Saving Lives Initiative in Wales
NPHS Draft Report
10th
October 2007
Dr. Layla Jader MB ChB, DA, MD, FFPHM
Consultant in Public Health Medicine
Background
• WAG & partners from WCfH, NLIAH,
NPHS & Clinical Governance Support and
Development Unit (CGSDU) planned to
launch a patient safety initiative in Wales,
the ‘1000 Lives’ campaign in 2007.
• It would adopt interventions similar to
those used in a US Campaign by Institute
of Healthcare Improvement (IHI) in 200506, the 100,000 Lives Campaign.
• The Welsh campaign was launched by the
Health Minister on September 27th 2007 &
will run for 18 months until February 27th
2009.
• Some of these interventions have already been
piloted in UK as Safer Patient Initiative (SPI) &
run by Health Foundation in collaboration with IHI.
• Initially, 4 hospitals were selected from across UK
for SPI 1, including Conwy & Denbighshire Trust.
• Since 2004 this hospital has
– reduced its rate of adverse events by > 50%
– reported fewer healthcare associated infections
– ventilator associated pneumonia has virtually
been eliminated from a previous level of 30%.
• Safer Patients Initiative phase 2 (SPI 2) is now
underway; Cardiff & Vale NHS Trust, Gwent
Health Care Trust & North East Wales NHS Trust
have been part of SPI 2 since February 2007.
The 12 IHI Initiatives
1. Deliver evidence based care for congestive heart failure
2. Reduce healthcare associated infection (reduce methicillin
resistant Staphylococcus aureus (MRSA) infection)
3. Prevent and reduce surgical complications
• Surgical site infection prevention:
• Beta Blockers for patients on who are beta blockers
• Venous thromboembolism (VTE) prophylaxis
• Post-operative pneumonia prevention for ventilated
patients
4. Prevent harm from high alert medications
5. Prevent adverse drug events (ADEs)
6. Prevent pressure ulcers
7. Deliver reliable, evidence based care for AMI
8. Deploy rapid response teams (RRT)
9. Prevent Central line infections
10.Prevent ventilator – associated pneumonia
11.Reduce surgical complications
12.Governance leadership: Getting the Board on Board
Time Table
• 12th July I was asked to work on the
project
• 1st August first meeting of the NPHS Team
with draft work proposal
• 8th August First Interim Report
• 21st September Second Interim Report
• Used for the Launch of the initiative on
27th September
• December 2007- Final Report
NPHS staff involved
1. Dr. Layla Jader, Consultant in Public Health
Medicine, the Lead
2. Dr. Mary Webb, Public Health Specialist
3. Dr. Eleri Davies, Consultant Microbiologist and
Director of NPHS Welsh Health Care Associated
Infection Programme
4. Ms Nuala Brennan, Consultant in Pharmaceutical
Public Health
5. Dr. Mark Temple, Consultant in Public Health
Medicine
6. Input from Public Health Information Department
(Nathan Lester & Hugo Cosh)
7. Input from Isabel Puscas -Public Health Library
Aim of the Report
To give public health advice to the Saving
Lives Campaign Coordinating Group
regarding:
– the evidence base for the identified 12
interventions,
– assess the transferability to Wales,
– estimate the likely outcomes in Wales &
– advise on monitoring.
Objectives
1. To search the evidence base identifying &
appraising evidence not accounted for by the IHI,
with an overall assessment of the effectiveness of
these interventions in public health terms.
2. Comment on the feasibility & transferability of
these interventions to NHS in Wales.
3. Based on 1 and 2 above, prioritise at least 4
interventions for initial implementation.
4. Provide an estimate of the range of possible
outcomes from this campaign in Wales.
5. Advise on monitoring.
Methodology
1. Literature search & pragmatic critical
appraisal of published papers/reports &
other similar campaigns in different
countries with public health commentaries
on their effectiveness.
2. Using existing NPHS links with various
organisations & NHS staff in Wales, to
build a picture that describes existing NHS
practice. Availability of data that are either
routine & system level type or those based
on limited audit data that are specific to
particular hospitals.
3. This required informal limited consultation
with various health professionals in Wales
Criteria We Used for the Selection of Top
4 IHI Interventions
1.
2.
3.
4.
5.
6.
Strength of the scientific evidence
Transferability for Welsh setting
Primary/secondary care interface
Existing Welsh initiatives/priorities
Ability to measure- is there a baseline?
Estimated current burden of health care
need (number of deaths, annual
incidence/prevalence and other data)
NO.
INTERVENTION
TRANSFERABILIT
Y FOR WELSH
NHS
PRIMARY/SECONDAR
Y CARE INTERFACE
EXISTING
WELSH
INITIATIVES/
PRIORITIES
1
Deliver reliable evidence
based care for congestive
heart failure. (Reduce readmissions)
Yes
Yes
Primary/secondary and
tertiary care relevance
Heart failure
service Pontypridd &
Rhondda NHS
trust
British Heart
Foundation
heart failure
nurses in place
in 13 Welsh
NHS trusts.
NO.
INTERVENTION
considered under IHI
initiative
1
Deliver reliable evidence
based care for congestive
heart failure. (Reduce readmissions)
Medical condition being
addressed
Congestive heart failure
STRENGTH OF
EVIDENCE
Numerous evidence
based guidelines.
Update of NICE
guideline due
December 2007.
Level 1 of good
quality
ABILITY TO
MEASURE – is
there a baseline?
Central Cardiac
Audit Database
(CCAD) heart
failure database.
WAG needs to
ensure that data
specific for Wales
can be extracted
from the CCAD
database
Estimated current (2007) burden of health care need
Number of
Deaths
Annual incidence/prevalence (I/P)
Further comments
354 (ECI 264 to
445)
(P) 33,000, (95% CI 1600 to 60,000)
14,000 (7,000 to 25,000)
aged under 75 yrs
RCT Heart Failure Service
(2001-07)
•
•
•
•
•
18% reduction in admissions to hospitals
55% reduction in readmissions
bed occupancy fell from 7.4% to 5.5%
decrease in length of stay by 4 days
decrease in cost by £23,000/month.
The 4 prioritised interventions
• Delivering reliable evidence based health
care for chronic heart failure
• Reducing health care associated infections
(HCAI)
• Preventing & reducing surgical complications
• Preventing harm from high risk medicines
(anticoagulants, insulin, sedatives &
narcotics)
In Summary
• ‘Boards on Board’ should be a given
• The potential to confuse NHS by launching a
national campaign whilst existing national initiatives
claim to be addressing the same issues
• Adequate consultation was needed with key
clinicians & managers before this stage
• Estimating the number of lives likely to be saved is
very difficult. For this reason we cautioned against
the use of the 1000 figure in the campaign title.
• Estimating the likely impact of such a campaign in
Wales requires building a predictive model based on
accurate data showing distribution of effects &
distribution of chosen outcomes that are expected
from these interventions.
1.
2.
3.
4.
5.
6.
Final Points
A high profile politically driven project
How far can our NPHS delivery team go
if we had misgivings? Can we influence
the direction of travel? But was that our
remit?
The signs are that much of our advice
was taken on board
Two months time scale in a holiday
season was not enough
A lot of pressure on the team to deliver to
a high standard and on short time scale
The work has been well received