Action Sets Case Study: Acute Upper GI Bleed in A&E

Group The BMJ Group Evidence Centre

Content and services for healthcare organisations

Over 30 titles Over 30 titles supporting supporting research research across multiple across multiple clinical clinical specialties. specialties

Resources to support Resources to support CPD, CPD, appraisal, appraisal, re-validation revalidation and exam preparation. and exam preparation

Evidence based Evidence based products products to support to support clinicians in clinicians in decision decision making making

What are they?

Production

Care Designer

Structure + Content

Benefits

Lists of actions, tests or treatments required to diagnose and manage patients

500 sets covering 150 conditions

Evidence based Designed for CPOE / Order Comms systems but can also be used for paper processes UK authored and peer reviewed

What are they?

Production

Care Designer

Structure + Content

Benefits

Support the whole care pathway Divided into appropriate care settings Include NICE guidelines and BNF Drug Information Can be customised to meet your local practice, formulary and guidelines Process in place for regular updates

Action Sets Implementation Overview

OriginalBMJ Evidence Original Action Action Master Set Set Action Set

Content review and localisation

Review Evidence Review Sheet Sheet Localisation Original Action Local Set protocols

BMJ

tools
Local evidence- BMJ Evidence Local evidencebased Action Set based Action Set Local evidencebased Action Set

Non-EHR implementation

EHR/CPOE integration

Integration into local workflow

BMJ Evidence

BMJ Evidence

Local Action Sets live

Continuous service improvement

Key Components of Measurable Improvement

BMJ Evidence

Embedding localised Action Sets into local workflow

Performance tracking

Clinical engagement

Patient care: More consistent Better co-ordinated

Clinical Governance and Localisation Process

Local clinical ownership and robust governance are essential for successful implementation The BMJ provides guidance on clinical governance and localisation process

Action Sets Localisation Tools

Editable HTMLs Web-based Care Designer
Lets put in option for daily glucose check. (4 times a day for most new diabetics would be very intimidating.)

Progress Tracking Tool Excel Review Sheet

Customisable Template for paper-based Action Sets

What are they?

Production

Care Designer

Structure + Content

Benefits

What are they?

Production

Care Designer

Structure + Content

Benefits

What are they?

Production

Care Designer

Structure + Content

Benefits

What are they?

Production

Care Designer

Structure + Content

Benefits

What are they?

Production

Care Designer

Structure + Content

Benefits

Improve patient safety Standardise care based on evidence rather than on current practice Eliminate unnecessary tests increase efficiency and reduce costs Eliminate handwriting errors facilitate coding and audit Properly implemented can reduce mortality, reduce length of stay, reduce costs and reduce readmissions

RFH Pilot

Royal Free Hospital pilot of BMJ Action Sets targeting the management of upper GI bleeding
Examined two quality indicators in the initial management Rockall Scores and use of i.v. proton pump inhibitors Rockall scoring is a simple risk assessment tool which takes account of age, signs of shock and co-morbidity 1 Patients with a score of 0 or 1 have <1% mortality 2

RFH Pilot - data 0% of acute clinicians calculated a Rockall score on admission

0% of gastroenterology clinicians calculated a Rockall score on admission

50% of inpatient endoscopy patients had a Rockall score of 0 (length of stay 3-5 days) 65% of patients received i.v. pantoprazole preendoscopy
1.

Unpublished data from the Royal Free Hospital, presented at the Cerner Health Conference by Dr James OBierne, September 2010

 RFH implemented the BMJ upper GI bleed Action Set in Cerner Millennium system Adapted it to their organisation Recent data presented at the BSG: Rockall score recorded 33% Discharge from A&E if Rockall score 0 100% Inappropriate PPI use 67% reduction
1.

THERE WILL BE BLOOD A COMPLETE AUDIT CYCLE. M. Pericleous, C. Murray, M. Hamilton, O. Epstein, R. Negus, J. O'Beirne. BSG 2011 - Abstract Submission, Health Service Research and IT BSG11-ABS-2046

RFH Pilot lessons learnt Action Sets offer a lot of value Customisation is not difficult and worth the resource BUT Action Sets need to be seen as part of a Quality Improvement Initiative, with ongoing support and training Implementing one at a time is not optimal

Ideally linked to fully functional EHR

Any Questions?
kbrunnhuber@bmjgroup.com