Venous Thromboembolus (VTE) Prophylaxis: Using...

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BC QUALITY FORUM CONFERENCE February 28 th 2013, Melanie Basso, RN, MSN, PNC(C) Senior Practice Leader-Perinatal Dorothy Shaw, MBChB, FRCSC Vice President, Medical Affairs BC Women’s Hospital and Health Centre Venous Thromboembolus (VTE) Prophylaxis: Using ImPROVE Methodology to Implement an Accreditation Canada Standard

Transcript of Venous Thromboembolus (VTE) Prophylaxis: Using...

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BC QUALITY FORUM CONFERENCE F e b r u a r y 2 8 t h 2 0 1 3 ,

M e l a n i e B a s s o , R N , M S N , P N C ( C ) S e n i o r P r a c t i c e L e a d e r - P e r i n a t a l

D o r o t h y S h a w , M B C h B , F R C S C

V i c e P r e s i d e n t , M e d i c a l A f f a i r s

B C W o m e n ’ s H o s p i t a l a n d H e a l t h C e n t r e

Venous Thromboembolus (VTE) Prophylaxis: Using ImPROVE Methodology to Implement an Accreditation Canada Standard

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Objectives

Primary project objective:

Ensure 100% of women who deliver at BCW, receive a VTE risk assessment

Presentation objectives:

Describe the use of ImPROVE - RPIW methodology to strengthen the implementation of a pre-existing protocol on Venous Thromboembolism (VTE) Prophylaxis

Identify the interventions used to sustain this accreditation Canada standard

Describe our lessons learned along the way

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Disclosure

Images of commercial products in the patient brochure are included as examples for illustration purposes and were obtained from “Google Images”.

These pictures do not represent the products used or endorsed by BC Women’s Hospital and Health Centre, or by the presenters.

Neither of the presenters has any disclosures of conflict of interest

D. Shaw is a member of several Advisory groups for non-profit organizations, none related to this presentation

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Background

BC Women’s Hospital has over 7000 births/ year

A lack of VTE prophylaxis protocol was identified as a Best Practice issue for our woman at risk.

In January 2011, we received the 2012 Accreditation Standards which included having a VTE Risk Prophylaxis protocol

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Between 1987-2004 there were 35 maternal deaths in BC

51% of obstetric deaths in BC were potentially avoidable

28% were related to blood clot issues

Developing a blood clots is a bad outcome. Patients are on blood thinners for extended periods of time if they get one and are always at an increased risk for additional clots in the future.

BC Statistics

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BC Women’s Statistics

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Staff Survey: Issues with VTE ImplementationIn person survey of 12 post partum nurses and 2 physicians (April 2nd-4th, 2012) on all BCW Post Partum Units

29% 29% 29%

64%

0%

20%

40%

60%

80%

100%

Pro

po

rtio

n o

f st

aff

wh

o m

enti

on

ed is

sues

wit

h V

TE im

ple

men

tati

on

Series1 64% 29% 29% 29%

Fragmin dose timing When to remove stockings? (mobility) MD Orders Incomplete More Info/Evidence

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Chart Audits: Defects in VTE Orders Audits conducted March, 2012 on all BCW Post Partum Units

19%

75%

29%

0%

20%

40%

60%

80%

100%

Def

ects

in V

TE C

har

t A

ud

its

by

freq

uen

cy o

f is

sue

Series1 29% 19% 75%

Patient received wrong dose Patients given incorrect protocol Risk Assessment incomplete

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Current State & Analysis Process Map

What are the system requirements?

Average of 19 women arriving to deliver at BCW (takt time) per day.

Approximately 9 women will receive the VTE protocol

Project Scope

All women who deliver at BCW (or are transferred post delivery to BCW)

RPIW Project Form Previously Linked RPIW #:

imPROVE: [email protected] Revision Date: Oct 31, 2011

Sponsors: Heather Mash/Ruth Dueckman

Process Owners: Pam O’Sullivan/Roane Preston

Team Leader: Melanie Basso Sub-team Leader: Dorothy Shaw

imPROVE Support: Lily Farris

Content Experts:Nancy Kent (MFM), Henry Woo (OB), Peter Tsang (Hematology), June Yee (Pharmacy), Simon Massey (Anesthesia)

Team Members/Dept. Team Members/Dept.

1. Lisa Scigliano (PP RN) 5. Caitlyn Atkinson (Birthing RN) 8. Thea Parkin (RM)

2. Cathy West (AP RN) 6. Sarah Saunders (OB Res) 9. Grace Dublanko (Quality)

3. Kathy Greenberg (FP) 7. Hanna Ezzat (OB)

Primary Objective

100% of women who deliver at BCW, receive a VTE risk assessment

Key Measure % of women who deliver at BCW, receive a VTE risk

assessment. Secondary Measure: % of women who are assessed as high or intermediate

risk receive VTE protocol until discharged or

reassessed.

Countermeasures Developed provider information sheet including evidence and implementation details, Revised order forms to

streamline process, and drafted a patient information sheet for VTE.

Current State (Cont.)

