VTE Community WebEx 13 th June 2013 2 – 3 p.m.
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Transcript of VTE Community WebEx 13 th June 2013 2 – 3 p.m.
VTE Community WebEx13th June 20132 – 3 p.m.
Agenda
Topic Speaker Time
Welcome A Hunter 5 mins
Board ProgressDr. Chris FosterRoyal Alexandra Hospital, GG&C
45 mins
Q & A All 5 mins
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VTE programme in RAH: The evolution of complexity
Dr C FosterConsultant in Acute Medicine SPSP Improvement Advisor in trainingIHI wave 28
The case for change Aim to prevent VTE – significant associated
comorbidity Non fatal e. g. post thrombotic syndrome, non fatal PE Fatal – PTE – a notorious underdiagnosed complication
Government drive SPSP Sepsis/VTE collaberative
Financial Nice estimate savings of £12,000 per 100,000 population per
year - £24,000/yr in our catchment
Our unit 3 geographically distinct areas
MAU – 8 beds, 11 trolleysAMU – 30 bedsHDU – variable mode 5 patients, range 1-9
2-3 Acute medicine consultants, 1-2 Fy2, 2-3 Acute Care ST3+ and some FY1’s – variable
Take around 40-50/day
Our ‘unit’ 1 downstream med ward acting as a
‘testbed’ Rest of the hospital....
Systemic/practical problems Large geographical area Small numbers in HDU Alot of people to get engaged Visiting PoW only 3x per year each – can
be tricky to make sure everyone remembers
Junior staff turnover?
Lets do stuff wellLets do stuff wellLets do stuff wellLets do stuff well
Acute Medicine
Other wards
Other specialities
Other hospitals
Spread the gains - The Quality virus method
What are we trying to accomplish?
By September 2013 aim to Improve the reliability of ongoing assessment and
appropriate prescription of low molecular weight heparin in the medical population being admitted through Medical Assessment (MAU), Acute Medical (AMU) or high dependency (HDU).
The expected outcome at this point will be a consistent 95% adherence to current national guidance and standards.
Further we aim to improve downstream compliance in our medical wards
How will we know that change is an improvement? Continuous weekly sampling of patients in
relevant units Qualitative feedback from ‘VTE action
group’ Informal feedback
What changes can we make that will result in an improvement?
Develop• Consistent
, reliable VTE bundle implementation –95%:
• Risk assessed
• Prescribed correctly
• Contraindications assessed
• Patient informed
By september 2013
Create reliable assessment of risk and need
Create reliable prescription and delivery of appropriate treatment
Consultant drives junior staff
Patient centred care
Create reliable downstream assessment (minimum 48 hourly)
Culture of responsibility develops
VTE tool in admission documentation
Increase awareness of necessity
Requirement is assessed and documented
All patients receive information leaflet
Leverage in SBAR tool, nurses/pharmacists empowered to remind medical staff
Ward round ‘sticker’ in notes
Formalised, documented assessment and prescription
Requirement to be assessed before leaves ward
Part of educational and induction programme
Info leaflet in ward admission pack
10 random notes/week reviewed in AMU/MAU/HDU• % Risk assessed• % Prescribed
correctly• %
Contraindications assessed
• % Patient informed
10 random notes/week reviewed in downstream ward• % Documented
evidence of review
• % Tool filled in in admission document
Qualitative feedback from involved staff through team representatives
AIM PRIMARY DRIVER SECONDARY DRIVER SPECIFIC CHANGES TO TEST PLANNED TEST
Survey nursing staff and feedback at VTE group
Junior staff survey
Pharmacy inform patients
VTE column on admission board, HDU safety check
Develop• Consistent
, reliable VTE bundle implementation –95%:
• Risk assessed
• Prescribed correctly
• Contraindications assessed
• Patient informed
By september 2013
Create reliable assessment of risk and need
Create reliable prescription and delivery of appropriate treatment
Consultant drives junior staff
Patient centred care
Create reliable downstream assessment (minimum 48 hourly)
Culture of responsibility develops
VTE tool in admission documentation
Increase awareness of necessity
Requirement is assessed and documented
All patients receive information leaflet
Leverage in SBAR tool, nurses/pharmacists empowered to remind medical staff
Ward round ‘sticker’ in notes
Formalised, documented assessment and prescription
Requirement to be assessed before leaves ward
Part of educational and induction programme
Info leaflet in ward admission pack
10 random notes/week reviewed in AMU/MAU/HDU• % Risk assessed• % Prescribed
correctly• %
Contraindications assessed
• % Patient informed
10 random notes/week reviewed in downstream ward• % Documented
evidence of review
• % Tool filled in in admission document
Qualitative feedback from involved staff through team representatives
Survey nursing staff and feedback at VTE group
