NIMC VTE Pilot - Australian Commission on Safety and Quality in

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Using the NIMC VTE Prophylaxis
Section
Overview
 The burden of VTE in Australia
 The NIMC VTE Pilot
 How to use the NIMC VTE prophylaxis section
 Frequently asked questions
Slide 2 of n
Extent of issue
In 2008:
VTE cases
14,716
Deaths
5,285
Working age
43%
Total inpatient costs
$81.2m
Comparison of deaths
Reference:
1. Access Economics Pty Limited (2008) The burden of venous thromboembolism in Australia. Report for the Australian and New
Zealand Working Party on the Management and Prevention of Venous Thromboembolism.
https://www.deloitteaccesseconomics.com.au/uploads/File/The%20burden%20of%20VTE%20in%20Australia.pdf.
Accessed 1 June 2013.
Reducing practice gaps
ENDORSE STUDY across 32 countries (including Australia) found that
only 59% of at-risk surgical and 40% of at-risk medical patients
received guideline-recommended VTE prophylaxis1
National Institute of Clinical Studies (NICS) Public Hospital VTE
Prevention Program2 (2005-07) showed:
• underuse of preventative measures
• pre-printed VTE section on medication chart improved use of VTE
prophylaxis in high risk patients
References:
1. Cohen AT, Tapson VF, Bergmann J, Goldhaber SZ, Kakkar AK, Deslandes B, Huang W, Zayaruzny M, Emery L,
Anderson FA. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): A
multinational cross-sectional study. The Lancet 2008;371(9610):387-94.
2. National Health and Medical Research Council. Preventing venous thromboembolism in hospitalised patients:
Summary of NHMRC activity 2003–2010. Melbourne: National Health and Medical Research Council; 2011.
Slide 5 of n
Australian Safety and Quality Goals for Health Care
 Goal 1 Safety of care: That people
receive their health care without
experiencing preventable harm
 Outcome 1.1.3: Adults experience fewer
venous thromboembolisms associated
with hospitalisation.
 There is strong evidence that appropriate
risk assessment and prophylaxis can
reduce the risk and incidence of venous
thromboembolism.
www.safetyandquality.gov.au/wp-content/uploads/2012/08/Goal-1.1-Medication-Safety-Action-Guide-PDF-486KB.pdf
NIMC VTE Pilot
 National piloting of a pilot NIMC with VTE section
was undertaken in two phases beginning in August
2010 and finishing in December 2012
 Over 30 hospitals from five states participated in the
pilots
 The results provided strong support for inclusion of a
VTE prophylaxis section in a new version of the
NIMC
NIMC VTE Pilot Results:
Quantitative Audit Results
Audit Parameter (% patients)
Phase
1
PreAudit
Phase
1
PostAudit
Phase
2
PreAudit
Phase
2
PostAudit
9.4%
17.2%
35.9%
57.2%
Documentation of VTE risk assessment in VTE
section
0%
17.2%
0%
44.7%
VTE prophylaxis prescribed (mechanical and/or
pharmacological)
58.1%
65.6%
65.2%
69.3%
Pharmacological VTE prophylaxis prescribed
55.1%
62.4%
59.4%
64.4%
n.c
66%
n.c
78.6%
18.6%.
19.2%
33.6%
32.3%
Documentation of VTE risk assessment
Pharmacological VTE prophylaxis prescribed in
the VTE section
Mechanical VTE prophylaxis ordered
NIMC VTE Pilot Results:
Safety features and administration errors (raw numbers)
Audit Parameter
Phase
1
PreAudit
Phase
1
PostAudit
Phase
2
PreAudit
Phase
2
PostAudit
Average charts per patient
1.54
1.51
1.56
1.56
Patients with pharmacological VTE prophylaxis
prescribed in VTE and regular meds section
n.c
24
n.c
2
Patients with active orders for both
pharmacological VTE prophylaxis and therapeutic
anticoagulant
23
29
n.c
2
Pharmacological VTE prophylaxis ordered when
contraindicated
n.c
15
8
4
Mechanical VTE prophylaxis ordered when
contraindicated
n.c.
