VTE Community WebEx Presenters: Maryanne Gillies Senior QI lead (Patient Safety) Dr Stewart Lambie SPSP Clinical Lead/Consultant Nephrologist NHS Highland Date: March 25 2014
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Acute Adult CEL (19) 9+ 2 patient Safety Priorities Focus on 9 Point of Care Priorities: 1. Deteriorating Patients 2. Sepsis 3. Heart Failure 4. Pressure Ulcers 5. Surgical Site Infections 6. 6. Venous Thromboembolism Venous Thromboembolism 7. Catheter associated urinary tract infections 8. Falls With Harm 9. Safer Medicines
Revised INFRASTRUCTURE Over-arching Executive Sponsor: Ian Bashford - Medical Director Over-arching Medical Clinical Lead: Dr Stewart Lambie - SPSP Clinical Lead, Consultant Nephrologist Over-arching QI Lead and Programme Manager: Maryanne Gillies - Senior Quality Improvement Lead (Patient Safety) Over-arching Data Analyst: John Mackintosh – Clinical Effectiveness Facilitator Reporting to: Senior SPSP Leadership Team, HQA leadership Team, Q & PS Committee and direct to Board on request Workstream: Name and Job Title Role Executive Sponsor To align the goals of SPSP with strategic goals. To monitor progress against objectives. To provide visible leadership to support change and remove obstacles. To Chair workstream team meetings. To lead teams to ensure progress with process and Medical Clinical Lead outcomes measures To remove barriers to progress as the teams encounter them and over see reliable spread. Nurse Clinical Lead To support change and move obstacles at nurse management level and to foster and ensure collaboration for all patient safety initiatives Management Sponsor To influence and give authority to allocate the time and resources necessary to achieve the front line stream teams’ aims QI Lead To provide leadership and advanced skills and knowledge in improvement science methodologies. To facilitate change at the frontline and increase Improvement capability through coaching and formal teaching. Pilot ward/Area Analysis (e.g pareto) to take place establish area of highest impact to proposed changes. Seek innovators, enthusiasts and early adopters who want to be involved in new pieces of work. Team members who are ‘movers and shakers’. Each ward team must have multidisciplinary Team members representation. Changes are tested and improvements demonstrated first in each of the pilot areas before consideration of spread.
Aim Primary Secondary Drivers Drivers Improve delivery of Prevent VTE by ensuring a documented VTE risk assessment is • Reliable evidence based completed within 24 hours of admission Recognition & care in Include all elements of SIGN 122 – prevention and management of • Assessment prevention of venous thromboembolism Venous Thromboembolism Ensure reliable and documented appropriate thromboprophylaxis • (VTE) Reliable Care Ensure timely prescribing and administration of anticoagulant • Outcome: Outcome: Delivery Delivery therapy/mechanical intervention therapy/mechanical intervention Reliable risk Reliable risk assessment 95% of adult Provide education and raise awareness of VTE and improvement • Education admissions in methodology. & pilot ward by Ensure competent practitioner completes risk assessment/prescribes • Awareness December 2012 and administers pharmacological/mechanical thromboprophylaxis 95% of all adult hospital Ensure Patient and family centred care • admissions by Provide patient information on admission • Patient & Family December 2014 Involve Patient/Family in risk assessment and treatment process • Centred Care Promote open communication among team and family • Optimise transitions to home or other facility • Aim: 95% or > Process Reliability NB. OUTCOME MEASURES DEVELOPED LOCALLY
Pan Highland Approach AIM: 1. A pan NHS Highland VTE assessment protocol will be produced to standardize across specialties by end December 2012 2 95% or > patients will be assessed for the Risk of VTE and correct treatment will be prescribed/administered 95% or > by end November 2013 MEASUREMENT: Process:1. Was the VTE assessment Protocol completed Correctly 2. Was the correct Treatment prescribed/administered prescribed/administered CHANGE IDEAS
Progress: Single Cross – Specialty Venous Thromboprophylaxis Assessment Do not administer anti-coagulant if a lumbar puncture, epidural or spinal anaesthetic is expected within 12 hours Or has been performed in the previous 4 hours Comments/variance to protocol
Challenges
Progress: Sticker for re-assessment VTE daily re-assessment Is the patient on VTE prophylaxis Yes No If yes – does their condition indicate that VTE prophylaxis should be discontinued? Yes No Discontinue Continue If no - does their condition now indicate that VTE prophylaxis should be commenced? Yes No Prescribe VTE prophylaxis Prescribe VTE prophylaxis VTE prophylaxis not required NB be aware of key changes • Does platelet (<75 x 109/L) or eGRF (<30) result change their VTE assessment? • Women under the age of 60 only: Has the oral contraceptive pill or hormone replacement treatment been prescribed or discontinued? • Has anticoagulant therapy commenced or discontinued since last VTE assessment • Any other key risks to VTE or contra indidications to VTE prophylaxis?
Evening before chemical venous thromboprophylaxis • Testing Patient self administration • Testing Admissions Lounge • Testing Community Hospital – protocol for the supply and/or administration of enoxaparin by nurses to patients requiring enoxaparin as vte prophylaxis the night before surgery using a patient specific direction surgery using a patient specific direction – Process map – Training materials – Contingency checks
Data:
Results for 6 months of admissions 99.7% valid CHI Admissions 27318 99.3% valid CHI RIS Examinations 1304 (1174 people) 23% Positive VTE Events 297 (277 people) 21% Subsequent to 65 admission
Data: Outcome: CT Pulmonary Angiograms Doppler, Ultrasound Scans of Lower Limb, Ventilation Perfusion Scans - in the Radiology RIS System; together with both DVT and PE's Identified at Post Mortem over a 9 month period. ( From a total of 27 318 admissions, 1304 had a RIS examination completed; from those 297 tested Positive for VTE . According to a pre-defined algorithm: • 6o (detected radiologically) and 3 (detected at Post Mortem) • DVT/PE events were likely to be causally related to an in-patient admission. •The overall event rate was 2.38 per 1000 admissions. •The overall event rate was 2.38 per 1000 admissions. •Sub-group analysis was performed by hospital and by Specialty, with one hospital specialty breakdown shown below:
Challenges: • Maintaining momentum and resilience • Effort v Risk and Evidence • Quality Improvement facilitated support • Data collection and interpretation • Data collection and interpretation • Involving Patient and Family • Re-assessment
Our Plans • Implementation through the use of the CAD • Test patient self-administration and other routes for evening before administration • Present Business Case to SMT regarding • Present Business Case to SMT regarding patient leaflet production • Test re-assessment sticker and consultant ward round checklist
Our Learning: Multi-disciplinary team – cross specialty – start the dialogue QI facilitated support required at front line: Test small, test again and test again React to the measurement and make changes Test innovative solutions small scale to reduce risk.. Aim high and seek the impossible…
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