Using the NIMC VTE Prophylaxis Section

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Overview

The burden of VTE in Australia

The NIMC VTE Pilot

How to use the NIMC VTE prophylaxis section

Frequently asked questions

Extent of issue

In 2008:

VTE cases 14,716

Deaths 5,285

Working age 43%

Total inpatient costs $81.2m

Comparison of deaths

Reference:1. Access Economics Pty Limited (2008) The burden of venous thromboembolism in Australia. Report for the Australian and NewZealand Working Party on the Management and Prevention of Venous Thromboembolism. https://www.deloitteaccesseconomics.com.au/uploads/File/The%20burden%20of%20VTE%20in%20Australia.pdf.Accessed 1 June 2013.

Reducing practice gaps

ENDORSE STUDY across 32 countries (including Australia) found that only 59% of at-risk surgical and 40% of at-risk medical patients received guideline-recommended VTE prophylaxis1

National Institute of Clinical Studies (NICS) Public Hospital VTE Prevention Program2 (2005-07) showed:

• underuse of preventative measures

• pre-printed VTE section on medication chart improved use of VTE prophylaxis in high risk patients

References:

1. Cohen AT, Tapson VF, Bergmann J, Goldhaber SZ, Kakkar AK, Deslandes B, Huang W, Zayaruzny M, Emery L,

Anderson FA. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): A multinational cross-sectional study. The Lancet 2008;371(9610):387-94.

2. National Health and Medical Research Council. Preventing venous thromboembolism in hospitalised patients: Summary of NHMRC activity 2003–2010. Melbourne: National Health and Medical Research Council; 2011.

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Australian Safety and Quality Goals for Health Care

Goal 1 Safety of care: That people receive their health care without experiencing preventable harm

Outcome 1.1.3: Adults experience fewer venous thromboembolisms associated with hospitalisation.

There is strong evidence that appropriate risk assessment and prophylaxis can reduce the risk and incidence of venous thromboembolism.

www.safetyandquality.gov.au/wp-content/uploads/2012/08/Goal-1.1-Medication-Safety-Action-Guide-PDF-486KB.pdf

NIMC VTE Pilot

National piloting of a pilot NIMC with VTE section was undertaken in two phases beginning in August 2010 and finishing in December 2012

Over 30 hospitals from five states participated in the pilots

The results provided strong support for inclusion of a VTE prophylaxis section in a new version of the NIMC

NIMC VTE Pilot Results:Quantitative Audit Results

Audit Parameter (% patients) Phase 1 Pre-Audit

Phase 1Post-Audit

Phase 2 Pre-Audit

Phase 2Post-Audit

Documentation of VTE risk assessment 9.4% 17.2% 35.9% 57.2%

Documentation of VTE risk assessment in VTE section

0% 17.2% 0% 44.7%

VTE prophylaxis prescribed (mechanical and/or pharmacological)

58.1% 65.6% 65.2% 69.3%

Pharmacological VTE prophylaxis prescribed 55.1% 62.4% 59.4% 64.4%

Pharmacological VTE prophylaxis prescribed in the VTE section

n.c 66% n.c 78.6%

Mechanical VTE prophylaxis ordered 18.6%. 19.2% 33.6% 32.3%

NIMC VTE Pilot Results:Safety features and administration errors (raw numbers)

Audit Parameter Phase 1 Pre-Audit

Phase 1Post-Audit

Phase 2 Pre-Audit

Phase 2Post-Audit

Average charts per patient 1.54 1.51 1.56 1.56

Patients with pharmacological VTE prophylaxis prescribed in VTE and regular meds section

n.c 24 n.c 2

Patients with active orders for both pharmacological VTE prophylaxis and therapeutic anticoagulant

