1. Working together to achieve nursing excellence in VTE Katrina Glaister Clinical Governance Facilitator (VTE Project Nurse) Salisbury NHS Foundation Trust

2. VTE prophylaxis in Salisbury  Who are we?  Where we were  Where we are now  Top tips!

3. Salisbury NHS Foundation Trust  500 beds. 200, 000 people locally  Specialist services to 3 million people  Spinal Unit services to 11 million people.

4. Where we were …..  July 2007  Policy  VTE Working Group  Aim: to develop a simple (evidence based) tool to assess VTE risk, implement and measure progress (improvement)

5. Where we are now…..  Demonstrated sustained improvement - Exemplar site  VTE nurse (part time)  VTE policy – Trust-wide  Risk assessment + patient self-assessment  Audit +++  Education, education, education  Patient information  Thrombosis Committee

6. VTE Risk Assessment  Local practice  Aim - one tool  Orthopaedics, palliative care, plastics, haematology & urology  Orthopaedics (oral prophylaxis)

7. Risk Assessment – documentation  Wanted it simple!  Audit Who assesses in Salisbury?  Surgery – nurses  Medicine – doctors  Either way, nurses are key

8. VTE prophylaxis  Low risk = advice only  High risk = fixed dose low molecular weight heparin (LMWH) unless contraindicated (if so then GCS if OK)  If high risk + history of previous VTE - LMWH plus GCS

10. Can patients self-assess? Outpatients in: Fracture clinic, Day Surgery, Oncology Can patients self-assess? Outpatients in: Fracture clinic, Day Surgery, Oncology

11. Audit  Pharmacists central to our success  Trust-wide audit  Reporting: Celebrated good practice League tables Clinical Governance newsletters Published article

12. Education & raising awareness  Staff 1:1, ward-based, awareness days, symposium, Clinical Governance Sessions, screen saver, Hospital Rounds, Junior Doctors, Physiotherapists, M&M meetings, feedback from incidents, RCA for all secondary VTE events ….  Patient stories  Patients are key! Governor on Thrombosis Committee, DVD, written information, plasma screens, Patientline/Hospedia, Foundation Constituency meetings, Annual Review article, Health Fairs, AGM ……. Message is : Get out of bed ASAP Exercise if on bed-rest Take deep breaths Stay hydrated.

13. An informed public?  Terminology – the general public vaguely understand what DVT is, but not VTE  From a member of public at a Wiltshire Health Fair “VTE is the thing you get on a plane or when you have an operation and three weeks later you die”

14. An informed public? I've heard of a DVT – what is a VTE? Is VTE the new buzz word? Is VTE a breakfast cereal? - I've heard of DVT - a pain in the leg!' I still call it DVT - never heard of VTE Never heard of VTE - is it when you have thick blood? They changed it did they? I knew DVT! I've had 3 DVTs - I wouldn't know VTE - I had sticky blood as part of Lupus

15. Educating patients  Written patient information: Average reading age in UK is around 11 years Health literacy is recognised as a problem in UK and elsewhere Coming into hospital patients are given many information sheets – do they read them? “Oh yes, I did get one of those, I sent it home with the wife, she’s much more interested in that sort of thing than me”

16. Information must be accessible

17. 1 = Policy approved, 2 = Policy launched, 3 = Audit data presented to wards as league tables, 4 = Intensive education & link nurse programme, 5 = Executive drivers & pharmacy mandate (no RA = no drugs) 1 2 3 4 5

18. Deaths with VTE at Salisbury 2007- 2009 0 2 4 6 8 10 12 Oct 07 - Mar 08 Apr 08 - Sep 08 Oct 08 - Mar 09 Apr 09- Sep 09 number of deaths Deaths with VTE Deaths from VTE

19. 20 secondary VTE, 5 PE* Oct 09-date

20. VTE in the Southwest

21. Top tips  Patient stories are a powerful learning tool/motivator  Regular early reinforcement about VTE ‘at the coal face’ ensures that risk assessment is embedded  Build ‘change’ into normal practice  Audit – essential and time consuming – IT helps!  Semi-competitive ‘league tables’ increase compliance  Provide VTE outcome data directly to staff  Executive endorsement ensures that work progresses  Work in progress, there is more to do!

22. Bottom line – drip feed!