Improvement Science Professional
Development Program
Venous Thromboembolism (VTE) Prevention
in Ward 9
Anne Blumgart
Principal Pharmacist DUE
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
Driver Diagram
Measures
Name of
Measure
% compliance with VTE risk assessment
within 24 hours of admission
Is this an Outcome,
Process or Balancing
Measure?
Process
Operational Definition
(e.g., numerator &
denominator)
Numerator: 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
Process
Numerator: 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
Name of
Measure
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
Is this an Outcome,
Process or Balancing
Measure?
Operational Definition
(e.g., numerator &
denominator)
Outcome
Numerator: 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 patientdays (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 anticoagulationrelated bleeding event.
Balancing
Numerator: 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
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 eModule
Increased knowledge and understanding of VTE/bleeding
risk, processes and clinical management of prevention increased knowledge and understanding resulting in
improved VTE prevention management
Results of your PDSAs
Target 90% +
VTE risk
Holiday period
assessment
reminder stickers
introduced
VTE risk
assessment
reminder
card inserted
in medication
chart
House
officer
rotation
House
officers
settling in
Appreciation for a System Psychology
• Busy clinical environment
• Clinician workflow
• Processes
• Culture
• Clinical opinion
• Prompts / reminders
• Staff behaviour
• Role-modeling
• Fear / lack of confidence
• Habit
• ‘Work-arounds’
Theory of Knowledge
Understanding Variation
• Change management
• Teaching and learning
• Data / statistics
• Population Health
• Best evidence / best practice
• Seasonal effects
• House officer rotations
• Staff shortages / changes
• Busyness
• Prioritisation
Profound Knowledge Worksheet
8
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
What next?
• CMH VTE Prevention Policy
• VTE Prevention eModule
routinely included in house
induction training
• VTE Prevention Week 29th
April - 3rd May
• Routine house officer teaching
• Further roll-out of CMH VTE
Prevention Programme
NHS East ©
Any questions?
Acknowledgements to the Ward 9
staff for all their excellent work on
the VTE Prevention initiative