Venous Thromboembolus (VTE)
Prophylaxis: Using ImPROVE
Methodology to Implement an
Accreditation Canada Standard
BC QUALITY FORUM CONFERENCE
F e b r u a r y 2 8 th 2 0 1 3 ,
Melanie Basso, RN, MSN, PNC(C)
Senior Practice Leader-Perinatal
Dorothy Shaw, MBChB, FRCSC
Vice President, Medical Affairs
BC Women’s Hospital and Health Centre
Objectives
Primary project objective:
Ensure 100% of women who deliver at BCW, receive a
VTE risk assessment
Presentation objectives:
Describe the use of ImPROVE - RPIW methodology
to strengthen the implementation of a pre-existing
protocol on Venous Thromboembolism (VTE)
Prophylaxis
Identify the interventions used to sustain this
accreditation Canada standard
Describe our lessons learned along the way
Disclosure
 Images of commercial products in the patient
brochure are included as examples for illustration
purposes and were obtained from “Google Images”.
 These pictures do not represent the products used or
endorsed by BC Women’s Hospital and Health
Centre, or by the presenters.
 Neither of the presenters has any disclosures of
conflict of interest
 D. Shaw is a member of several Advisory groups for
non-profit organizations, none related to this
presentation
Background
 BC Women’s Hospital has over 7000 births/ year
 A lack of VTE prophylaxis protocol was identified as
a Best Practice issue for our woman at risk.
 In January 2011, we received the 2012 Accreditation
Standards which included having a VTE Risk
Prophylaxis protocol
BC Statistics
 Between 1987-2004 there were 35 maternal deaths
in BC
 51% of obstetric deaths in BC were potentially
avoidable
 28% were related to blood clot issues
 Developing a blood clots is a bad outcome.
Patients are on blood thinners for extended
periods of time if they get one and are always
at an increased risk for additional clots in the
future.
BC Women’s Statistics
Staff Survey: Issues with VTE Implementation
Proportion of staff who mentioned issues with VTE implementation
In person survey of 12 post partum nurses and 2 physicians (April 2nd-4th, 2012) on all BCW Post Partum Units
100%
80%
60%
40%
64%
20%
0%
Series1
29%
29%
29%
Fragmin dose timing
When to remove stockings? (mobility)
MD Orders Incomplete
More Info/Evidence
64%
29%
29%
29%
Chart Audits: Defects in VTE Orders
Audits conducted March, 2012 on all BCW Post Partum Unit s
Defects in VTE Chart Audits by frequency of issue
100%
80%
60%
40%
75%
20%
29%
19%
0%
Series1
Patient received wrong dose
Patients given incorrect protocol
Risk Assessment incomplete
29%
19%
75%
RPIW Project Form
Previously Linked RPIW #:
RPIW 47 & Project Name: VTE Standardization
RPIW Week (Date):
April 30th – May 4th 2012
Sponsors: Heather Mash/Ruth Dueckman
Current State (Cont.)
Process Owners: Pam O’Sullivan/Roane Preston
Team Leader: Melanie Basso Sub-team Leader: Dorothy Shaw
Assessment and Treatment: 75% of VTE risk assessment incomplete
imPROVE Support: Lily Farris
Staff process: 64% of staff surveyed mentioned lack of clarity on when
to provide fragmin doses
Content Experts:Nancy Kent (MFM), Henry Woo (OB), Peter Tsang (Hematology), June Yee
(Pharmacy), Simon Massey (Anesthesia)
Team Members/Dept.
Team Members/Dept.
1. Lisa Scigliano (PP RN)
5. Caitlyn Atkinson (Birthing RN)
8. Thea Parkin (RM)
2. Cathy West (AP RN)
6. Sarah Saunders (OB Res)
9. Grace Dublanko (Quality)
3. Kathy Greenberg (FP)
7. Hanna Ezzat (OB)
Patients: 0% of patients refused the VTE protocol, 0% of patients
received written information on VTE
Chart Audit: % of patients with
Chart Audit: % of patients who
risk assessment complete
receive appropriate treatment
100%
90%
Background
80%
70%
Maternal mortality and morbidity found to be associated in BC with a lack of prophylaxis
protocol in place. Guidelines being implemented internationally/nationally/provincially
and to meet RoP
VSM Name, Date & Related Goal:
Accreditation RoP VTE
60%
50%
40%
30%
25%
20%
10%
0%
% of women who received VTE risk
assessment
Pre-Kaizen
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
25%
81%
Pre-Kaizen
81%
Problem statement:
No assessment of risk or prevention of VTE post partum at BCW existed.
Current State & Analysis
Process Map
Women with pre-existing
history assessed as high
risk
Patient
Delivers SVD
Women with intermediate
risk receive protocol
Patient assessed for
VTE Risk
Patient
Patient
Ready for Cesarean
Delivers Cesarean
assessment.
