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

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

2. Agenda

3. Ask questions: via the chat box • There is no ‘beep on entry’ so please tell us who you are • Use chat now to tell us who you are, where your are and who is with you

4. VTE programme in RAH: The evolution of complexity Dr C Foster Consultant in Acute Medicine SPSP Improvement Advisor in training IHI wave 28

5. 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

6. Our unit • 3 geographically distinct areas • MAU – 8 beds, 11 trolleys • AMU – 30 beds • HDU – 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

7. Our ‘unit’ 1 downstream med ward acting as a ‘testbed’ Rest of the hospital....

8. 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?

9. Spread the gains - The Quality virus method Other wards Lets do stuff well Lets do stuff well Lets do stuff well Lets do stuff well Acute Medicine Other hospitals Other specialities

10. 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

11. 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

12. What changes can we make that will result in an improvement?

13. AIM PRIMARY DRIVER SECONDARY DRIVER SPECIFIC CHANGES TO TEST PLANNED TEST VTE column on admission board, HDU safety check • 10 random notes/week reviewed in AMU/MAU/HDU • % Risk assessed • % Prescribed correctly • % Contraindications assessed • % Patient informed Culture of responsibility develops Consultant drives junior staff Create reliable assessment of risk and need VTE tool in admission documentation Formalised, documented assessment and prescription Develop • Consistent, reliable VTE bundle implementation –95%: • Risk assessed • Prescribed correctly • Contraindications assessed • Patient informed By september 2013 Part of educational and induction programme Increase awareness of necessity Create reliable prescription and delivery of appropriate treatment Junior staff survey Requirement to be assessed before leaves ward Leverage in SBAR tool, nurses/pharmacists empowered to remind medical staff Survey nursing staff and feedback at VTE group • 10 random notes/week reviewed in downstream ward • % Documented evidence of review • % Tool filled in in admission document Create reliable downstream assessment (minimum 48 hourly) Requirement is assessed and documented Ward round ‘sticker’ in notes All patients receive information leaflet Info leaflet in ward admission pack Qualitative feedback from involved staff through team representatives Patient centred care Pharmacy inform patients

14. AIM PRIMARY DRIVER SECONDARY DRIVER SPECIFIC CHANGES TO TEST PLANNED TEST VTE column on admission board, HDU safety check • 10 random notes/week reviewed in AMU/MAU/HDU • % Risk assessed • % Prescribed correctly • % Contraindications assessed • % Patient informed Culture of responsibility develops Culture of responsibility develops Culture of responsibility develops Culture of responsibility develops Culture of responsibility develops Culture of responsibility develops Culture of responsibility develops Culture of responsibility develops Consultant drives junior staff Consultant drives junior staff Create reliable assessment of risk and need VTE tool in admission documentation VTE tool in admission documentation Formalised, documented assessment and prescription Formalised, documented assessment and prescription Formalised, documented assessment and prescription Formalised, documented assessment and prescription Formalised, documented assessment and prescription Formalised, documented assessment and prescription Formalised, documented assessment and prescription Formalised, documented assessment and prescription Develop • Consistent, reliable VTE bundle implementation –95%: • Risk assessed • Prescribed correctly • Contraindications assessed • Patient informed By september 2013 Part of educational and induction programme Part of educational and induction programme Increase awareness of necessity Increase awareness of necessity Increase awareness of necessity Increase awareness of necessity Increase awareness of necessity Increase awareness of necessity Increase awareness of necessity Create reliable prescription and delivery of appropriate treatment Junior staff survey Junior staff survey Requirement to be assessed before leaves ward Requirement to be assessed before leaves ward Requirement to be assessed before leaves ward Requirement to be assessed before leaves ward Requirement to be assessed before leaves ward Requirement to be assessed before leaves ward Leverage in SBAR tool, nurses/pharmacists empowered to remind medical staff Leverage in SBAR tool, nurses/pharmacists empowered to remind medical staff Survey nursing staff and feedback at VTE group Survey nursing staff and feedback at VTE group • 10 random notes/week reviewed in downstream ward • % Documented evidence of review • % Tool filled in in admission document • 10 random notes/week reviewed in downstream ward • % Documented evidence of review • % Tool filled in in admission document Create reliable downstream assessment (minimum 48 hourly) Requirement is assessed and documented Requirement is assessed and documented Ward round ‘sticker’ in notes Ward round ‘sticker’ in notes All patients receive information leaflet All patients receive information leaflet Info leaflet in ward admission pack Info leaflet in ward admission pack Qualitative feedback from involved staff through team representatives Patient centred care Pharmacy inform patients