Junior staff survey
Consultant drives junior staff
Culture of responsibility develops
VTE tool in admission documentation
Increase awareness of necessity
Requirement is assessed and documented
All patients receive information leaflet
Leverage in SBAR tool, nurses/pharmacists empowered to remind medical staff
Ward round ‘sticker’ in notes
Formalised, documented assessment and prescription
Requirement to be assessed before leaves ward
Part of educational and induction programme
Info leaflet in ward admission pack
10 random notes/week reviewed in downstream ward• % Documented
evidence of review
• % Tool filled in in admission document
AIM PRIMARY DRIVER SECONDARY DRIVER SPECIFIC CHANGES TO TEST PLANNED TEST
Survey nursing staff and feedback at VTE group
Junior staff survey
Culture of responsibility develops
Formalised, documented assessment and prescription
Increase awareness of necessity
Culture of responsibility develops
Formalised, documented assessment and prescription
Requirement to be assessed before leaves ward
Increase awareness of necessity
Culture of responsibility develops
Formalised, documented assessment and prescription
Requirement to be assessed before leaves ward
Increase awareness of necessity
Culture of responsibility develops
Formalised, documented assessment and prescription
Requirement to be assessed before leaves ward
Increase awareness of necessity
Culture of responsibility develops
Formalised, documented assessment and prescription
Requirement to be assessed before leaves ward
Increase awareness of necessity
Culture of responsibility develops
Formalised, documented assessment and prescription
Pharmacy inform patients
VTE column on admission board, HDU safety check
Create reliable assessment of risk and need
Culture of responsibility develops
Increase awareness of necessity
Part of educational and induction programme
Requirement to be assessed before leaves ward
Leverage in SBAR tool, nurses/pharmacists empowered to remind medical staff
Consultant drives junior staff
VTE tool in admission documentation
Formalised, documented assessment and prescription
Primary driver Secondary driver Intervention
VTE column on admission board, HDU safety check
Create reliable prescription and delivery of appropriate treatment
Culture of responsibility develops
Increase awareness of necessity
Part of educational and induction programme
Requirement to be assessed before leaves ward
Leverage in SBAR tool, nurses/pharmacists empowered to remind medical staff
Consultant drives junior staff
VTE tool in admission documentation
Formalised, documented assessment and prescription
Primary driver Secondary driver Intervention
VTE column on admission board, HDU safety check
Create reliable downstream assessment (minimum 48 hourly)
Requirement is assessed and documented
Ward round ‘sticker’ in notes
Primary driver Secondary driver Intervention
Patient centred care
All patients receive information leaflet
Info leaflet in ward admission pack
Primary driver Secondary driver Intervention
Pharmacy inform patients
Methodology
Plan
DoStudy
Act
Initial AMU work
1st cycle
Plan
DoStudy
Act
To improve all indices in AMU to > 95%Consultant input dailySet up appropriate sampling
Plan
DoStudy
Act
Acute med consultant daily speaks to junior staff about the importance of VTE (and Med rec and sepsis)
Became evident that reliable collection of data could be variable as individual dependant
Junior staff were feeding back however
Became evident that there was confusion with the clarity of data collection
1st cycle
1st cycle
Plan
DoStudy
Act
Sampling took too many weeks for data pointsWe weren’t bad to start with, but not greatWe weren’t consistentDocumented review at 48 hours was an issueIt’s not clear what ‘patient informed’ constitutesMarked downstream improvementWe did a lot at once on an individual reliant basis
1st cycle
Plan
DoStudy
Act
Continue with current. Multi disciplinary involvement
2nd cycle
Plan
DoStudy
Act
Nurses to prompt doctorsCN McP to encourage nursing staff
Plan
DoStudy
Act
CN McP encouraged nursing staff to ..... Prompt Dr’s
2nd cycle
2nd cycle
Plan
DoStudy
Act
Didn’t workNursing teams already had enough to do
2nd cycle
Plan
DoStudy
Act
Abandoned
3rd cycle
Plan
DoStudy
Act
I (annoyingly?) can’t take any credit.....Junior med staff took initiative and put a column on the admission board
Plan
DoStudy
Act
Dr N put a new column on the admissions board – “VTE”
3rd cycle
3rd cycle
Plan
DoStudy
Act
There was a continuing improvement – effect unclear as following trend – would have been clearer if we had undertaken a ‘planned experiment’, but impracticalHowever, it was getting used for every patient – I suspect if nothing else is a reliable reminder, and I think made a difference
1a. Is there a documented VTE risk assessment for patient and admission related risks within 24 hours of admission?
