Clinical Leadership is called for in all sectors of patient care1. As practitioners, we are asked to step forward and lead change and use the NHS leadership and qualities framework to support our work2.
In many cases it is not easy. In the last three years multiple bodies have published expert opinion and guidance to support the delivery of thromboprophylaxis to hospitalised patients. Venous thromboembolism (VTE) causes an estimated 25,000 preventable deaths3.
As a result, prevention and management of VTE is promoted within the NHS4. The National Institute for Health and Clinical Excellence (NICE) has issued guidance but a national audit of acute hospital trusts to investigate how organisations have responded to this agenda shows differing uptake and on-going poor practice5.
Anticoagulants are the cornerstone of successful prophylaxis and are one of the classes of medicines most frequently identified as causing preventable harm to patients as recognised by the National Patient Safety Agency (NPSA)6.
In recognising this area as a national priority, Southampton University Hospitals Trust (SUHT) established a multidisciplinary thrombosis committee, developed and implemented trust-wide guidelines and through a series of four audits we have shown that these guidelines are adhered to. Low Molecular Weight Heparin prescribing has escalated by 28% so more patients receive prophylaxis than before guideline implementation.
It has also been identified that prescribers are prompted by risk assessment labels in clinical notes to assess and document the risk. We have moved from 10-20% compliance to 80% correctly provided thromboprophylaxis – see attached file.
Why did it work?
The complexity of the evidence, clinicians’ personal experience and the huge number of stakeholders meant creating a practical, evidence based and trust-wide guideline was difficult. However, this strong political agenda was seized as an opportunity to influence patient care by linking the national agenda to local work, at the highest trust level, and doing so by ensuring the issue was made mainstream – through embedding it within the trust’s patient improvement framework.
Where evidence was lacking, the ability to empower others, leading discussions outside the thrombosis committee and bringing a decision back to the table was fundamental. Timing of post operative doses was discussed at forums with both surgery and anaesthetics and led by specialists from those areas. The multidisciplinary committee worked through the complex information to reach a final conclusion.
A key to the success of the project was the jointly held vision for safe and effective care. The shared core belief that the service should protect the patient enabled us to obtain a pragmatic consensus where evidence had ambiguity.
Significant progress on venous thromboembolism prevention has been made in our organisation. This is due to the leadership skills of the key individuals involved and their passion to deliver this vision in a practical way. We have celebrated how far we have come and we look forward to new challenges in the area of thromboprophylaxis.
1. Stephens, M; Clinical Leadership required – and that means you! Br. J. Clin. Pharm; 2009: 1: 115
2. NHS Institute for Innovation and Improvement. The leadership and Qualities framework. November 2006 available at www.nhsleadershipqualities.nhs.uk
3. Report of the independent expert working group on the prevention of venous thromboembolism in hospitalised patients. March 2007, DOH; Gateway Ref 7666,
4. Sir Liam Donaldson, Letter, April 2007 DOH; Gateway Ref 6855,
5. Venous Thromboembolism. Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients undergoing surgery April 2007, NICE. ISBN 0-9549760-3-7
6. All Party Parliamentary Thrombosis Group. Thrombosis; Awareness, Assessment, Management and Prevention. An audit of Acute Trusts November 2007.
7. NPSA alert. March 2007 Ref NPSA/2007/18.
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Sharron Millen – head of clinical pharmacy (SUHT), Dr Juliane Kause – consultant physician (Portsmouth Hospitals).