What are we trying to achieve?
With many of the known risk factors (such as older age, immobility, surgery and obesity) increasing in society, VTE is an important and growing health problem. In November 2011, we started the VTE Prevention Project with the aim of achieving an increased use of evidence-based guidelines and recommendations to support best practice VTE prevention in hospitalised adult patients.
The purpose of the VTE prevention project was to ensure that:
- 90% patients have a VTE risk assessment completed and documented
- appropriate clinical decisions are made about their care
What did we find?
Using a combination of historical data and observations we identified three key issues:
- there were a number of existing documents and international guidelines available, leading to confusion about which guidelines were the most up-to-date
- there is no current requirement to document a VTE Risk Assessment in the patients’ notes
- there were no systems to measure ongoing performance
Preventative Medicine Audit (October 2006 – April 2007)
Preventative Medicine in Medical Patient Audit (November 2011)
- 25% of medical patients were eligible for preventative medicine, however only a quarter of them received it
- 98% of surgical patients were eligible for preventative medicine, with 96% receiving some form of preventative medicine, however 45% are incorrectly dosed
- 32% of patients were assessed for VTE risk, of which 49% of patients identified as being high risk
- 35% of at risk patients received appropriate VTE prophylaxis (prevention treatment)
What have we done?
We put together a project group with key clinicians from general medicine, general surgery and orthopaedics.
1. VTE Risk Assessment Tool and Prophylaxis Guidelines
The clinicians agreed on a simplified tool that supported staff to both identify at risk patients, and select appropriate interventions. This tool was then published on all sites regularly used by staff, and available on the wards as well.
2. Risk assessment documentation
Our existing documentation did not have a specific section for documenting VTE risk assessments. It was agreed that the "Admission to Discharge (A-D) Planner" was the most appropriate place for this, as this document is used for every patient. The updated Planner was rolled out across both hospitals by end of June 2012.
VTE risk assessment in Admission to Discharge (A-D) Planner
In July, we were informed that the Health Quality and Safety Commission had included a VTE Risk Assessment in the revised version of the National Medication Chart that was to be rolled out to all hospitals nationwide the following month.
To avoid confusion we rolled back the recently implemented changes to the A-D Planner and now only use the VTE risk assessment in the National Medication Chart.
VTE risk assessment in National Medication Chart
3. Risk assessment audit process
We set up a process to audit a random sample of patient notes across our medical and surgical services to provide performance feedback and track progress towards the goal of 90% of patients having their VTE Risk Assessment documented in their notes.
Communication and Engagement
One of the challenges the team faced was how to engage with a large number of staff to ensure they are aware of the importance of VTE prevention. We undertook an awareness campaign to get staff involved and spread the message. Some examples are:
- Personalised letters to all junior medical staff from their clinical leaders, outlining the importance of risk assessments and preventative medicine for patients.
- Providing lanyard cards to all staff outlining assessment criteria and preventive medicine options.
- Creation of a VTE Prevention website which can be accessed directly from our intranet, where all documents and forms were centrally located for easy access when required.
Personalised letters to staff
VTE Lanyard Cards
VTE Prevention website
We developed a brochure that is available for patients and their families with information about how to reduce the risk of blood clots in your legs and lungs while in hospital.
[click on brochure to download a copy]
Did we make a difference?
We performed weekly audits of charts and reported performance against target by service. Despite delivery of the required tools and support structures, including a communications strategy and continuous feedback, there was little change in our performance.
This chart shows the percentage of audited charts that had the VTE risk assessment completed. The blue line is the percentage complete, an average of 11%, with the red line being the target of 95%.
Despite our senior clinicians agreeing to the standardised approach we didn’t get sufficient engagement with our front-line clinical staff.
Where to from here?
So, we have gone back to the beginning to try and get the clinical engagement that is critical to these projects. We have analysed all of our incidences of VTE for the past 5 years to identify where we should target improvement activity. The data told us that the highest number of VTEs at Waitemata DHB result from major hip and knee surgery.
In the next phase of the project, we are focusing on our orthopaedic service in two ways:
- Risk assessment: Continuing education and communication about the importance of documenting patients’ risk assessments as well as periodically auditing performance
- Thromboprophylaxis (preventing a clot): The project team are completing chart reviews of all patients that develop either a DVT or PE following major hip or knee surgery to ensure that best practice has been followed. Where improvement opportunities are identified, these will be addressed directly with our staff