Successful approaches by Peterborough and Regina Qu'Appelle
In the 2015 Accreditation Canada Report on Required Organization Practices (ROP), Quality and Safety in Healthcare Organizations, the Venous Thromboembolism (VTE) Prophylaxis ROP showed the greatest change in compliance from 2012 to 2014, increasing from 77 to 85 per cent. The ROPs are evidence-informed practices that mitigate risk and contribute to the quality and safety of health services.
VTE is a condition that includes both deep vein thrombosis, the formation of a blood clot usually in the leg or pelvic veins, and pulmonary embolism when that clot dislodges and travels to the lungs. Thrombosis affects thousands of Canadians each year, and many are preventable. Dr. William Geerts, Director of the Thromboembolism Program at Sunnybrook Health Sciences Centre and lead of the Safer Healthcare Now! VTE intervention was the driving force behind the VTE required organizational practice. He has worked tirelessly to help hospitals, doctors and pharmacists across the country and around the world that are implementing quality improvement initiatives in the prevention of VTE.
"While VTE is a common complication in hospitalized medical and surgical patients, the evidence clearly shows that it is preventable," says Dr. Geerts. "It is gratifying to see that the ROP has helped Canadian hospitals to recognize the risks of VTE and put comprehensive policies in place to protect patients from death due to pulmonary embolism after a surgical procedure, or an acute illness requiring admission."
Peterborough aims for 100 per cent VTE compliance
The VTE prevention program at Peterborough Regional Health Centre (PHRC) is well-established and showing impressive results. Quarterly reporting by service is collected through random audits. Evidence-based VTE prevention is a key component of the Quality Improvement Plan, aiming for 100 per cent compliance by March 31, 2016. The year-end results achieved an overall 93 per cent (Medicine 96 per cent; Surgery (epidural) 93 per cent, Surgery (non-epidural) 90 per cent, and Gynaecology 84 per cent).
Prior to 2012, VTE prevention at the PHRC was rather a hit and miss approach. Standalone order sets on the patient's chart were often lost or incomplete. The Director of Quality, Risk and Patient Relations challenged teams to come up with a plan and get buy-in from their peers. A VTE Task Force was formed, led by corporate physician champion, Dr. Lynn Mikula, who continues to provide support throughout the sustainability phase. Having a committed and enthusiastic champion onboard was key to achieving buy in from physicians.
The approach taken was to first educate physicians and medical staff on the evidence, showing why VTE prophylaxis was important and how it could help. All medical departments signed off on a new policy and guidelines. VTE prophylaxis is now embedded in order sets and has become part of regular orders for patients. The order set also preauthorizes changes so that the pharmacist can adjust dosages based on body size and weight and includes a quick guideline to follow. Now, if VTE prophylaxis it is not administered, it is up to the physician to indicate on the patient's chart, why not.
"Once we got things rolling, it snowballed and has been a success," says pharmacist Greg Soon (now leading the antimicrobial stewardship program at PRHC). "Initially, we implemented a Risk Stratification Scoring System that made it simple. With this approach, there were significantly fewer exceptions. We also had a pharmacist trained in anti-coagulation as a part of the team and that provided our physicians with the comfort and evidence to move ahead."
Clinical educators conduct monthly random audits. When anything that looks like a potential failure or inappropriate results are shown, discussions with nurses, pharmacists and physicians take place to determine the why.
"The PRHC has a fantastic culture of collaboration where everyone is encouraged to work together," says Mitch Peart, Clinical Pharmacist responsible for VTE prevention at PHRC. "When you can open conversation on the topic and find out reason behind prescribing patterns, that discussion is what drives the change going forward."
Regina Qu'Appelle Health Region system-wide approach to VTE
The pharmacy department at Regina Qu'Appelle Health Region (RQHR) were the motivators behind a region-wide change in VTE prophylaxis. The journey began in 2001, with a process comprised of three phases over a 10-year period: preparation, active intervention, and maintenance and improvement. From 2004 to 2009, hospital pharmacy residency projects were conducted and preprinted orders were implemented. Through a multi-disciplinary approach, VTE prophylaxis is now engrained into physician, nurse and pharmacist practices. The rate of appropriate in-patient VTE prophylaxis is currently at 92 per cent in surgery and 89 per cent in medical.
"We were successful because we really tried to understand our culture at RQHR," says Bill Semchuk, lead pharmacist. "Initially we tried to reach out to medicine, nursing and pharmacy in an identical manner, but we were unsuccessful. The medical culture is different from the nursing and pharmacy cultures. As an organization we are now working together as a team."
Pharmacists are more black and white, and it was an evidence-based approach that worked for that group. The medical group and physicians are very evidence-informed and experientially-based. They base their decisions on their experience; therefore a case-based format was used for this group. Nurses are protective of their patients; therefore linking VTE prophylaxis to specific patient cases where negative outcomes occurred was a significant motivator for nurses.
Annual VTE audits are mandated by the hospitals Pharmacy and Therapeutic Committee. For the past decade, RQHR has used pharmacy students to collect the data. The students spend a couple of days being educated on VTE prophylaxis and the parameters around who should get it and who should not get it. This year, 16 pharmacy students visited the wards to collect data for all adult in-patient populations, excluding mental health.
"By auditing on an annual basis, we can identify trends in VTE prophylaxis administration and areas of concern at any given time," says Bill Semchuk. "Whenever an area of concern comes up, we will meet with the individual group and discuss corrective actions."
Semchuk says that the prevention of VTE is an ongoing journey. You continually have to look at the why when your numbers drift down and have discussions on how to fix it. Support from national groups such as Safer Healthcare Now! has helped them to benchmark their results against other healthcare institutions and that has been so powerful. Finally, they are thankful to be able to connect with national leaders like Dr. Geerts, who share their expertise and that has helped them to engrain VTE prevention into the RQHR culture.