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

















10 random notes/week reviewed in AMU/MAU/HDU• % Risk assessed• % Prescribed

correctly• %

Contraindications assessed

• % Patient informed


evidence of review


Qualitative feedback from involved staff through team representatives


Junior staff survey














evidence of review


AIM PRIMARY DRIVER SECONDARY DRIVER SPECIFIC CHANGES TO TEST PLANNED TEST


Junior staff survey

































Primary driver Secondary driver Intervention






















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


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


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


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


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?

Documents

VTE Community WebEx 13 th June 2013 2 – 3 p.m