The Aga Khan University Hospital, Karachi

10/22/2013
Pakistan – A quick primer
The Aga Khan University Hospital,
Karachi - Pakistan
Challenges
A country of varied landscapes, high mountains, lush plains,
beautiful coastline, rich history
Pakistan
Pakistan
K2 the second highest mountain in the world
5 out of 14 highest peaks in the world
World’s highest paved international road
Pakistan
Pakistan
Karimabad, Gilgit Baltistan
Tarbela Dam, KPK
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Pakistan
Pakistan
The Khyber Pass between Afghanistan and Pakistan.
Ancient Silk Road. One of the oldest known passes in the world
Islamabad in Autumn
Pakistan
Pakistan
The Faisal Mosque in Islamabad
Largest mosque in Pakistan and South Asia
World’s Largest Deep Sea Port: Gawader
Pakistan
Pakistan
Khewra Mines: Second Largest Salt Mine in the World
Thar Desert: Amongst the largest deserts in the World
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Pakistan
Haleji Lake: Asia’s largest Bird Sanctuary
Pakistan
The land of oldest Civilization: Indus Valley and Mohenjo-Daro
A Bronze Age Civilization (3300–1300 BCE; mature period 2600–1900 BCE)
Pakistan
Pakistan
180 Million: 6th largest Nation of the World
Karachi: 20 Million people
Pakistan
AKUH
Hospital: Inaugurated in November 1985
• Tertiary Care Teaching Hospital
• JCIA accredited and ISO 9001:2008 certified
• 599 beds
• 51,030 admissions (in 2012)
• 674,537 outpatient visits (in 2012)
9th in the world for English as the official language
7th largest pool of scientists and Engineers in the World
Radiology
Topic
Moin Ali Nawazish making a World Record with 22 A’s in A level Exams
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AKUH Vision
Department of Radiology:
• 218,335 radiology examinations
• Covering all modalities
• Home grown Hospital Information System (HIS) &
Radiology Information System (RIS)
• Picture Archiving and Communication System (PACS)
& Voice Recognition System (VRS)
AKUH will be recognized as one of the best health care
institutions in Pakistan and the developing world. We will
achieve this:
• 31 Radiologists, 76 Technologists & 66 support staff
• 5-yr Residency, 2-yr Technologist traineeship,
2-yr Physicist traineeship & 1-yr Fellowship
CT
MRI
US
VIR
NM
X-ray
Mammogram
•By providing compassionate, ethical, accessible and high Quality
care that meets or exceeds the needs and expectations of our
patients, their families and others whom we serve.
•By providing an outstanding work environment that
fosters motivation and commitment in our staff.
•By enabling leadership in education and research that improves the
health of the people in the region.
Topic
Topic
vision
Quality Under Question:
Assessing The Success Rate Of
Perma Catheter (Permacath) Insertion for
procedures carried out in the Radiology
department in a tertiary Care JCI Accredited
teaching hospital in the developing world.
Perma Cath
A Perma Cath is an access device used for
exchanging blood to and from Haemodialysis
machine from and to the patient.
By: Amin Rajani , Syed Sohail,
Tanveer ul Haq & Asif Bilal
Perma Cath
http://www.chartingandassessment.com/CCRN/kidney/long-dialysis.jpg
Pakistan
PAKISTAN
COUNTRY
GDP Health 2011
ESRD Patients
Per Capita
%
Per Annum / Million
US $
USA
18
369
47.88
UK
9.3
136
38.91
INDIA
3.9
2.5
0.60
100
1.52 / 2
100
1.18 / 2
PAKISTAN
AKUH
Perma Cath: Rs.38,060 ($ 358) Jo-Cath: Rs.23,780 ($ 223)
Dialysis
Catheter Placement
Year
Male
Female
Total
Perma Cath
Jo-cath
2008
390
282
672
11
73
2009
330
226
556
43
87
2. Pakistan has 150 ESRD patients / annum / million, so each year we shall
2010
308
202
510
54
76
have 16,000 ESRD patients.
The cost of treatment is about Rs. 150,000 - 200,000 per patient / per annum
(US$ 2000). BUT
2011
393
276
669
93
66
2012
361
294
655
52
58
1. Our government spends 0.6% of GDP on health. The per capita income is
about US$700 per annum (2 dollars /day).
http://www.who.int/countries/pak/en , http://www.usrds.org/2012/view/v2_12.aspx ,
AKUH
http://www.ishib.org/journal/16-2s2/ethn-16-2s2-20.pdf
Background
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Quality Under Question
Background:
Audit Cycle
In one of the RCAs it was found that the
patient had Perma Cath placement but
Perma Cath was found with decreased
functionality during hemodialysis. After
this it was suggested to make a quality
indicator to assess failure rate of Perma
Cath. This study was initiated in April 2011.
