Horizon Health Network in New Brunswick looks for every opportunity to advocate and educate on the importance of safe healthcare practices. Their approach to preventing venous thromboembolism (VTE) was no different. With strong leadership support, Horizon has implemented a program that includes a risk assessment tool, clinical order sets, measurement tools, data analysis, education and communication.
When four health authorities joined together to form the Horizon Health Network (Horizon) in 2008, each authority had different processes and ways of doing things. In December 2012, the Horizon VTE Advisory Group was formed to take a regional approach for VTE prophylaxis. The multidisciplinary team of physicians, pharmacy, nursing, and patient safety representatives set out to foster a consistent approach to VTE prophylaxis administration and develop performance indicators to monitor progress. A regional policy and guidelines were put in place and the team looked at best practices that could be adopted.
One of the first tasks was to come up with a risk assessment tool that would provide a standardized method of determining which patients were at risk of VTE. The risk assessment tool was shared with physicians and the multidisciplinary teams, and a pocket card was made available in hard copy and on the Horizon intranet for download.
The next task was to inventory all clinical order sets for those including VTE prophylaxis. The inventory found surgical services had clinical order sets in place; in medical services there were few order sets where VTE prophylaxis was indicated. Under the leadership of Pharmacy Services, a Medical Inpatients VTE Prophylaxis order set was created that could be adopted across Horizon. A consistent list of medications on the order set ensures consistency and provides options for the physicians to select from.
In order to foster a consistent approach across Horizon, it was identified the previous four health authorities, now Horizon Health Network, had variations in medication formularies for VTE prophylaxis. Formulary standardization was required to decrease the patient’s risk of harm and dosing errors. In August 2013, the Horizon VTE Advisory Group sent a letter to the Provincial Chair of the Formulary Review Committee requesting a class review of low molecular weight heparin. In June 2014, the Provincial formulary was standardized to two choices and the Medical Inpatient clinical order set was revised.
Next, the team looked at education. VTE Simplified pamphlets for patients and staff information were used to spread the word. “With limited resources and time, we did not want to reinvent the wheel, so we used the VTE Simplified materials to educate patients and staff,” says Alice Damon, Chief Patient Safety Officer, Horizon Health Network.
A physician fact sheet was created for distribution from the Regional Medical Advisory Committee to all physicians across Horizon. “We had to develop a consistent process and ensure everyone was on the same page, using the same process,” adds Alice.
“Physician champions were identified as means to spread the importance of VTE prophylaxis and educate their peers. Having physician champions will get you further along, as they will talk with their peers one-on-one or in a group setting. It is important to have that in place.”
This initiative is a multidisciplinary responsibility although the prescriber is responsible to determine if VTE prophylaxis is ordered. Nursing and pharmacy play an important role in identifying patients that may not been screened for VTE prophylaxis upon admission and bring this to the attention of the prescriber. An online video was created for nurses and pharmacy staff to illustrate their role in relation to the regional approach for VTE prophylaxis and to reinforce patient education. The video is available 24/7 on the intranet to accommodate shift workers. Patient Safety Consultants also visited each nursing floor, asking staff to watch the video and to raise awareness about VTE at the unit level.
The final step was measurement. Horizon has adopted a three-fold approach. First, a process indicator was developed for assessing if a patient had a risk assessment done for VTE. The team worked with Health Information Professionals, in the Health Records department, to ensure a consistent method of measuring VTE risk assessment across all facilities. Now, when the Health Information Professionals gather data from patient charts, they also gather information to confirm if a VTE risk assessment had been completed for the patient. This information is used to identify and address areas for improvement. Secondly, the Safer Healthcare Now! audit tool is used for random and periodic sampling to determine if order sets were used and if the appropriate prophylaxis was administered. Patient Safety Consultants, with some assistance from Nursing, complete these audits to reduce some of the burden on the unit staff. Finally, an outcome indicator on deep vein thrombosis and pulmonary embolism combined for medical and surgical in-patients is being reviewed for opportunities for improvement. “As an organization we are constantly looking at ways to get data that is meaningful, and ensure the collection process does not overload staff,” says Alice.
Horizon participated in the Safer Healthcare Now! VTE Audit Day in April 2013 to gather baseline data, and again in October 2014 to monitor any improvement. The Safer Healthcare Now! audit tool is currently used on a quarterly basis to determine if patients are receiving the appropriate prophylaxis. Compliance is at 82 per cent.
“To change or transform healthcare practices you need a good change management strategy,” says Alice. “Communication is vital! You will always have resistance and you need to find ways to overcome that. Change takes a long time to happen; it does not happen overnight -- if you think you can do it all in a year, it will take three. To be successful, you need to stay on top of it.”