Assessment and Treatment: 75% of VTE risk assessment incomplete

Staff process: 64% of staff surveyed mentioned lack of clarity on when

to provide fragmin doses

Patients: 0% of patients refused the VTE protocol, 0% of patients

received written information on VTE

RPIW 47 & Project Name: VTE Standardization RPIW Week (Date): April 30th – May 4th 2012

Background Maternal mortality and morbidity found to be associated in BC with a lack of prophylaxis

protocol in place. Guidelines being implemented internationally/nationally/provincially

and to meet RoP

VSM Name, Date & Related Goal:

Accreditation RoP VTE

Problem statement: No assessment of risk or prevention of VTE post partum at BCW existed.

Sustainment Plan

Audits: Chart audits

Audit Leader: Melanie Basso

Patient assessed for

VTE Risk

Patient

Delivers SVD

Patient receives VTE

protocol until discharge

Women with pre-existing

history assessed as high

risk

Women with intermediate

risk receive protocol

Patient

Delivers Cesarean

Patient assessed for

VTE Risk

Patient receives VTE

protocol until

discharge

Patient

Ready for Cesarean

TEDs applied to

all women

Women with intermediate or

high risk receive protocol

25%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% of women who received VTE risk

assessment

25%

Pre-Kaizen

Chart Audit: % of patients with

risk assessment complete

Chart Audit: % of patients who

receive appropriate treatment

81%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

81%

Pre-Kaizen

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RPIW Plan: Goals for the week

Audit and observe VTE process and develop kaizen Revise VTE orders and implement Review audit of oozy wounds and develop kaizen Draft, revise, and implement patient pamphlet Revise “Anticoagulant Chart” CV0700 Appendix C Review Second Trimester Induction orders, develop new process, draft new orders, implement new process Develop evidence reference and fact sheet (SHORT) Visual cue for Fragmin patients How do we make the standard obvious, self explanatory and mistake proof ? How do we energize staff to have a “standard work” culture? Same practice for everyone Explore training communication to care team (MD, Nurse, etc.) and patient

How do we make BCWs standard obvious to the providers? (regular staff and others)

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Adapted from RCOG

Green Top Guidelines

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BC Women's Hospital RPIW #47

Chart Audit: Providers Completing VTE OrdersAudit of 12 charts April 20th-May 2nd, 2012

58%

42%

17% 17%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

58% 42% 17% 17%

1 2 3 4

Ob/Gyn

Family

Practice

Maternal Fetal

Medicine

Registered

Midwife

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Provider Information (EXAMPLE)

Background: VTE occurs in 0.5 – 3/1000 pregnancies.[1] Pulmonary embolism (PE), along with pre-eclampsia, is the number one cause of maternal death in Canada. Of the 1,054,828 live births in Canada between 1997 and 2000, there were 44 direct maternal deaths, 9 of these were the result of PE. This makes PE the leading potentially preventable cause of maternal mortality.[2] Review of BC women’s data from the past 8 years identified at least 18 postpartum inpatient thrombotic events equally divided between vaginal and c-section births. Of these, 11 were PEs. Even in low risk women, VTE is at least 5 times more common in pregnant than in non-pregnant women. The greatest increase in risk is in the postpartum period. (~22 fold)

Multiple studies have been done to identify patients at greatest risk for VTE. One of the most consistently identified and strongest risk factors is emergency c-section, with a risk for VTE of 0.5% to 2%.[3] Many other patient factors can increase the risk further, hence the basis for stratifying patients into risk categories.

[1] Sultan et al, British Journal of Hematology, 2011 [2] Health Canada. Special Report on Maternal Mortality and Severe Morbidity in Canada- Enhanced surveillance: The Path to Prevention. Ottawa: Minister of Public Works and Government Services Canada, 2004 [3] Jacobsen et al, Thrombosis Research, 2004

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VTE Patient Survey Comments

Patient 1- The nurse said the stockings are to keep the blood flowing; nurse said ‘you need stockings’; nurse said ‘If you walk more you can take off stockings’

Patient 2 – The nurse in delivery suite measured my legs and put on the stockings. She said that the stockings and medication would help me avoid blood clots so I said definitely

Patient 3- When the nurse told me that the stockings and meds would prevent clots that made sense to me. I would like a short pamphlet -1 page of bullets on benefits, risks (if there are any). Don’t put it in the prenatal package because I won’t remember it, already too much information.

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Workshop Summary

So, what did we accomplish?

We revised all the Prescriber Order Forms related to VTE Prophylaxis Protocol and embedded them in existing practices

Developed Provider Information Sheets (evidence- based)

Developed the Patient Information Sheet

Drafted the education roll-out plan

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Lessons Learned

Project implementation success is not guaranteed just because it is a “must do”

Need staff buy in –don’t just tell them what to do, they want to have evidence

Patients want answers too, and need resources created for them at the appropriate literacy level

Embedding practice change into existing processes, try not to create additional paper work

Audits keep you honest about how your project is going and identify areas for further development/strategy.

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Questions

Thank you

Questions?

Email: Melanie Basso [email protected]

Dorothy Shaw [email protected]