RR 13

Technical Concept Operational Feasibility Trial - PDSA Cycle #1 • I site - new Technical Concept Operational Feasibility Trial - PDSA Cycle #1 • I site - new facility with new technical and structural infrastructure • 1 site 50 year old facility with a fragmented technical infrastructure and significant structural limitations • wireless transmission & point of care equipment Clinical Concept • differing case mix patient groups to test algorithmic specificity & clinical response • testing clinical operational concept and required processes to ensure clinical success & sustainability • preliminary data collection for concept confirmation 14

Feasibility Outcomes Decision Point # 5 - technical & clinical concepts Technical resource requirements Feasibility Outcomes Decision Point # 5 - technical & clinical concepts Technical resource requirements identified !!! confirmed as feasible • • • Wireless improvements additional portable wheeled computers refresh of stationary desktops Clinical requirements identified • Algorithm adjustments required to provide optimal clinical recognition for differing case mix groups • Clinical operational processes will need more fulsome review in a longer term pilot Technical 15

SIX (6) Month Pilot Clinical Pilot – Continuous PDSA Cycles SIX (6) inpatient medical SIX (6) Month Pilot Clinical Pilot – Continuous PDSA Cycles SIX (6) inpatient medical wards, 3 at each site FOUR (4) medical clinical disciplines Tested: clinical algorithm specificity, clinical processes & practices Measured: clinical performance Defined: additional Resources 16

 • wireless device management Clinical Pilot – Challenges • Meditech documentation limitations • • wireless device management Clinical Pilot – Challenges • Meditech documentation limitations • • end of life clinical technical tools point of care resources limited for point of care documentation • manual data collection processes 17

Pilot Outcomes Average CODE Blue rate decreased by 35% 8. 3 to 5. 4 Pilot Outcomes Average CODE Blue rate decreased by 35% 8. 3 to 5. 4 CODE Blue events/1000 ward admissions Average unplanned ICU transfer rate decreased by 17. 5% 31. 5 to 26 unplanned ICU admissions/1000 ward admissions Average inpatient ward mortality rate decreased by 2 -4 lives/month 38 to 36 deaths/1000 ward admissions Despite an expected low positive predictive value of 15% for the outcomes the alert frequency was manageable, 3 -6 per day per ward Charge nurses felt the system facilitated improved communication with bedside and CCRT nurses as well as with attending physicians 18

Additional 13 inpatient units including Surgical Program Corporate Implementation Additional Resources Required 1. Project Additional 13 inpatient units including Surgical Program Corporate Implementation Additional Resources Required 1. Project Manager 2. Clinical Champion Continued Focus on Process Improvements Time to documentation Meditech Documentation & Optimization Performance Metrics & Performance follow up 19

Addition of a Champion – BIG Benefits!!! 1. Strong communication skills 2. Experienced and Addition of a Champion – BIG Benefits!!! 1. Strong communication skills 2. Experienced and knowledgeable in current ward processes and skilled in day to day clinical care & documentation 3. Have a positive attitude 4. Clinical frontline role model 5. Demonstrate the potential to be a successful leader 20

Benefits of Adding of a Project Manager Keeping the project…. 1. within scope 2. Benefits of Adding of a Project Manager Keeping the project…. 1. within scope 2. on time 3. and within budget 21

Time to Documentation Time to documentation continues to improve on the 19 AEGIS units Time to Documentation Time to documentation continues to improve on the 19 AEGIS units Average Time was 4. 7 hours …NOW 1. 27 hours 90 th Percentile was 6. 85 hours. . . NOW 2. 8 hours 22

Meditech Vital Signs Documentation & AEGIS 23 Meditech Vital Signs Documentation & AEGIS 23

Meditech Optimization for AEGIS Pre-set data fields for each vital sign allowed for the Meditech Optimization for AEGIS Pre-set data fields for each vital sign allowed for the data entry of extra digits within the boxes. ke tro ys Ke of A keystroke error created false AEGIS alerts. ion rors % !! ct du Er o 0. 5 e QI # 1: R field was set for the t Each pre-set data exact number of digits required. 0% m 1 QI # 2: fro Pop-up messages were created to alert the nurse if the entries were outside of normal limits. 24