0%10%20%30%40%50%60%70%80%90%100%
Month
2. Is there a documented assessment of contra-indication to pharmacological or mechanical thromboprophylaxis?
0%10%20%30%40%50%60%70%80%90%
100%
Month
3. Has correct pharmacological / mechanical thromboprophylaxis been prescribed and administered?
0%10%20%30%40%50%60%70%80%90%100%
Month
4b. If the answer to Question 4a is Yes, is there a documented reassessment of VTE risk as per local policy (48 hours)?
0%10%20%30%40%50%60%70%80%90%100%
Month
6. Compliance with SIGN Bundle
0%10%20%30%40%50%60%70%80%90%100%
Month
5. Has the patient been informed of VTE risk and treatment on admission?
0%10%20%30%40%50%60%70%80%90%
100%
Month
3rd cycle
Plan
DoStudy
Act
It was a simple intervention Impact unclear but I suspect helpedSo we didn’t change a thing
4th cycle – VTE group
4th cycle
Plan
DoStudy
Act
To gain a multi disciplinary viewWill expect find that the current ideal planned process (system) doesn’t tally with reality and build our knowledge on this basis Understand the variation in the system – can we find any special or common causes of this?To be carried out on an informal basisProcess mapping and affinity diagrams
Plan
DoStudy
Act
Meeting (eventually) went ahead
Good turnout from junior/senior medical/nursing and pharmacy
4th cycle
4th cycle
Plan
DoStudy
Act
Process in fact turned out to be relatively close to the system we had plannedCommon themes arose
Too much paperwork (in general)Some varying views on who should perform the
assessment – FY1? Admitting doctor?Sometimes information is not available e.g. eGFRThere are common causes of variation – mainly that the process reliability falls down come 5pm when staff levels drastically fall (esp FY1)Special causes of variation also exist – e.g. HAN members not having been through the medical unit
4th cycleStudy
Some communication issues between nursing/medical staff – e.g. both wanting kardexes concurrentlyHowever, constructive outcomes also arose
We have introduced an assessment sheet into the HDU nursing checksheetPharmacists are going to inform the patients why they are on LMWHNursing teams in HDU/MAU are engaged in the regular sampling process (and will prompt medical staff)AMU ward manager will encourage her nurses to prompt Dr’s
4th cycle
Plan
DoStudy
Act
New simplified medical assessment tool made for HDUWeekly sampling of patients in HDU instigated2 patients daily sampled in MAUPharmacy becoming involved when they review kardex’sLesson learned – it’s difficult to get people to a meeting
Ward round sticker
Back to AMU
5th cycle
Plan
DoStudy
Act
Aims remain to achieve 95% reliability Aim to demonstrate reliability with non individual dependant data collectionImprove patient information - Pharmacists will inform patients and document thisReliable 48hrly (or better) review – daily ward round sticker to be usedLarger and more frequent sampling
Plan
DoStudy
Act
Acute med consultant (still) daily speaks to junior staff about the importance of VTE (and Med rec and sepsis)
A daily ward round sticker has been made and is used for every ward round >24hrs. With a little cajoling and encouragement, this is happening
Sampling 10 pts per week – joint responsibility between consultant, registrar and engaged FY1 has reaped benefits including clarity of measuring
There was a lack of clarity among the pharmacy team how they were providing input – now clarified
5th cycle
5th cycle
Plan
DoStudy
Act
Data collection far better, and in better numbersAll groups seem well engaged
01/04