n.c
3
2
% anticoagulant doses documented as given
87.1%
87.3%
95.6%
96.4%
% checks mechanical prophylaxis documented
74.0%
43.0%
75.1%
68.9%
n.c = not collected
NIMC VTE Phase 2 Pilot Results:
Mechanical VTE prophylaxis documentation
NIMC VTE Pilot Study conclusions
 Introduction of a VTE section across a range of hospitals
significantly increased rates of VTE risk assessment
documentation and VTE prophylaxis prescribing while
not increasing the risk of duplicate anticoagulant
therapy being prescribed
 VTE section did not increase the number of active
medication charts per patient nor increase the risks
associated with multiple charts
NIMC VTE Pilot Study conclusions
 VTE prophylaxis section on the NIMC only one
part of a hospital-wide VTE prevention policy
 Other essential components include:
 Senior executive and clinician support
 Explicit policies for VTE prevention
 Sufficient resources for education/implementation
 Education on conducting a VTE risk assessment
 Instruction on correct use of the VTE section
How to use the
NIMC VTE prophylaxis section
The VTE section has been placed
above the warfarin section to assist
with the recognition of patients who
are already receiving therapeutic
anticoagulation and do not require
additional VTE prophylaxis
Slide 14 of n
VTE prophylaxis section: How it works
Slide 15 of n
Step 1: Document patient’s VTE risk assessment
Authorised clinician:
Determines patient’s risk for VTE (as per local policy)
Assesses patient’s risk of bleeding/contraindications to VTE prophylaxis vs. benefits of VTE
prophylaxis and formulates overall risk assessment
Documents if VTE prophylaxis NOT required/contraindicated by ticking the appropriate box*
Documents assessment is complete by ticking the VTE risk assessed box and signing and
dating in the field provided
* Specific contraindications to VTE prophylaxis should be documented in the medical record
Slide 16 of n
Step 2: Order pharmacological VTE prophylaxis
Prescriber selects an appropriate agent if indicated
Choice of agent depends on patient’s VTE risk level (See hospital policy or NHMRC
clinical practice guideline for VTE prevention)
Specify route, dose, frequency & administration times
Nurse initials the administration of medication
Order pharmacological prophylaxis if
indicated: medication, route, dose and
frequency
Document administration of
medication
Slide 17 of n
Step 3: Order mechanical VTE prophylaxis
Authorised clinician orders mechanical prophylaxis where appropriate (e.g.
graduated compression stockings, foot pump)
Authorised personnel - a nurse or a doctor, as per hospital policy
Nurse signs when mechanical prophylaxis checked
Order mechanical prophylaxis if
required
Document mechanical
prophylaxis checked
Slide 18 of n
Frequently asked questions
Q: How do I order mechanical VTE prophylaxis on the
NIMC?
A: In the space in the VTE section titled ‘Mechanical prophylaxis’ write
in the type of mechanical prophylaxis being used e.g. TEDS, GCS, IPC
etc. Sign, print your name and your contact details e.g. pager number
Slide 19 of n
Frequently asked questions (cont.)
Q: What does documenting mechanical prophylaxis checks on the
VTE section mean?
A: The hospital’s policy on VTE prophylaxis should include regular monitoring
of mechanical prophylaxis to ensure correct application. This varies by hospital
but can include checks for skin integrity (colour, warmth, pulse, pressure area
etc) and that stockings are being worn. This is usually done morning and
evening and the responsible clinician should sign their initials in the space
provided when the check has been satisfactorily completed.
Slide 20 of n
Frequently asked questions (cont.)
Q: What should I do if VTE prophylaxis is contraindicated?
A: Complete the risk assessment section indicating that VTE
prophylaxis is contraindicated and cross out the relevant ordering
section (pharmacological and/or mechanical). The prescriber should
also write “contraindicated” and sign in the administration section.
Slide 21 of n
Frequently asked questions (cont.)
Q: What should I do if the VTE prophylaxis ordered needs to be
changed?
A: If the dose of VTE prophylaxis medicine needs to be changed, a
new order should be prescribed on a subsequent chart.
Q: Where should VTE treatment be ordered on the chart?
A: If VTE therapy is required e.g. for a pre-existing DVT, it should be
ordered in the regular medicines space and not in the pre-printed VTE
prophylaxis section.
Slide 22 of n
www.safetyandquality.gov.au/our-work/medication-safety/vte-prevention-resource-centre/
Contact details:
<< Hospital name >>
Ph: << 0000 0000 pager XXXX >>
Email: <<add email address>>
Slide 24 of n
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