What still needs to be achieved in What still needs to be achieved in the clinical situation?the clinical situation?

VTE Symposium – sharing good practiceVTE Symposium – sharing good practice

2121stst September 2010 September 2010

Dr Tamara Everington

1 2 3 4 5 6

12%

56%

24%

0%2%

6%

1.1. DoctorDoctor

2.2. NurseNurse

3.3. PharmacistPharmacist

4.4. Risk ManagerRisk Manager

5.5. ExecutiveExecutive

6.6. OtherOther

What is your background?What is your background?

NICE Quality Standard 1NICE Quality Standard 1

““All patients, on admission, receive an All patients, on admission, receive an assessment of VTE and bleeding risk”assessment of VTE and bleeding risk”

How do we crack the last 10%?How do we crack the last 10%?

VTE risk assessment at Salisbury Hospital 2008-2010

0

20

40

60

80

100

Jun-

08

Aug-0

8

Oct-08

Dec-0

8

Feb-0

9

Apr-0

9

Jun-

09

Aug-0

9

Oct-09

Dec-0

9

Feb-1

0

Apr-1

0

Jun-

10

Aug-1

0Pe

rce

nta

ge

(%

) ri

sk

as

se

ss

ed

Which 1 of these do you think is most Which 1 of these do you think is most likely to increase compliance with VTE likely to increase compliance with VTE risk assessment?risk assessment?

1 2 3 4 5

0% 0%

6%

41%

53%

1.1. CQUINS targetsCQUINS targets

2.2. Executive DriversExecutive Drivers

3.3. Better staff Better staff educationeducation

4.4. Electronic SystemsElectronic Systems

5.5. Productive WardsProductive Wards

NICE Quality Standard 2NICE Quality Standard 2

““Patients are re-assessed within 24 hours Patients are re-assessed within 24 hours of admission for risk of VTE and bleeding”of admission for risk of VTE and bleeding”

How should you document repeat How should you document repeat VTE RA at 24 hours?VTE RA at 24 hours?

1 2 3 4 5

28%

41%

11%

15%

4%

1.1. Repeat the initial VTE Repeat the initial VTE RA documentRA document

2.2. Document in the Document in the clinical pathway clinical pathway (PTWR)(PTWR)

3.3. Pharmacy checkPharmacy check

4.4. Nurse checkNurse check

5.5. OtherOther

NICE Quality Standard 3NICE Quality Standard 3

““Patients assessed to be at risk of VTE are Patients assessed to be at risk of VTE are offered VTE prophylaxis in accordance offered VTE prophylaxis in accordance with NICE guidance”with NICE guidance”

Which groups would you adjust Which groups would you adjust thromboprophylaxis dose in?thromboprophylaxis dose in?

1 2 3 4 5 6

16%

4%

24%

53%

0%2%

1.1. Renal impairmentRenal impairment

2.2. ObesityObesity

3.3. Cancer patients Cancer patients with cachexiawith cachexia

4.4. Recurrent “fallers”Recurrent “fallers”

5.5. All of the aboveAll of the above

6.6. None of the aboveNone of the above

Which day cases do you plan to Which day cases do you plan to risk assess?risk assess?

1 2 3 4 5 6 7

6%

0%4%

71%

15%

4%0%

1.1. Day surgery under GADay surgery under GA

2.2. Day surgery under LADay surgery under LA

3.3. Fracture clinicFracture clinic

4.4. Chemotherapy Chemotherapy patientspatients

5.5. Medical day casesMedical day cases

6.6. 1,(2), 3 & 41,(2), 3 & 4

7.7. All of the aboveAll of the above

In theory we could reduce In theory we could reduce secondary VTE by 65%?secondary VTE by 65%?

Secondary VTE at Salisbury Hospital 2008-2010

01020304050607080

Oct 07-Mar 08

Apr 08-Sep 08

Oct 08-Mar 09

Apr 09-Sep 09

Oct 09-Mar 10

No

. o

f ca

ses

Secondary DVT

Secondary PE

Secondary VTE

How will you pick up secondary How will you pick up secondary VTE?VTE?

1 2 3 4 5 6

11%

2%

77%

0%0%

11%

1.1. Via anticoagulant Via anticoagulant referralsreferrals

2.2. Via radiology reports Via radiology reports of VTEof VTE

3.3. Via clinical codingVia clinical coding4.4. Via death certificatesVia death certificates5.5. Via the CoronerVia the Coroner6.6. Combination of the Combination of the

above?above?

NICE Quality Standards 4 & 5NICE Quality Standards 4 & 5

““Patients / carers are offered verbal and Patients / carers are offered verbal and written information on VTE prevention at written information on VTE prevention at time of admission…. & as part of the time of admission…. & as part of the discharge process”discharge process”

If only!!!If only!!!

Simples!!!!

What information is most likely to What information is most likely to work?work?

1 2 3 4

2%

93%

5%0%

1.1. Written Written informationinformation

2.2. Visual informationVisual information

3.3. Face-to-face Face-to-face explanationexplanation

4.4. A mixture of the A mixture of the aboveabove

NICE Quality Standard 6NICE Quality Standard 6

““Patients provided with anti-embolism Patients provided with anti-embolism stockings have them fitted and monitored stockings have them fitted and monitored in accordance with NICE guidance”in accordance with NICE guidance”

Which of the following have you Which of the following have you seen on patients?seen on patients?

1 2 3 4 5 6

0%

7%

22%

64%

7%

0%

1.1. Which of the following have Which of the following have you seen on patients?you seen on patients?

2.2. Stockings causing a Stockings causing a ‘tourniquet’ effect‘tourniquet’ effect

3.3. Damaged legs from Damaged legs from stockingsstockings

4.4. Soiled stockingsSoiled stockings

5.5. All of the aboveAll of the above

6.6. ““I wish you hadn’t asked I wish you hadn’t asked that question”that question”

NICE Quality Standard 7NICE Quality Standard 7

““Patients receive extended postoperative Patients receive extended postoperative VTE prophylaxis in accordance with NICE VTE prophylaxis in accordance with NICE guidance”guidance”

A 65 year old woman with a history of VTE has A 65 year old woman with a history of VTE has incurable ovarian cancer with reduced mobility incurable ovarian cancer with reduced mobility which can be controlled with indefinite which can be controlled with indefinite chemotherapy. chemotherapy.

1 2 3 4

10%

70%

13%8%

How long would you How long would you continue continue thromboprophylaxis?thromboprophylaxis?

1.1. Not at allNot at all

2.2. Aspirin onlyAspirin only

3.3. For 28 days For 28 days following surgeryfollowing surgery

4.4. IndefinitelyIndefinitely

Root cause Root cause analysis – analysis – How do we How do we

do this?do this?

Which method of RCA do you think Which method of RCA do you think will be most effective?will be most effective?

1 2 3 4

22%

59%

7%

13%

1.1. RCA by the RCA by the Thrombosis Thrombosis CommitteeCommittee

2.2. RCA by the VTE RCA by the VTE nursenurse

3.3. RCA by Clinical riskRCA by Clinical risk

4.4. RCA by Clinical RCA by Clinical teamsteams