/2013
08/04
/2013
15/04
/2013
22/04
/2013
29/04
/2013
06/05
/2013
13/05
/2013
20/05
/2013
27/05
/2013
0
20
40
60
80
100
120
AMU % Contraindications assessed
% Documented assessment con-traindication
Median
01/0
4/20
13
08/0
4/20
13
15/0
4/20
13
22/0
4/20
13
29/0
4/20
13
06/0
5/20
13
13/0
5/20
13
20/0
5/20
13
27/0
5/20
13
0
20
40
60
80
100
120
AMU % VTE risk assessed
% VTE risk assessedMedian
01/0
4/20
13
08/0
4/20
13
15/0
4/20
13
22/0
4/20
13
29/0
4/20
13
06/0
5/20
13
13/0
5/20
13
20/0
5/20
13
27/0
5/20
13
0
20
40
60
80
100
120
AMU % Correct prescribed
% Correct prescribedMedian
01/04
/2013
08/04
/2013
15/04
/2013
22/04
/2013
29/04
/2013
06/05
/2013
13/05
/2013
20/05
/2013
27/05
/2013
0
20
40
60
80
100
120
AMU % Informed
% Patient Informed
Median
01/04
/2013
08/04
/2013
15/04
/2013
22/04
/2013
29/04
/2013
06/05
/2013
13/05
/2013
20/05
/2013
27/05
/2013
0
20
40
60
80
100
120
AMU % All done correctly
% All AchievedMedian
02/05
/2013
09/05
/2013
16/05
/2013
23/05
/2013
0
20
40
60
80
100
120
AMU % rechecked at 48 hrs
% Rechecked at 48 hrs (if applicable)
Median
5th cycle
Plan
DoStudy
Act
Continue as current for a month or so and allow everything to ‘bed in’Feedback from team – Plan a further VTE group meetThere are multiple other issues to be addressed – staffing, responsibility, communication issues, getting required information etc – a lot of cycles to be done…..And some brainstormingI would like some even greater reliability for data collection – any ideas gratefully receivedAlso capturing data at weekends is not happening at current – can’t think of a reliable way thus far
MAU
6th cycle
Plan
DoStudy
Act
Aim to develop a reliable measurement programme and hopefully demonstrate reliable adherence to our targetsCan we put a reliable system of data collection into place? – 2 patients be sampled a day as they leave the unitHow compliant and reliant are we?Expect to be fairly good as we have a small team of dedicated individuals
Plan
DoStudy
Act
Staff engagement is good
Data collection put into place – 5th patient leaving and 1 patient after 6pm per day
6th cycle
6th cycle
Plan
DoStudy
Act
No negative feedbackStaff don’t see it as a hinderance/hassle
19/04
/2013
26/04
/2013
03/05
/2013
10/05
/2013
17/05
/2013
24/05
/2013
31/05
/2013
8486889092949698
100102
% VTE risk assessed
% VTE risk assessedMedian
19/04
/2013
26/04
/2013
03/05
/2013
10/05
/2013
17/05
/2013
24/05
/2013
31/05
/2013
8486889092949698
100102
% Contraindications assessed
% Docu-mented as-sessment contraindica-tion
Median
19/04
/2013
26/04
/2013
03/05
/2013
10/05
/2013
17/05
/2013
24/05
/2013
31/05
/2013
84
86
88
90
92
94
96
98
100
102
% Informed
% Patient In-formedMedian
19/04
/2013
26/04
/2013
03/05
/2013
10/05
/2013
17/05
/2013
24/05
/2013
31/05
/2013
84
86
88
90
92
94
96
98
100
102
% Correct prescribed
% Correct prescribedMedian
19/04
/2013
26/04
/2013
03/05
/2013
10/05
/2013
17/05
/2013
24/05
/2013
31/05
/2013
84
86
88
90
92
94
96
98
100
102
% All done correctly
% All Achieved Median
6th cycle
Plan
DoStudy
Act
Not planning to change anything just now
HDU
7th cycle
Plan
DoStudy
Act
Can we put a reliable system of data collection into place? – will our sample volume be high enoughHow are we doing so far? – collect baseline dataExpect to be ok but reliability of documentation will fall down as the admission pro formas are not used on PTWR – hopefully improve with separate nursing checksheetAll Medical patients in the unit on a Friday will be sampled
Plan
DoStudy
Act
