1. VTE Assessments in Acute General Medicine at the John Radcliffe Hospital Srimathy Vijayan CMT 1, John Radcliffe Hospital Learning To Make a Difference

2. Encompassed in the NICE VTE guidelines (Jan 2010) Important issue: – Patient Safety - VTE prophylaxis shown to reduce the number of deaths in patients – Trusts are monitored re. performance and financial implications are great Rationale

3. Project Aim(s) 1.By July 2012, 100% of patients admitted via AGM will have VTE assessments completed within 24 hours of admission 2.To ensure that in 100% of cases of those NOT on VTE prophylaxis, there is clear documentation as to why in the medical notes and a corresponding online VTE assessment completed

4. Action Planning What are we trying to accomplish? 1.All pts admitted via AGM will have VTE assessments completed within 24 hrs of admission 2.For pts NOT on VTE (as per Drug chart) – there is clear documentation in notes as to why not 3.For pts not on VTE, a corresponding VTE assessment form was completed online How will we know that a change is an improvement? By analysing end point data at various time points to evaluate the trends (before and after an intervention) What changes can we make that will result in improvement? Appropriate awareness to all AGM Drs re. the importance of this topic by correspondence via Email Appropriate use of PTWR sheet (used at JR)

5. Process mapping Pt admitted to AGM Seen by Dr : History, Examination, Investigations, Diagnosis considered Management Plan: including need for VTE Online completion of VTE assessment form Appropriate prescription of VTE Daily RV for need of VTE prophylaxis

6. Driver Diagram VTE assessments in AGM Education on Drs partAccess to case notesPrescribing correctly in DCReview by Seniors Integral part of pt admission like DC/CXR etc… Reasons for VTE and NOT for VTE Locums who do not have this must inform others Appropriate dosing as per protocol Review on PTWR using appropriate proforma

7. Performed at JR Hospital, Level 7 (AGM wards), 3 Wards selected 5 patients on each ward randomly selected. For each patient: Admission date noted Drug chart screened for VTE prescription For those who did NOT have VTE prescribed Medical notes screened for explanation Online system ‘casenotes’ used to determine whether VTE assessment was completed and on what date Those Pts not on VTE – online case notes assessment evaluated to see if it corresponds with NOT needing VTE Methods

8. Data Collection: Baseline (Week 0), Week 1, Week 2, Week 3 Intervention: 1 day after Baseline data collected Consisted of Email to all Staff working on AGM Methods contd…

9. Runchart

10. No of pts not on VTENo of pts for whom reason given Week 0 (Baseline)73 (43%) Week 194 (44%) Week 298 (89%) Week 366 (100% target) Number of Patients who were not on VTE and percentage of those with reasons for no VTE Results

11. No of patient NOT on VTENo of patients with corresponding online VTE assessments Baseline (week 0)73 (43%) Week 192 (22%) Week 293 (33%) Week 364 (67%) Number of Patient who were not on VTE and had correctly completed online VTE assessments Results

12. By Week 3, Target of 100% for VTE assessments completed within 24 hours of admission achieved. Ongoing Issues with ‘poor documentation’ as to why patients are not on LMWH - why? For those patients not on VTE – the online form very rarely reflects ‘no VTE required’ or ‘offer anti- embolic stockings’ only. In the Majority of cases still filled out as needing prophylactic VTE – why? 14 January, 2011 Discussion

13. Next Steps What do you plan to do next? Continue data collection for a few further weeks to evaluate trends Discuss results with local Audit department Address the issues of poor documentation in notes for those not on VTE – perhaps at next AGM clinical governance meeting? As well as need for accurate VTE completion online and ‘updating’ issue What has been the learning? The importance of the need to consider VTE in pts admitted to hospital and the need to document in those cases where you feel VTE not appropriate