15. Primary driver Secondary driver Intervention VTE tool in admission documentation Formalised, documented assessment and prescription VTE column on admission board, HDU safety check Create reliable assessment of risk and need Consultant drives junior staff 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

16. Primary driver Secondary driver Intervention VTE tool in admission documentation Formalised, documented assessment and prescription VTE column on admission board, HDU safety check Create reliable prescription and delivery of appropriate treatment Consultant drives junior staff 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

17. Primary driver Secondary driver Intervention Create reliable downstream assessment (minimum 48 hourly) Ward round ‘sticker’ in notes Requirement is assessed and documented

18. Primary driver Secondary driver Intervention Patient centred care All patients receive information leaflet Info leaflet in ward admission pack Pharmacy inform patients

19. Methodology Act Plan Study Do

20. Initial AMU work

21. 1st cycle To improve all indices in AMU to > 95% Consultant input daily Set up appropriate sampling Act Plan Study Do

22. 1st cycle 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 Act Plan Study Do

23. 1st cycle Sampling took too many weeks for data points We weren’t bad to start with, but not great We weren’t consistent Documented review at 48 hours was an issue It’s not clear what ‘patient informed’ constitutes Marked downstream improvement We did a lot at once on an individual reliant basis Act Plan Study Do

24. 1st cycle Continue with current. Multi disciplinary involvement Act Plan Study Do

25. 2nd cycle Nurses to prompt doctors CN McP to encourage nursing staff Act Plan Study Do

26. 2nd cycle CN McP encouraged nursing staff to ..... Prompt Dr’s Act Plan Study Do

27. 2nd cycle Didn’t work Nursing teams already had enough to do Act Plan Study Do

28. 2nd cycle Abandoned Act Plan Study Do

30. 3rd cycle I (annoyingly?) can’t take any credit..... Junior med staff took initiative and put a column on the admission board Act Plan Study Do

31. 3rd cycle Dr N put a new column on the admissions board – “VTE” Act Plan Study Do

32. 3rd cycle There was a continuing improvement – effect unclear as following trend – would have been clearer if we had undertaken a ‘planned experiment’, but impractical However, it was getting used for every patient – I suspect if nothing else is a reliable reminder, and I think made a difference Act Plan Study Do

36. 3rd cycle It was a simple intervention Impact unclear but I suspect helped So we didn’t change a thing Act Plan Study Do

37. 4th cycle – VTE group

38. 4th cycle To gain a multi disciplinary view Will 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 basis Process mapping and affinity diagrams Act Plan Study Do

39. 4th cycle Meeting (eventually) went ahead Good turnout from junior/senior medical/nursing and pharmacy Act Plan Study Do

40. 4th cycle Process in fact turned out to be relatively close to the system we had planned Common 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. eGFR There 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 Act Plan Study Do

41. Act Plan Study Do 4th cycle Some communication issues between nursing/medical staff – e.g. both wanting kardexes concurrently However, constructive outcomes also arose We have introduced an assessment sheet into the HDU nursing checksheet Pharmacists are going to inform the patients why they are on LMWH Nursing 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

44. 4th cycle New simplified medical assessment tool made for HDU Weekly sampling of patients in HDU instigated 2 patients daily sampled in MAU Pharmacy becoming involved when they review kardex’s Lesson learned – it’s difficult to get people to a meeting Act Plan Study Do

45. Ward round sticker

47. Back to AMU

48. 5th cycle Aims remain to achieve 95% reliability Aim to demonstrate reliability with non individual dependant data collection Improve patient information - Pharmacists will inform patients and document this Reliable 48hrly (or better) review – daily ward round sticker to be used Larger and more frequent sampling Act Plan Study Do

49. 5th cycle 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 Act Plan Study Do

50. 5th cycle Data collection far better, and in better numbers All groups seem well engaged Act Plan Study Do