September 2010

PenCLAHRC: Peninsula Collaboration for Leadership in Applied Health Research and Care.

Research Findings in Risk Assessment for VTE in the South West

The Researchers

PenCLAHRC- The Peninsula Collaboration for Leadership in Applied Health.

Professor Rod Sheaff – Professor in Health Services Research r.sheaff@plymouth.ac.uk

Dr Sue Child – Research Fellow in Health Services Research

susan.child@plymouth.ac.uk

Dr Olga Boiko – Associate Research Fellow in Health Services Research olga.boiko@pms.ac.uk

Sarah Dawkins – Project Facilitator

sarah.dawkins@pms.ac.uk

Background

An estimated 25,000 hospital patients in the UK die from preventable venous thromboembolism (VTE) every year.

VTE risk assessment instruments developed and implemented at Derriford have exemplar status.

Initiatives to prevent VTE are occurring in all acute hospitals covered by PenCLAHRC ...

… but nationally, coverage is patchy (NICE).

New NICE guidance early 2010.

Conditions favouring (or impeding) implementation are not well understood.

RQ1: What are the implementers trying to do?

What models for implementing VTE risk assessment and prevention are applied in hospitals (in the territory served by PenCLAHRC)?

Concretely, for each site:

a) What VTE prevention 'technologies' do they exploit?

b) What skill mix, staff time and physical resources do sites assume are required?

c) What 'information technologies' (medical records systems, monitoring systems) are assumed?

e) Whose support is assumed?

f) What other conditions are assumed necessary for implementation?

RQ2: Incidence of VTE

In each study site, what is the incidence of VTE among general medical and orthopaedics in-patients:

a) at admission?

b) cumulatively?

Of the patients who developed VTE, what proportion were suitable for the prophylaxes stipulated in the protocol?

RQ3: Fidelity of implementation

In each study site, what is the level of compliance with the local / national VTE protocol?

Specifically, what proportions of eligible patients receive:

a) re-assessment of risk?

b) information about prevention and treatment of VTE?

c) prescribing advice in the discharge letter to GP?

RQ4: Variants of implementation

What working practices and organisational conditions favour or impede implementation of VTE protocols in each study site? Do they differ by:

a) clinical speciality?

b) admission route (planned GP referral vs. A&E vs. MAU)?

c) workload (ALoS; case-mix)

d) skill-mix (e.g. If nurses perform the assessment)?

How do the sites compare in design, assumptions and conditions required for implementation of VTE prevention guidance?

For example, we hypothesise: A speciality with high proportion of planned admissions (orthopaedics) will find implementation easier than one with a high proportion of unplanned admissions (general medicine).

Multiple Methods (1): Policy and Plans

RQ1: How is VTE prevention intended to work?

Elaborate protocol content and assumptions by:

a) content-analysis of guidance and policy documents

b) content-analysis of transcripts of interviews of policy-makers, managers and clinicians who invented the initiatives.

c) description of site's methods (pathways) for VTE prevention.

Multiple Methods (1): Policy and Plans

RQ1: How is VTE prevention intended to work?

Elaborate protocol content and assumptions by:

a) content-analysis of guidance and policy documents

b) content-analysis of transcripts of interviews of policy-makers, managers and clinicians who invented the initiatives.

c) description of site's methods (pathways) for VTE prevention.

Multiple Methods (2)

RQ2: Incidence of VTE?

Sample survey, based on content analysis of two samples of medical records: 2 specialties (general medicine, orthopaedics) per site * 4 sites.

RQ3: Fidelity to protocols?

Difference-in-differences evaluation of impact of protocol implementation, comparing compliance scores pre- and post- NICE protocol, same sites as above.

Multiple Methods (3)

RQ4: Implementation helps / barriers.

In each site, realistic evaluation of the organisational conditions that produce – or displace - protocol implementation.

Context = local history, managerial structures, resources etc.

Mechanism = local approach to implementation and its assumptions

Outcomes = protocol compliance

Systematic ('framework') comparison across study sites.

Sampling: Organisational level

Orthopaedic and general medical in-patients at Derriford and at alternative-model sites (Royal Cornwall, Royal Devon and Exeter, Salisbury).

