1. Dr N Mudondo (FY2) Mr C Chatzdimitriou (SpR Breast Surgery) Mr M Haider (SpR Breast Surgery)

2. Contents Introduction Audit question Audit aims Methods Cycle 1 results Implemented changes following the audit Cycle 2 results Changes between cycle 1 and 2 For future auditing Conclusion

3. Introduction TEDS stockings are well-documented to prevent the occurrence of DVTs and PE’s both in surgical and medical, non-mobile patients (VTE reducing the risk (June 2014) NICE guidelines CG92)

4. Audit question We noticed in our surgical department that several patients who had TEDS stockings prescribed were not wearing them. This was particularly obvious in SAU, where all the patients are under general surgery, and should either have TEDS stockings on, or a well-documented reason why TEDS stockings were withheld. How many patients who were prescribed TEDs stockings actually received them to benefit from them clinically?

5. Audit aims 100% of patients should receive TEDS stockings if they are prescribed If TEDS stockings are not given to patient, there should be a reason why they are not given The first cycle of the audit was performed between December 2014 and January 2015

6. Method Auditor checked: Are TEDS prescribed on drugchart Are they worn by the patient? Patient criteria TEDS must be prescribed to be included in audit Patient should be under general surgery, located in SAU, ward 6 or ward 8 Duration of stay when TEDS were checked should be documented, especially for patients without TEDS stockings. This is to: Give the nurses enough time to give the TEDS stockings Assess how long patients have stayed without therapy All results should be documented with no identifiable data

7. Cycle 1 results WardStandardAchievedNot achieved SAU 100% of patients should receive prescribed TEDS stockings 10/28 36% 18/28 64% Ward 6 100% of patients should receive prescribed TEDS stockings 4/11 36% 7/11 67% Ward 8 100% of patients should receive prescribed TEDS stockings 2/7 28% 5/7 71% Total100% of patients should receive prescribed TEDS stockings 16/46 35% 30/46 65%

8. Adverse event in Cycle 1 – One patient developed a PE (prescribed but not given TEDS stockings). She was only given the stockings after she had the diagnosis of a PE This highlighted that 1. TEDS stocking were not considered until it was too late 2. There was a failure to see the role of TEDS stockings as prophylaxis rather than therapeutic against DVTs and PE’s 3. Patients were coming to harm because of omitted treatment.

9. Changes implemented in order to re-audit the TEDS audit Discussion with Sisters in charge (Jayne and Angela) in SAU by SpR Mr Chatzdimitriou on 25 February 2015 Highlights SAU is where TEDS should be prescribed The results of the audit Nurses stated these problems: The storage of TEDS stockings in the right size and quantities Staffing Doctors do not document clearly whether TEDS should be given Patients are not checked for TEDS stockings Suggestions: to bleep the admitting doctor to ask whether TEDS should have been prescribed or not to include a TEDS tick box in the vascular section of the proforma To check patients for TEDS prior to SAU departure to the inpatient wards To try and give TEDS stockings within the first hour of admission, when the other paper work is being done.

10. Cycle 2 results WardStandardAchievedNot achieved SAU 100% of patients should receive prescribed TEDS stockings 9/14 64% 5/14 36% Ward 6 100% of patients should receive prescribed TEDS stockings 9/9 100% 0/9 0% Ward 8 100% of patients should receive prescribed TEDS stockings 4/7 57% 3/7 43% Total100% of patients should receive prescribed TEDS stockings 22/30 73% 8/30 27%

11. Changes between cycles 1 and 2 Cycle 1Cycle 2Percentage difference Total prescribed and given TEDs 35%73%38% (more than double percentage)

12. For future auditing Another re-audit to assess for long-term improvements Implementation of suggestion listed above (following discussions with the ward sisters), namely: To bleep the admitting doctor to ask whether TEDS should have been prescribed or not To include a TEDS tick box in the vascular section of the clerking proforma To check patients for TEDS prior to SAU departure to the inpatient wards To try and give TEDS stockings within the first hour of admission, when the other paper work is being done.

13. Conclusion TEDS stockings prevent the occurrence of DVTs and PE’s both in surgical and medical, non-mobile patients Patients come to harm without adequate prophylaxis Simple changes can be implemented to save more lives