Baseline data collectedEvery patient in the unit on Friday sampled
7th cycle
7th cycle
Plan
DoStudy
Act
Initial sampling variable but improved now bedded in
7th cycle
Plan
DoStudy
Act
Continue with current monitoringTime to introduce measures
8th cycle
Plan
DoStudy
Act
Introduce new VTE assessment into patient admission pack
Plan
DoStudy
Act
SN ER (VTE group member) to introduce assessment tool and concept/plans to nursing staff
8th cycle
8th cycle
Plan
DoStudy
Act
Incomplete distribution of plansVariable who was aware depending on staff. Also variable who remembered
8th cycle
Plan
DoStudy
ActD/w CN LG as to best way to standardise the requirement for VTE thromboprophylavis assessment
9th cycle
Plan
DoStudy
Act
D/w CN LG and put suggestion into action
Plan
DoStudy
Act
‘VTE thromboprophylaxis assessed’ introduced into nursing safety checkIf not done, nurses will prompt dr’s on ward round
9th cycle
9th cycle
Plan
DoStudy
Act
Is happeningGood effectNursing teal all engaged
26/0
3/20
13
02/0
4/20
13
09/0
4/20
13
16/0
4/20
13
23/0
4/20
13
30/0
4/20
13
07/0
5/20
13
14/0
5/20
13
21/0
5/20
13
28/0
5/20
13
0
20
40
60
80
100
120
% Contraindications assessed
% Docu-mented as-sessment contraindica-tion
Median
26/0
3/20
13
02/0
4/20
13
09/0
4/20
13
16/0
4/20
13
23/0
4/20
13
30/0
4/20
13
07/0
5/20
13
14/0
5/20
13
21/0
5/20
13
28/0
5/20
13
0
20
40
60
80
100
120
% Informed
% Patient In-formedMedian
26/03
/2013
02/04
/2013
09/04
/2013
16/04
/2013
23/04
/2013
30/04
/2013
07/05
/2013
14/05
/2013
21/05
/2013
28/05
/2013
0
20
40
60
80
100
120
% VTE risk assessed
% VTE risk assessedMedian
26/03
/2013
02/04
/2013
09/04
/2013
16/04
/2013
23/04
/2013
30/04
/2013
07/05
/2013
14/05
/2013
21/05
/2013
28/05
/2013
0
20
40
60
80
100
120
% Correct prescribed
% Correct prescribedMedian
23/03
/2013
30/03
/2013
06/04
/2013
13/04
/2013
20/04
/2013
27/04
/2013
04/05
/2013
11/05
/2013
18/05
/2013
25/05
/2013
01/06
/2013
0
20
40
60
80
100
120
% rechecked at 48 hrs
Rechecked at 48 hrs (if applicable)
Median
26/0
3/20
13
02/0
4/20
13
09/0
4/20
13
16/0
4/20
13
23/0
4/20
13
30/0
4/20
13
07/0
5/20
13
14/0
5/20
13
21/0
5/20
13
28/0
5/20
13
0
20
40
60
80
100
120
% All done correctly
% All AchievedMedian
9th cycle
Plan
DoStudy
ActContinue as current and let changes settle in
Downstream
10th cycle
Plan
DoStudy
Act
We’re aiming for 95% in reliable assessment at 48 hoursHow good is our baseline of checking 48 hourlyHow will the introduction of ward round stickers be receivedWill it be effective?
Plan
DoStudy
Act
In the main, uptake was surprisingly good with most individualsPsychological factors are the downfallSampling is not problematic
10th cycle
10th cycle
Plan
DoStudy
Act
UnderwayResults so far…
29/03
/2013
05/04
/2013
12/04
/2013
19/04
/2013
26/04
/2013
03/05
/2013
10/05
/2013
17/05
/2013
24/05
/2013
0
20
40
60
80
100
120
% VTE risk assessed at 48 hours
% VTE risk assessed at 48 hours
Median
10th cycle
Plan
DoStudy
Act
Feedback run charts are available for ward staffNeed further engagement with the team and feedback as to the barriers they have found
Where are we now? SBAR now been changed – VTE integrated Allow changes to bed in Further VTE group meet Need solutions to weekend data collection New Dr’s starting in August – time to
disseminate the info
In summary Teamwork is the most important Try to look at positives rather than
negatives There will always be natural variation –
SPC charts useful when you have enough data
Improvement is possible Don’t be disheartened by natural variation
In summarry Thanks
Any questions?