Hardwiring Excellence & Building Clinical Performance Set & Communicate Expectations Audit & Review Communicate Hardwiring Excellence & Building Clinical Performance Set & Communicate Expectations Audit & Review Communicate Performance 25

Accountability Documentation Multiple Alerts from same vital signs Nursing action Orders from MD The Accountability Documentation Multiple Alerts from same vital signs Nursing action Orders from MD The nurse is required to document the intervention called AEGIS alert after each alert received for his/her patient. 26

Compliance Audit 27 Compliance Audit 27

Monthly Metrics Available Meaningful Accessible Visible Time to Documentation ICU Transfer Rate CODE Blue Monthly Metrics Available Meaningful Accessible Visible Time to Documentation ICU Transfer Rate CODE Blue Rate Mortality Rate CCRT New Consult Rate Time to CCRT Notification 28

Market your project well Prepare your marketing toolbox Staff Communication & Training Hit the Market your project well Prepare your marketing toolbox Staff Communication & Training Hit the road and hold hands with the stakeholders Remember the 5 Rights Right information Right people Right time to get the right attention and get the right results ! 29

Address Challenges 30 Address Challenges 30

Sustainability & Outcomes Measure…Measure Shout ate e. R Blu DE CO 3. 33 !!! Sustainability & Outcomes Measure…Measure Shout ate e. R Blu DE CO 3. 33 !!! e rat good news uction and spread the. 88 rpo 3 Co red 15% her 3 months, not A 6 months, 12 months, 18 months 31

Review unexpected outcomes 32 Review unexpected outcomes 32

Address Interdependencies ICU Transfer Email Notification 33 Address Interdependencies ICU Transfer Email Notification 33

Next steps… 2. More spread …into the Emergency department 3. Scale up to include Next steps… 2. More spread …into the Emergency department 3. Scale up to include LHIN partners at Headwaters Healthcare 34

Referencesr. , Hillman, K. , Chen, J. , Finfer, S. , & Flabouris, A. Referencesr. , Hillman, K. , Chen, J. , Finfer, S. , & Flabouris, A. (2008). Respiratory rate: The neglected vital sign. Cretikos, M. , Bellomo, Medicine Journal, 188, (11). 657 -659. Cooksley, T. , Kitlowski, E. , Haji-Michael, P. (2012). Effectiveness of Modified Early Warning Score in predicting outcomes in oncology patients. Quality Journal of Medicine, doi: 10. 1093/qjmed/hcs 138 Fullerton, J. , Price, C. , Silvey, N. , Brace, S. , & Perkins, G. (2012). Is the modified early warning system (MEWS) superior to clinician judgement in detecting critical illness in the pre-hospital environment? Resuscitation, 83, 557 -562. doi: 10. 1016/j. resuscitation. 2012. 01. 004 Ghanem-Zoubi, N. , Vardi, M. , Laor, A. , Weber, G. , & Bitterman, H. , (2011). Assessment of disease severity scoring systems for patients with sepsis in general internal medicine department. Critical Care 2011, 15: R 95 http: //ccforum. com/content/15/2/R 95 Higgins Y et al. (2008). Promoting patient safety using an early warning scoring system. Nursing Standard. 22(44), 35 -40. Ludikhizen, J. , Smorenburg, S. , de Rooij, S. E. , de Jong, E. (2012). Identification of deteriorating patients on general wards; measurement of vital parameters and potential effectiveness of the Modified Early Warning Score. Journal of Critical Care 27, 424 e 7 -424 e 13. Nursing Executive Center (2009), The critical thinking toolkit. The Advisory Board Company. https: //www. advisory. com/international/research/global-centre-for-nursing-executives/studies/2009/the-critical-thinking-toolkit Royal college of Physicians (2013). The Medical patient at risk: Recognition and care of the seriously ill or deteriorating medical patient. Acute Care Toolkit 6. Subbe. C. , Kruger, M. , Rutherfornd, P. , & Gemmel, L. (2001). Validation of a modified early warning score in medical admissions. Quality journal of Medicine, 94, 521 -526. 35

OUR VISION PATIENT-INSPIRED HEALTH CARE WITHOUT BOUNDARIES 36 OUR VISION PATIENT-INSPIRED HEALTH CARE WITHOUT BOUNDARIES 36