The Safer Healthcare Now! Venous Thromboembolism (VTE) intervention promotes the use of pre-printed order sets and timely administration of the appropriate thromboprophylaxis to reduce hospital-acquired VTE. We asked three teams to share their journey in implementing evidence-based best practices to reduce VTE. The Safer Healthcare Now! VTE Getting Started Kit helped these teams to develop VTE protocols and the teams participated in VTE Audit Day to obtain a snapshot and measure their results. Here are their stories:
Central Health overcomes resistance in implementing a VTE strategy across the region
When Central Health embarked upon developing a Venous Thromboembolism Policy and Pre-printed Order Sheets, a baseline audit found that some physician groups were administering thromboprophylaxis in accordance with evidence-based guidelines. The VTE team knew there were areas for improvement to ensure all clients were receiving appropriate prophylaxis. A physician group identified as having VTE prophylaxis embedded in their daily practice was approached to be champions to help move a VTE strategy throughout the health authority. After some discussion, the team recognized that they needed to engage a physician group who were keen to champion the initiative and were interested in making changes in their practice to align with the evidence-based practices for VTE prophylaxis.
A new physician order sheet was developed as a trigger tool to ensure clients were risk-assessed for VTE prophylaxis and it was appropriately administered. It also enabled the team to measure compliance through audits and provide feedback for staff with respect to areas for improvement. The Pre-Printed Order Sheet was then rolled out to physicians at Central Health’s two referral centres and rural sites across the region. A robust education rollout ensued and the Chiefs of Staff were engaged to support the initiative and promote participation. It took just over a year to implement the strategy across the region with all physician groups taking part.
“You have to listen to find your physician champions and work with them,” says Melanie Hewett, Safer Healthcare Now! Coordinator, Central Health. “You need to determine who is passionate about the particular care issue and who can help you drive the initiative.”
“We were very committed and we promoted the fact that the VTE strategy was being implemented for the safety of the patient,” says Melanie Hewett. “We partnered with physicians to make the Pre-printed Order Sheet more user-friendly and adapted it along the way. It was challenging to introduce the form across a large geographic area, but we did a considerable amount of advance communication with our staff to ensure VTE was a priority.”
Central Health participated in VTE Audit Day in April 2013. They prepared a one-pager to summarize their results, which mirrored the national average, and shared it with the CEO, Chiefs of Staff, physicians and staff across the region. “People read our report and we received a lot of feedback,” says Melanie Hewett. “We would definitely participate in the VTE Audit Day again.”
Halton Healthcare engages physicians to reduce hospital-acquired VTE
When venous thromboembolism (VTE) became an Accreditation Canada Required Organizational Practice, Halton Healthcare knew that their physician practice with Preprinted Order Sets and the appropriate use of thromboprophylaxis was quite high. A VTE treatment working group had been established as far back as 2001 to address deep vein thrombosis. They had provided education on VTE and implemented different strategies; however, limited auditing had been done over the years.
Two years ago, an interdisciplinary team that included representatives from surgery, medicine, internal medicine, chiefs of staff and others was formed to revisit Halton’s VTE strategy. The team did a baseline audit, developed a project charter, and conducted major and minor tests for compliance to see what work they needed to do. Developing an improved Pre-printed Order Set for both medical and surgical patients and having many physician champions participating on the interdisciplinary team made the difference in strengthening compliance with appropriate thromboprophylaxis.
Halton Healthcare Services is comprised of three hospitals. Committed physicians at each site emerged as the key physician VTE leaders. “They could see that they were in this together and wanted to make it happen,” says Lynn Budgell, Patient Safety Coordinator. “We were able to succeed in putting something together that our physicians could stand behind.”
“There was great leadership and tremendous interest clinically about the importance of this,” adds Lynn Budgell. “We created the new order sets and after much discussion and debate about the inclusion of a risk scoring tool, the consensus was that it would serve as a good tool to support decision-making for physicians in ordering prophylaxis.”
Colourful signage for both healthcare providers and patients helped to educate and keep VTE at the forefront. A ‘Dear Doctor’ letter was created by the Working Group physicians and is sent by pharmacy staff to physicians when prophylaxis is not ordered on admission for appropriate patients. The interdisciplinary team physicians were consulted as to the appropriate formats for education of the physician groups. The team is now refining the process for auditing and submitting data so that ongoing measurement of progress is an organizational priority.
“Physician involvement was essential to our success and included physicians from different disciplines across all three sites,” says Dr. Jane Wilkinson, VTE interdisciplinary team member at Halton Healthcare Services. “Physicians provided our interdisciplinary team with the lens of the frontline provider, anticipating obstacles and acting as champions amongst their colleagues. Audit results are made available to physicians frequently as feedback and to provide solutions where needed.”
Audits and patient participation help Moncton hospital achieve 100 per cent compliance with administering thromboprophylaxis
The staff at Dr. Georges-L.-Dumont University Hospital Centre in Moncton, New Brunswick first started working on a venous thromboembolism strategy in 2008. They have established Preprinted Order Sets that clinicians continually update; held educational sessions to get physicians and frontline staff onboard; and regularly conduct audits through chart reviews.
Most recently, a walking program was established for patients with venous thromboembolism. A patient brochure has been prepared that talks about how to recognize the signs and symptoms of thromboembolism and illustrates exercises when immobile, such as how to move your toes, so that the patient can participate in their care.
Andrée Guy, Quality and Patient Safety Advisor, Dr. Georges-L.-Dumont University Hospital Centre (Vitalité Health Network) says that the Safer Healthcare Now! Venous Thromboembolism strategy is a goldmine that has helped them achieve 100 per cent compliance with administering appropriate thromboprophylaxis. “The VTE strategy has everything in it and provides evidence-based best practice.”
Audits determine if Preprinted Orders have been used and if the appropriate thromboprophylaxis was administered on patients. To provide a more complete picture of venous thromboembolism, about 30 charts are also pulled and reviewed for patients discharged in the previous three months. They look to see if medication was given on discharge and if the patient came back to Emergency for a problem related to VTE.
“You need to audit on a regular basis and bring the results back to the table for everyone to see,” says Andrée Guy. “It takes time to get everyone on board. Never give up; show your staff and physicians what they have accomplished and let them take ownership for their results.”
“If you wait for all of the players to get involved in developing your strategy, it won’t happen. If a doctor believes in what you are doing, they don’t have the time to write the strategy. Nursing staff need to do the work and use your doctors as consultants to review and provide feedback on the strategy.”
For more information and resources on venous thromboembolism, and to download the Safer Healthcare Now! Venous Thromboembolism Getting Started Kit, visit www.saferhealthcarenow.ca