Secondary Measure: % of women who are assessed as high or intermediate
risk receive VTE protocol until discharged or
reassessed.
Patient receives VTE
protocol until discharge
Women with intermediate or
high risk receive protocol
TEDs applied to
all women
Primary Objective
100% of women who deliver at BCW, receive a VTE risk assessment
Key Measure % of women who deliver at BCW, receive a VTE risk
Patient assessed for
VTE Risk
Patient receives VTE
protocol until
discharge
What are the system requirements?
Average of 19 women arriving to deliver at BCW (takt time) per day.
Approximately 9 women will receive the VTE protocol
Project Scope
All women who deliver at BCW (or are transferred post delivery to BCW)
imPROVE: improve@phsa.ca Revision Date: Oct 31, 2011
Countermeasures
Developed provider information sheet including evidence and implementation details, Revised order forms to
streamline process, and drafted a patient information sheet for VTE.
Sustainment Plan
Audits: Chart audits
Audit Leader: Melanie Basso
RPIW Plan: Goals for the
week
Audit and observe VTE process and develop kaizen
Revise VTE orders and implement
Review audit of oozy wounds and develop kaizen
Draft, revise, and implement patient pamphlet
Revise “Anticoagulant Chart” CV0700 Appendix C
Review Second Trimester Induction orders, develop new process,
draft new orders, implement new process
Develop evidence reference and fact sheet (SHORT)
Visual cue for Fragmin patients
How do we make the standard obvious, self explanatory and mistake proof?
How do we energize staff to have a “standard work” culture? Same practice for everyone
Explore training communication to care team (MD, Nurse, etc.) and patient

How do we make BCWs standard obvious to the providers? (regular staff and others)
Adapted from RCOG
Green Top Guidelines
BC Women's Hospital RPIW #47
Chart Audit: Providers Completing VTE Orders
Audit of 12 charts April 20th-May 2nd, 2012
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Ob/Gyn
58%
Family
Practice
42%
Maternal Fetal
Medicine
Registered
Midwife
17%
17%
1
2
3
4
58%
42%
17%
17%
Provider Information (EXAMPLE)
 Background: VTE occurs in 0.5 – 3/1000 pregnancies.[1] Pulmonary
embolism (PE), along with pre-eclampsia, is the number one cause of maternal
death in Canada. Of the 1,054,828 live births in Canada between 1997 and 2000,
there were 44 direct maternal deaths, 9 of these were the result of PE. This
makes PE the leading potentially preventable cause of maternal mortality.[2]
Review of BC women’s data from the past 8 years identified at least 18
postpartum inpatient thrombotic events equally divided between vaginal and csection births. Of these, 11 were PEs. Even in low risk women, VTE is at least 5
times more common in pregnant than in non-pregnant women. The greatest
increase in risk is in the postpartum period. (~22 fold)
 Multiple studies have been done to identify patients at greatest risk for VTE. One
of the most consistently identified and strongest risk factors is emergency csection, with a risk for VTE of 0.5% to 2%.[3] Many other patient factors can
increase the risk further, hence the basis for stratifying patients into risk
categories.
[1] Sultan et al, British Journal of Hematology, 2011
[2] Health Canada. Special Report on Maternal Mortality and Severe Morbidity in Canada- Enhanced surveillance: The Path to Prevention. Ottawa: Minister of Public Works and Government Services Canada, 2004
[3] Jacobsen et al, Thrombosis Research, 2004
VTE Patient Survey
Comments
Patient 1- The nurse said the stockings are to keep the blood flowing;
nurse said ‘you need stockings’; nurse said ‘If you walk more you can take
off stockings’
Patient 2 – The nurse in delivery suite measured my legs and put on the
stockings. She said that the stockings and medication would help me avoid
blood clots so I said definitely
Patient 3- When the nurse told me that the stockings and meds would
prevent clots that made sense to me. I would like a short pamphlet -1 page
of bullets on benefits, risks (if there are any). Don’t put it in the prenatal
package because I won’t remember it, already too much information.
Workshop Summary
 So, what did we accomplish?
 We revised all the Prescriber Order Forms related to
VTE Prophylaxis Protocol and embedded them in
existing practices
 Developed Provider Information Sheets (evidencebased)
 Developed the Patient Information Sheet
 Drafted the education roll-out plan
Lessons Learned
 Project implementation success is not guaranteed just because it is a
“must do”
 Need staff buy in –don’t just tell them what to do, they want to have
evidence
 Patients want answers too, and need resources created for them at the
appropriate literacy level
 Embedding practice change into existing processes, try not to create
additional paper work
 Audits keep you honest about how your project is going and identify
areas for further development/strategy.
Questions
Thank you
Questions?
Email: Melanie Basso mbasso@cw.bc.ca
Dorothy Shaw dshaw@cw.bc.ca