1. Different models of care for VTE prevention. SHA-wide review of current practice in VTE prevention will be the sampling frame.

2. Within each site, two specialities (orthopaedics and general medicine).

Sampling: Patient level

File sample of admissions:

1. ≥50 admissions per speciality (N=100) per site, to enable empirical estimate of the standard deviation and 90% confidence interval for compliance scores (and an initial indication of findings).

2. From (1), decide the scale of a 2nd round of data collection about recent admissions.

Data Collection

Stage 1: Interview key informants

Current and previous practice in VTE prevention

Assumptions of current interventions

Implementation aids / barriers

Stage 2: Data extraction from medical records. Two stages:

A. Initial scoping (50+50 records)

B. Retrospective and prospective data extraction – scale depends on findings from analysis of first 50+50 records.

Analyses (1): Discourse Analysis

Discourse analysis to elaborate 'programme theory' of VTE prevention:

Problematisation (For whom is VTE a 'problem'? Why? How big a problem?)

How does VTE prevention arise from / contribute to other health care priorities, problems, policy agendas?

How is it assumed that VTE prevention works?

Analyses (2): Statistical and Normative

Incidence of VTE:

a) Estimate population parameters from the observed data.

b) Test for clustering by sub-categories of patient e.g. by referral source, speciality, consultant, ICD10 code, age/sex.

Normative evaluation of fidelity:

a) Compare observed compliance scores with a norm of 100% compliance.

b) Mapping of actual pathways (as opposed to normative pathways)

Analyses (3): Framework Analysis

Systematic comparison - apply a common framework across the sites to compare and contrast:

Did the sites confront different kinds or scales of VTE 'problem'?

How did different sites implementations differ and why?

Did the different implementations produce different degrees of fidelity of implementation?

What modes of implementation appear best adapted to which conditions?

Activity so far

Research protocol defined

Ethical approval negotiated

Collecting national documentation

Stage 1 data collection completed at Derriford

Stage 1 data collection completed at Royal Cornwall Hospitals Trust

Stage 2 data collection commenced at Derriford

Stage 2 data collection to commence at RCHT in October 2010

Findings so far Health Warning:

These are still provisional

1. Nurses' and sessional GPs' perception of VTE prevention policy and practice diverges from the consultants' in some cases.

2. VTE policy can become fragmented and plural between and within specialties. In effect,several policies in one hospital. .

3. Pharmaceutical prophylaxis generally preferred to mechanical. 4. Drugs/prescribing sheets an important medium of communication

(including to GP on discharge). 5. Erratic patterns of repeat (i.e. post-admission) risk assessment. 6. Clear VTE protocols don't prevent 'hard' clinical decisions. 7. Sporadic audit of VTE prevention. 8. Fewer resources allocated for VTE prevention than for preventing

hospital-acquired infection – despite CQUIN. .

Implications for practice so far (Still more provisional)

1. Establish VTE Committees with wide membership – including Chief Executive.

2. Commit similar resources and priority to VTE prevention as to infection control.

3. Share: - meaningful peer review activity- good working practices and assessment / treatment guidelines - VTE awareness events.

4. Ensure patients get appropriate, rather than standardised, thromboprophylaxis.

5. Ensure that CEQUIN monies earned by compliance with VTE risk assessment guidelines goes back into improving VTE risk assessment (not lost in general hospital operating budget).

Next steps (1)

Preliminary 'proof of concept' analyses of data from first two study sites (Derriford, Royal Cornwall)

Any necessary

revisions to research design

supplementary data collection

Start data collection in:

Salisbury

RD&E

Develop local activities to disseminate findings.

Full-scale NIHR Research for Patient Benefit research proposal – Evaluation of the National Programme

Next steps (2)

Constructive criticisms and better ideas are always welcome ...

There is a VTE Group on the CLAHRC Community Social Network, which we find useful for updating each other and posting documents. To have a look, click on  http://community.clahrc.net , then click on register. The site will send you a link. Once in you'll create a password. Then find the VTE Group and request to join.