VTE is a significant cause of mortality, long-term disability and chronic ill health. It is thought that there are around 25,000 deaths from VTE each year in hospitals in England.
The simple step of assessing a patient’s risk of VTE which in turn triggers consideration by healthcare professionals to consider appropriate prophylaxis has the potential to save many thousands of lives each year.
Clinical consensus guidelines for VTE prevention and prophylaxis have been available internationally for many years but their systematic implementation by healthcare professionals has been patchy across all healthcare systems.
This is exactly the kind of problem the National Institute for Health Research in England’s Collaborations for Leadership in Applied Health Research and Care program was designed to address. NIHR CLAHRC had two main drivers; the CMO High Level Group on Clinical Effectiveness and the Cooksey Review.
They concluded that one of two main reasons for variations in practice was a failure to implement much existing evidence and Cooksey identified two important steps to tackling this: identify effective interventions and implement these into practice.
The NHS in England is the first healthcare system to introduce a comprehensive approach to VTE risk assessment. Commissioning for VTE prevention has been strengthened. From 1 June 2010, within CQUIN, all providers of NHS acute services are required to report monthly the completion of a risk assessment for every adult patient on admission to hospital. The national data collection is intended to provide public confidence that every patient can expect to have their risk for VTE assessed and appropriate preventative action taken every time they are admitted to NHS acute care in England.
NHS Southwest, itself the first region to be awarded exemplar status for this work, commissioned the new NIHR CLAHRC in the Southwest Peninsula to provide an Evaluation of the Implementation Strategies for Preventing Venous Thromboembolism. The evaluation is well under way and is revealing important early learning as the work of implementation progresses.
The Southwest initiative made five initial recommendations to its commissioners and providers:
1. Policy and leadership: strong clinical leadership is considered essential for the development of a consistent, systematic approach to VTE prevention. A dedicated VTE committee is a must, with the medical director being a key driver for change.
In fact the learning is that the CEO has an essential leadership role and the engagement of stakeholders must be from “board to bedside”.
2. Risk assessment: All patients should have a documented risk assessment and should receive appropriate prophylaxis (mechanical and / or pharmacological) in accordance to their risk assessment status. Risk assessment tools should be clear and easy to use and should be incorporated into existing trust documentation rather than be stand-alone forms. A signature of a member of staff is needed to record that the risk assessment has been undertaken. The risk assessment process should be reviewed during inpatient stay and within 72 hours of admission.
The evaluation emphasises the importance of ownership achieved in working to create and adopt locally relevant protocols.
3. Measurement and audit: Compliance with the risk assessment process and prescribing of appropriate thrombo-prophylaxis should be monitored frequently using small, sample audit methodology. Audit results should be fed back to teams to drive up standards in quality and improvement. All serious incidents should be reported as adverse events.
Here the key learning is the importance of an active peer review process with good inter-site working.
4. Staff education and training: This may require the appointment of an educational lead for the trust. Link medical/nursing staff is essential for dissemination of consistent messages across all departments. Mandatory VTE assessment and prevention should be included in trust induction programmes for medical, nursing and pharmacy staff. This may require a multimedia approach.
VTE awareness events for staff should be extended to include the public.
5. Patient awareness and education: Patients should be well informed in a clear and concise manner. Where extended thromboprohylaxis is needed patients should be taught to self-administer LMW Heparin prior to discharge from hospital, and if they are unable to do so, suitable arrangements should be made.
The early learning from the evaluation offers two additional recommendations:
1. Treat VTE prevention with the same importance by which infection control is now regarded in hospitals.
2. Ensure that CQUIN monies earned are ring fenced and used for improving VTE risk assessment and prevention.
The evaluation continues and will report through 2010 and 2011.
Dr Peter Aitken is the Lead for Improvement at NIHR CLAHRC for the Southwest Peninsula