23 29 n.c 2

Pharmacological VTE prophylaxis ordered when contraindicated

n.c 15 8 4

Mechanical VTE prophylaxis ordered when contraindicated

n.c. n.c 3 2

% anticoagulant doses documented as given 87.1% 87.3% 95.6% 96.4%

% checks mechanical prophylaxis documented 74.0% 43.0% 75.1% 68.9%

n.c = not collected

NIMC VTE Phase 2 Pilot Results:Mechanical VTE prophylaxis documentation

NIMC VTE Pilot Study conclusions

Introduction of a VTE section across a range of hospitals

significantly increased rates of VTE risk assessment

documentation and VTE prophylaxis prescribing while

not increasing the risk of duplicate anticoagulant

therapy being prescribed

VTE section did not increase the number of active

medication charts per patient nor increase the risks

associated with multiple charts

NIMC VTE Pilot Study conclusions

VTE prophylaxis section on the NIMC only one part of a hospital-wide VTE prevention policy

Other essential components include: Senior executive and clinician support Explicit policies for VTE prevention Sufficient resources for education/implementation Education on conducting a VTE risk assessment Instruction on correct use of the VTE section

How to use the NIMC VTE prophylaxis section

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The VTE section has been placed above the warfarin section to assist with the recognition of patients who

are already receiving therapeutic anticoagulation and do not require

additional VTE prophylaxis

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VTE prophylaxis section: How it works

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Step 1: Document patient’s VTE risk assessment

Authorised clinician:

Determines patient’s risk for VTE (as per local policy)

Assesses patient’s risk of bleeding/contraindications to VTE prophylaxis vs. benefits of VTE prophylaxis and formulates overall risk assessment

Documents if VTE prophylaxis NOT required/contraindicated by ticking the appropriate box*

Documents assessment is complete by ticking the VTE risk assessed box and signing and dating in the field provided

* Specific contraindications to VTE prophylaxis should be documented in the medical record

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Step 2: Order pharmacological VTE prophylaxis

Prescriber selects an appropriate agent if indicated

Choice of agent depends on patient’s VTE risk level (See hospital policy or NHMRC clinical practice guideline for VTE prevention)

Specify route, dose, frequency & administration times

Nurse initials the administration of medication

Order pharmacological prophylaxis if indicated: medication, route, dose and

frequency

Document administration of medication

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Step 3: Order mechanical VTE prophylaxis

Authorised clinician orders mechanical prophylaxis where appropriate (e.g. graduated compression stockings, foot pump)

Authorised personnel - a nurse or a doctor, as per hospital policy

Nurse signs when mechanical prophylaxis checked

Order mechanical prophylaxis if required

Document mechanical prophylaxis checked

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Frequently asked questions

Q: How do I order mechanical VTE prophylaxis on the NIMC?

A: In the space in the VTE section titled ‘Mechanical prophylaxis’ write in the type of mechanical prophylaxis being used e.g. TEDS, GCS, IPC etc. Sign, print your name and your contact details e.g. pager number

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Frequently asked questions (cont.)

Q: What does documenting mechanical prophylaxis checks on the VTE section mean?

A: The hospital’s policy on VTE prophylaxis should include regular monitoring of mechanical prophylaxis to ensure correct application. This varies by hospital but can include checks for skin integrity (colour, warmth, pulse, pressure area etc) and that stockings are being worn. This is usually done morning and evening and the responsible clinician should sign their initials in the space provided when the check has been satisfactorily completed.

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Frequently asked questions (cont.)

Q: What should I do if VTE prophylaxis is contraindicated?

A: Complete the risk assessment section indicating that VTE prophylaxis is contraindicated and cross out the relevant ordering section (pharmacological and/or mechanical). The prescriber should also write “contraindicated” and sign in the administration section.

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Frequently asked questions (cont.)

Q: What should I do if the VTE prophylaxis ordered needs to be changed?

A: If the dose of VTE prophylaxis medicine needs to be changed, a new order should be prescribed on a subsequent chart.

Q: Where should VTE treatment be ordered on the chart?

A: If VTE therapy is required e.g. for a pre-existing DVT, it should be ordered in the regular medicines space and not in the pre-printed VTE prophylaxis section.

www.safetyandquality.gov.au/our-work/medication-safety/vte-prevention-resource-centre/

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Contact details:

<< Hospital name >>

Ph: << 0000 0000 pager XXXX >>

Email: <<add email address>>