1. Using the NIMC VTE Prophylaxis Section

2. Slide 2 of n Overview  The burden of VTE in Australia  The NIMC VTE Pilot  How to use the NIMC VTE prophylaxis section  Frequently asked questions

3. Extent of issue In 2008: VTE cases14,716 Deaths5,285 Working age43% Total inpatient costs$81.2m

4. Comparison of deaths Reference: 1. Access Economics Pty Limited (2008) The burden of venous thromboembolism in Australia. Report for the Australian and New Zealand 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.

5. 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 prophylaxis 1 National Institute of Clinical Studies (NICS) Public Hospital VTE Prevention Program 2 (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. Slide 5 of n

6. 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

7. 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

8. NIMC VTE Pilot Results: Quantitative Audit Results Audit Parameter (% patients)Phase 1 Pre- Audit Phase 1 Post- Audit Phase 2 Pre- Audit Phase 2 Post- 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.c66%n.c78.6% Mechanical VTE prophylaxis ordered 18.6%.19.2%33.6%32.3%

9. NIMC VTE Pilot Results: Safety features and administration errors (raw numbers) Audit ParameterPhase 1 Pre- Audit Phase 1 Post- Audit Phase 2 Pre- Audit Phase 2 Post- Audit Average charts per patient 1.541.511.56 Patients with pharmacological VTE prophylaxis prescribed in VTE and regular meds section n.c24n.c2 Patients with active orders for both pharmacological VTE prophylaxis and therapeutic anticoagulant 2329n.c2 Pharmacological VTE prophylaxis ordered when contraindicated n.c1584 Mechanical VTE prophylaxis ordered when contraindicated n.c.n.c32 % 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

10. NIMC VTE Phase 2 Pilot Results: Mechanical VTE prophylaxis documentation

11. 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

12. 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

13. How to use the NIMC VTE prophylaxis section

14. Slide 14 of n 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

15. Slide 15 of n VTE prophylaxis section: How it works

16. Slide 16 of n 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

17. Slide 17 of n 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

18. Slide 18 of n 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

19. Slide 19 of n 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

20. Slide 20 of n 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.

21. Slide 21 of n 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.

22. Slide 22 of n 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.

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

24. Slide 24 of n Contact details: > Ph: > Email: >email address