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Improving Prescription of Venous Thromboembolism Prophylaxis for Admitted Medical Patients

Project Added:
29 April 2016
Last updated:
29 July 2016

Improving Prescription of Venous Thromboembolism Prophylaxis for Admitted Medical Patients

Summary

Liverpool Hospital implemented an education program for emergency department (ED) staff, to ensure venous thromboembolism (VTE) prophylaxis is prescribed to all appropriate patients on admission.

Aim

To improve compliance of VTE prophylaxis prescription for appropriate admitted patients in Liverpool Hospital ED from 5% to 50% within 12 months.

Benefits

  • Reduces the risk of VTE in admitted patients.
  • Reduces the risk of recurring thrombosis.
  • Reduces morbidity and mortality from post-thrombotic syndrome.
  • Increases staff knowledge of VTE and awareness of patients’ risk.
  • Reduces delays to VTE risk assessment.
  • Reduces delays to VTE prophylaxis prescription.

Background

VTE involves the formation of a blood clot within the deep veins, which can result in deep venous thrombosis (DVT). These blood clots can become dislodged and obstruct the pulmonary artery or one of its branches, causing a pulmonary embolism. The incidence of VTE has been shown to be 100 times greater in hospital patients than in the community, with up to 50% of VTE cases occurring during or soon after hospitalisation.

Although VTE is preventable, it can lead to an increased risk of recurring thrombosis, morbidity from post-thrombotic syndrome or death. In fact, it is responsible for 7% of all hospital deaths. Effective prevention of VTE is achieved through an assessment of risk factors and the provision of a VTE treatment, or prophylaxis.

Prior to the project, it was perceived that prescription rates of VTE prophylaxis for admitted patients in Liverpool Hospital ED was low, with many patients not prescribed VTE prophylaxis on admission to the ED. Prescription of VTE prophylaxis is a key expectation of clinical practice at a state and national level. Prior to the project, the VTE rate per 1000 admissions at Liverpool Hospital ED was 0.4 and rate per 1000 bed days was 3.7.

It was determined that education on VTE prophylaxis to ED teams would encourage doctors to prescribe it more frequently, particularly after hours when they may not be seen by inpatient teams for several hours, depending on the day and time of admission.

Implementation

  • The diagnostic phase included a flowchart of processes that occur in the ED, during the prescription of VTE prophylaxis for appropriate admitted patients. This identified eight causes for the delay in prescribing VTE prophylaxis:
    • no risk assessment tool
    • assumption that the inpatient doctor will do it
    • cognitive overload of ED staff (outside scope of project)
    • too many charts to fill out
    • uncertainty around who completes the prescription
    • uncertainty about the details of relevant policies and procedures
    • uncertainty about what drug to prescribe
    • lack of knowledge of clinical indications.
  • VTE Risk Assessment Tool forms developed by the Clinical Excellence Commission were ordered and distributed within the ED and uploaded to the ED intranet.
  • Educational resources were developed and uploaded to the ED intranet, as well as emailed to all ED doctors with regular reminders to prescribe VTE prophylaxis on admission.
  • Informal discussions and reminders were added to the agenda at departmental meetings.
  • Reminders were posted on the roster clipboard and ED noticeboard.
  • Formal face-to-face education took place with ED consultants, registrars and junior medical officers.

Project status

  • Implementation - the initiative is ready for implementation or is currently being implemented, piloted or tested.

Key dates

  • June 2015 – June 2016

Implementation site

  • Emergency Department, Liverpool Hospital, South Western Sydney Local Health District

Partnership

Results

  • A point prevalence study of 100 admitted patients was completed in June 2015, as part of the diagnostic phase of the project, to confirm prescription rates. Results were as follows:
    • 65% of admitted medical patients in the ED without contraindications were not prescribed VTE prophylaxis
    • 35% of patients had VTE prophylaxis prescribed, with 5% charted by ED doctors and 30% charted by inpatient teams
    • medical patients were less frequently prescribed VTE prophylaxis compared to surgical patients.
  • Following project implementation, another point prevalence survey in December 2015 on 50 admitted medical patients showed an improvement in prescription rates. Results were as follows:
    • 43% of admitted medical patients in the ED without contraindications were not prescribed VTE prophylaxis
    • 57% of patients had VTE prophylaxis prescribed, with 34% charted by ED doctors and 23% by inpatient teams.
  • A final point prevalence study was conducted in June 2016 on 50 admitted medical patients. Results were as follows:
    • 30% of admitted medical patients in the ED without contraindications were not prescribed VTE prophylaxis
    • 69% of patients had VTE prophylaxis prescribed, with 39% charted by ED doctors and 30% by inpatient teams.
    • The pilot project achieved sustained improvement in prescription of VTE prophylaxis for appropriate admitted patients.

Lessons learnt

  • We learned that clinical practice improvement isn’t always as straight-forward as it seems and uptake can be slow. Patience is essential during the process of change.
  • We needed to keep persisting to get the right people involved, meeting in ‘ad hoc’ groups and using email to communicate.
  • There were fluctuations in our project team due to external factors such as maternity leave and people who transferred to roles outside Liverpool Hospital. Rotating staff also meant there was a loss of knowledge within the ED on the project.
  • The workload demands of ED staff meant that uptake on change was slow and it was difficult to get teams to work together, as they are time poor and often undertake shift work.

Related resources

Contact

Dr Penelope Weir
Deputy Director of Emergency, Liverpool Hospital
South Western Sydney Local Health District
Phone: 02 8738 3990  / 0416 122 182
Penelope.Weir@sswahs.nsw.gov.au

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