Audit Cycle
Define & Plan the
Audit
Implement the
Audit
Improve &
hold the gain
Review the
Audit
Plan
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PLAN:
Define and Plan the Audit
Pre Audit Prep
Subject of Audit?
To monitor and assess procedure failure/complication rates
for Perma Catheter (Permacath) insertion.
Why it is Selected?
• Assessment of performance
• Identify areas of Improvement
• Match with international standard
Has it been addressed before?
Not at AKUH but in most of the developing world
Audit Team
Radiologist, Imaging technologists, Nurses & Administration
Plan
DO:
Implement the Audit
To conduct:
We referred to international literature, reviewed already
available data and discussed with internal stakeholders.
Conclusion:
Development of a monitoring template with number of
insertions and incidence of complications
It was identified that the current brand was introduced only last year and
that was based on informal feedback from different stakeholders. The
issues were mainly related to its shape (straight versus curved).
References: Hemodialysis Adequacy, Peritoneal Dialysis Adequacy and Vascular Access. Am J Kidney Dis 48:S1-S322, 2006 (suppl 1)
http://www.kidney.org/professionals/kdoqi/guidelines_updates/doqiupva_vi.html. (KDOQI)
Indicator
PLAN:
Define and Plan the Audit
What are the objectives of the Audit?
1. Develop and monitor indicator to assess procedure
failure/complication rates for Perma Catheter (Permacath)
insertion and take appropriate actions to preclude failures /
complications, if needed.
2. Bring success rate according to international standards.
3. Identify the weak areas of performance and rectify them.
Methodology
Data collection method
Sample size
Data analysis tool
Audit period
Document procedures in log
All Perma Cath procedures
Tables & Graphs in Excel
April -2011 to December -2012
Do
Indicator
Measure: Overall Compliance to successful insertion of Perma Cath
Target goal: Overall Compliance of ≥ 95 %
Reporting schedule: Monthly
Definition: Perma Cath must be inserted successfully and checked
for patency in Radiology. Percentage of success of Perma Cath
insertion will be measured by
Numerator: Number of Perma Catheter Insertion Success
X 100
Denominator: Total number of Perma Catheter Insertions
Definition of Failure: If catheter is reported non-functioning within
48 hrs of placement
Indicator
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CHECK:
Check for Improvement
Indicator
Evaluation: Done for all Perma Cath insertion
Feedback and Comparison for technical performance:
Individual feedback was taken from
Interventional Radiologists
Referring Physicians
Dialysis Unit
Infection Control Department
Shape: Curved vs. Straight
Currently using Curved shape catheters; however, previously we
used straight shape catheters.
Indicator Result
Check
CHECK:
Check for Improvement
Indicator
QTR-2
2011
QTR-3
2011
QTR-4
2011
QTR-1
2012
QTR-2
2012
QTR-3
2012
QTR-4
2012
TOTAL
Numerator
23
14
20
19
15
6
7
104
Denominator
24
14
19
15
6
7
105
100%
100%
100%
100%
99.05%
20
Success
Rate/100
95.83%
100%
100%
Graph
Indicator Result
CHECK:
Check for Improvement
CHECK:
Check for Improvement
Perma Cath
QTR-2
2011
QTR-3
2011
QTR-4
2011
Size
Indicator Result
QTR-1
2012
QTR-2
2012
QTR-3
2012
QTR-4
2012
TOTAL
Quantity
12.5
13
12
4
4
4
0
1
38
14.5
11
2
16
15
11
6
6
67
Check Action
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CHECK:
Check for Improvement
Assess the effects of action
Period: April 2011 to December 2012
Total Perma Cath Placement: 105
Success rate: Quarter 2, 2011: 95.83% (1 out of 24 reported failed)
Quarter 3, 2011 to December 2012: 100%.
Total Failure: 1
Overall Success rate: 99.05%
Our Observations:
Evaluation period neither showed any failure nor any decreased
functionality noted during hemodialysis.
Patient’s complaint for low flow: Very few; but on assessment,
Catheter was found functioning
Frequency of referrals: Decreased over the period.
Act Outcome
ACT:
Improve & Hold the Gain
Outcome
The overall result achieved is in compliance with the target set for
the measurement.
Monitor
Based on feedback and the audit results, it was decided to:
• Standardize the changes
• Continue with the recently introduced shape
• Hold the gains
Conclusion
CONCLUSION
It was a wise decision to initiate monitoring of Perma Cath
performance especially due to the fact that the brand (with
new shape) had been introduced only a year ago but
performance had not been documented. Though the
earlier brand was also internationally recognized and was
in use at various institutions throughout the world, in our
case, the referring physicians as well as the interventional
radiologists were not satisfied and had already replaced it.
The performance monitoring gave us confidence to
continue with its use.
Thank
You
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