1. Anne Blumgart Principal Pharmacist DUE Improvement Science Professional Development Program Venous Thromboembolism (VTE) Prevention in Ward 9

2. Content and Aim Aim To increase the percentage of adult inpatients being VTE risk-assessed within 24 hours of admission (from 3%) to 90% by the end of July 2013. System Systems-based approach to achieving whole-of-hospital VTE prevention programme, including routine, documented VTE risk assessment for all admitted adult patients to guide appropriate VTE prevention. Guidance Identification of ‘the problem’ and current status quo Review of best evidence International best practice - NHS South West VTE Exemplar Sites, Global VTE Prevention Forum - UK, USA, Canada, Japan, Australia, Germany, New Zealand National Policy Framework: VTE Prevention in Adult Hospitalised Patients in NZ ISIA methodology for ward 9 pilot Constraints 1. Technological 2. Financial 3. Clinical opinion

3. Driver Diagram

4. Name of Measure Is this an Outcome, Process or Balancing Measure? Operational Definition (e.g., numerator & denominator) % compliance with VTE risk assessment within 24 hours of admission ProcessNumerator: No. of admitted adult patients (LOS ≥ 24 hrs) VTE risk assessed within 24 hours of admission Denominator: No. of adult patients hospitalised for ≥ 24 hours % of at-risk adult hospitalised patients with a LOS ≥ 24 hours receiving appropriate VTE prophylaxis within 24 hours of admission ProcessNumerator: No. of admitted adult patients requiring VTE prophylaxis who receive it as per CMH guidelines Denominator: Total no. of admitted adult adult patients who are appropriate candidates for VTE prophylaxis Measures

5. Name of Measure Is this an Outcome, Process or Balancing Measure? Operational Definition (e.g., numerator & denominator) Number of admitted adult patients with a LOS ≥ 24 hours who develop a VTE event, (specifically, proximal lower extremity DVT / PE), during hospitalisation, or within 90 days of discharge OutcomeNumerator: No. of adult patients who develop confirmed proximal lower extremity DVT / PE during hospitalisation, or who are readmitted within 90 days of discharge with proximal lower extremity DVT / PE. Denominator: Total no. of patient- days (for the month being audited) for adult hospitalised patients with LOS > 24 hours % of adult hospitalised patients who receive pharmacological VTE prophylaxis who experience an anticoagulation- related bleeding event. BalancingNumerator: No. of adult hospitalised patients who experience a bleeding event related to pharmacological VTE prophylaxis. Denominator: Total no. of admitted adult patients receiving pharmacological VTE prophylaxis Measures

6. Change Concepts & Ideas for PDSAs Idea for Testing in a PDSA Theory and prediction about what will happen when you test this idea Red reminder stickers in clinical notes and on the VTE prevention section of the medication chart Prompt to spur action – increased awareness and compliance with risk assessment process Large VTE risk assessment reminder and information card placed in medication chart Process prompt and specific information on VTE risk assessment process - increased knowledge and compliance with process Detailing of new house officers on the ward Relationship building to increase house officer knowledge of processes and expectations, and increase cooperation - increased knowledge and compliance with process VTE Prevention eModuleIncreased knowledge and understanding of VTE/bleeding risk, processes and clinical management of prevention - increased knowledge and understanding resulting in improved VTE prevention management

7. Results of your PDSAs VTE risk assessment reminder stickers introduced Holiday period VTE risk assessment reminder card inserted in medication chart House officer rotation House officers settling in Target 90% +

8. 8 Profound Knowledge Worksheet Appreciation for a System Busy clinical environment Clinician workflow Processes Culture Clinical opinion Prompts / reminders Psychology Staff behaviour Role-modeling Fear / lack of confidence Habit ‘Work-arounds’ Theory of Knowledge Change management Teaching and learning Data / statistics Population Health Best evidence / best practice Understanding Variation Seasonal effects House officer rotations Staff shortages / changes Busyness Prioritisation

9. Process Changes and Results VTE Prevention-related activity as part of PGY1 ‘The Amazing Race’ orientation: ─PGY1s aware of VTE risk assessment process - baseline 3% Routine, documented VTE risk assessment process - reminders / prompts / one-on-one and group detailing and encouragement: ─65% documented VTE risk assessment process in ward 9 Printed & verbal patient information routinely provided to patients ─Impact to be assessed VTE Prevention eModule - routine completion as part of induction training ─Impact to be assessed Newly introduced CMH VTE Prevention Policy ─Impact to be assessed

10. What next? CMH VTE Prevention Policy VTE Prevention eModule routinely included in house induction training VTE Prevention Week 29 th April - 3 rd May Routine house officer teaching Further roll-out of CMH VTE Prevention Programme NHS East ©

11. Any questions? Acknowledgements to the Ward 9 staff for all their excellent work on the VTE Prevention initiative