A Strategy for Auditing VTE Prevention Rebecca Brown Carol Law

Rebecca. Brown@eschola.co.uk West Herts Hospital Thrombosis Nurse Rebecca. Brown@eschola.co.uk

University of Hertfordshire Carol Law University of Hertfordshire Principal Lecturer c.law@herts.ac.uk

University of Hertfordshire (UH) Thromboprophylaxis (TP) teaching in action

The Audit Cycle Review Evidence Re-audit Devise standards Identify data sources Action Plan This provides pilot for students to reaudit Design audit tool Analyse and disseminate Collect data 5

What can audit do? Identify weaknesses and strengths in structure, processes and outcomes of health care activities Help identify specific areas to target rather than feeling overwhelmed by perceived or real failure Offers ‘hard’ rather than ‘soft’ evidence for negotiation of resources Foster team spirit and morale – recognition of good practice / outcomes Develop critical thinking and leadership skills Significant financial rewards (payment by results)

Limitations of audit Can’t offer a quick fix Can be done to you rather than owned by you Associated with ‘paper work’ rather than ‘real life’ Can be punitive and disheartening Can be quite limiting – what is being measured & what is considered ‘important’ Quality of service or qualities that are measured?

UH Audit: Risk Assessment Documentation of Risk Risk factors Contra-indications to chemical and mechanical interventions Accurate prescription of TP Has patient received the appropriate prescription?

All Party Thrombosis Group Audit. Audits in 2007 & 2008 Data collection Tool sent to CEO’s In 2008 99% of 138 Acute Trusts surveyed replied 86% have Thrombosis Committees 93% of Acute Trusts have written TP policy 70% of Acute Trusts undertake a documented mandatory risk assessment

70%????

Real Life Experiences - Endorse Challenges with collecting Data Length and complexity of form Time Recruitment of volunteers to collect data Lack of ownership of audit 358 HOSPITALS ACROSS 32 COUNTRIES 11

Endorse - Local Trust Findings Most patients have Risk Assessment Model (RAM) in notes because it is attached to clerking performa Many patient’s risk assessment documentation not completed If RAM completed sometimes recommended thromboprophylaxis is not prescribed Thromboprophylaxis prescribed but no risk assessment completed TEDS often prescribed but not fitted

Endorse – Local Findings The only unit with 100% of patients risk assessed and 100 % appropriate thromboprophylaxis given was the surgical pre-assessment unit. Nurses perform assessment and ensure doctors write prescription.

Student Audits at UH 320 students to date Average number of patients each student audits = 30 Total number audited = 9,600

Real Life Experience - UH course Common Themes: Staff unaware of existence of RA Model or TP protocol Risk assessment not documented (assumption it hasn’t happened) More nurses completed risk assessment than doctors Information from Risk Assessment not transferred to Prescription Chart Limited prescription of TP despite risk assessment Many prescriptions do not follow Trust protocol (especially for anti-embolic stockings) Results can be influenced by where and when risk assessment takes place in patient journey. Having a protocol and documentation in place is not an end in itself.

Trends Increase in number of Thromboprophylaxis Committees, comprehensive protocols and Risk Assessment Models Poor completion of Risk Assessment Models Increased prescription of Thromboprophylaxis Increased number of Trusts using opt out system Continued resistance and lack of awareness

Summary UH student feedback support All Party Thrombosis Group findings But Poor quality of patient documentation Need appropriate audit questions Need audits that can be owned by local staff Need to review and update audit questions as Trusts develop their effectiveness in TP Need feedback at unit level Need continuous education to all staff regarding best practice for TP

Strategy for VTE prevention audit Needs to be relevant to ward, hospital and Trust Ask: Is there a Risk Assessment Model in place? Is this Model being used? Where and when in patient’s journey is risk assessment taking place? Is TP being prescribed? Is it appropriate TP, are there contraindications and has it been given? Who is completing risk assessment and prescribing TP? This should be mandatory to ensure audit assesses quality of TP not just the presence of documentation.

References All Party Thrombosis Group 2008 Second Annual Audit of Acute NHS Hospital Trusts htpp://www.publications.parliament.uk Cohen A, Tapson V, Bergmann J, Goldhaber S, Kakkar A, Deslandes B, Huang W, Zayaruzny M, Emery L, Anderson Jnr F 2008 Venous Thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. The Lancet 371 (9610) 387-394