A Strategy for Auditing VTE Prevention Rebecca Brown Carol Law

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A Strategy for Auditing VTE PreventionRebecca
BrownCarol Law
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Rebecca Brown
West Herts Hospital
Thrombosis Nurse
Rebecca. Brown_at_eschola.co.uk
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Carol Law
University of Hertfordshire
Principal Lecturer
c.law_at_herts.ac.uk
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University of Hertfordshire (UH)

• Thromboprophylaxis (TP) teaching in action

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The Audit Cycle
Review Evidence
Re-audit
Devise standards
Identify data sources
Action Plan
Design audit tool
Analyse and disseminate
Collect data
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What can audit do?

• Identify weaknesses and strengths in structure,
  processes and outcomes of health care activities
• Help identify specific areas to target rather
  than feeling overwhelmed by perceived or real
  failure
• Offers hard rather than soft evidence for
  negotiation of resources
• Foster team spirit and morale recognition of
  good practice / outcomes
• Develop critical thinking and leadership skills
• Significant financial rewards (payment by
  results)

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Limitations of audit

• Cant offer a quick fix
• Can be done to you rather than owned by you
• Associated with paper work rather than real
  life
• Can be punitive and disheartening
• Can be quite limiting what is being measured
  what is considered important
• Quality of service or qualities that are
  measured?

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UH Audit

• Risk Assessment
• Documentation of Risk
• Risk factors
• Contra-indications to chemical and mechanical
  interventions
• Accurate prescription of TP
• Has patient received the appropriate prescription?

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All Party Thrombosis Group Audit.

• Audits in 2007 2008
• Data collection Tool sent to CEOs
• In 2008
• 99 of 138 Acute Trusts surveyed replied
• 86 have Thrombosis Committees
• 93 of Acute Trusts have written TP policy
• 70 of Acute Trusts undertake a documented
  mandatory risk assessment

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70????
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Real Life Experiences - Endorse

• Challenges with collecting Data
• Length and complexity of form
• Time
• Recruitment of volunteers to collect data
• Lack of ownership of audit

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Endorse - Local Trust Findings

• Most patients have Risk Assessment Model (RAM) in
  notes because it is attached to clerking performa
• Many patients risk assessment documentation not
  completed
• If RAM completed sometimes recommended
  thromboprophylaxis is not prescribed
• Thromboprophylaxis prescribed but no risk
  assessment completed
• TEDS often prescribed but not fitted

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Endorse Local Findings

• The only unit with 100 of patients risk assessed
  and 100 appropriate thromboprophylaxis given
  was the surgical pre-assessment unit.
• Nurses perform assessment and ensure doctors
  write prescription.

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Student Audits at UH

• 320 students to date
• Average number of patients each student audits
  30
• Total number audited 9,600

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Real Life Experience - UH course

• Common Themes
• Staff unaware of existence of RA Model or TP
  protocol
• Risk assessment not documented (assumption it
  hasnt happened)
• More nurses completed risk assessment than
  doctors
• Information from Risk Assessment not transferred
  to Prescription Chart
• Limited prescription of TP despite risk
  assessment
• Many prescriptions do not follow Trust protocol
  (especially for anti-embolic stockings)
• Results can be influenced by where and when risk
  assessment takes place in patient journey.
• Having a protocol and documentation in place is
  not an end in itself.

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Trends

• Increase in number of Thromboprophylaxis
  Committees, comprehensive protocols and Risk
  Assessment Models
• Poor completion of Risk Assessment Models
• Increased prescription of Thromboprophylaxis
• Increased number of Trusts using opt out system
• Continued resistance and lack of awareness

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Summary

• UH student feedback support All Party Thrombosis
  Group findings
• But
• Poor quality of patient documentation
• Need appropriate audit questions
• Need audits that can be owned by local staff
• Need to review and update audit questions as
  Trusts develop their effectiveness in TP
• Need feedback at unit level
• Need continuous education to all staff regarding
  best practice for TP

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Strategy for VTE prevention audit

• Needs to be relevant to ward, hospital and Trust
• Ask
• Is there a Risk Assessment Model in place?
• Is this Model being used?
• Where and when in patients journey is risk
  assessment taking place?
• Is TP being prescribed?
• Is it appropriate TP, are there contraindications
  and has it been given?
• Who is completing risk assessment and prescribing
  TP?
• This should be mandatory to ensure audit
  assesses quality of TP not just the presence of
  documentation.

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References

• All Party Thrombosis Group 2008 Second Annual
  Audit of Acute NHS Hospital Trusts
  htpp//www.publications.parliament.uk
• Cohen A, Tapson V, Bergmann J, Goldhaber S,
  Kakkar A, Deslandes B, Huang W, Zayaruzny M,
  Emery L, Anderson Jnr F 2008 Venous
  Thromboembolism risk and prophylaxis in the acute
  hospital care setting (ENDORSE study) a
  multinational cross-sectional study. The Lancet
  371 (9610) 387-394