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Abstract
Introduction The Health Select Committee Report on the prevalence of venous thromboembolism (VTE) in 2005 suggested that poor awareness of the risks of VTE contributed significantly to mortality and morbidity in hospitalised patients. It recommended that all hospitalised patients should undergo a VTE risk assessment. In 2006, an audit in medical patients at Guy's and St Thomas' NHS Foundation Trust (GSTFT) revealed a lack of documentation of VTE risk assessment and poor use of thromboprophylaxis in ‘at risk’ patients. In 2007, the GSTFT ‘Venous Thromboembolism in Adult Medical Inpatients’ guideline was approved. The aim was to achieve a thromboprophylaxis culture within Acute Medicine and, in doing so, achieve a high adherence rate.
Methods The guideline was launched and implemented using a multidisciplinary and multiple intervention approach involving education and feedback, IT intervention, verbal and written reminders, regular audit and process redesign.
Results An audit in 2008 showed that the rate of adherence had increased from 56% preguideline to 96%. However, a repeat audit in 2009 suggested that even though the majority of patients were receiving appropriate thromboprophylaxis, risk assessment documentation was poor. This resulted in treatment being provided to some low-risk patients when it was not required.
Conclusion In conclusion, the most effective means of achieving VTE guideline adherence is to establish a thromboprophylaxis culture. This can be accomplished through a multiple intervention and continuous feedback approach. However, it is essential to ensure that a comprehensive VTE risk assessment is carried out to ensure that those not requiring treatment do not receive it unnecessarily.
- Audit
- clinical practice guidelines
- compliance
- continuous quality improvement
- evidence-based medicine
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Introduction
The Health Select Committee Report of 2005 showed that as few as 20% of hospitalised patients were receiving appropriate thromboprophylactic measures, which could significantly increase mortality and morbidity.1 In response, the Department of Health established an independent expert working group to investigate how current best practice and guidance on venous thromboembolism (VTE) could be promoted and improved. In 2007, they recommended that all adult patients admitted to hospital have a formally documented VTE risk assessment and be considered for thromboprophylactic measures.2
Recent evidence suggests that thromboprophylaxis for medical inpatients is still significantly underutilised throughout the UK. The Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the acute hospital care setting (ENDORSE) study was a multinational survey looking at the prevalence of VTE in the acute hospital setting and the provision of thromboprophylaxis in at-risk patients.3 ENDORSE clearly illustrated the gap between evidence and practice worldwide. The study found that 41% of UK hospitalised medical patients were deemed to be at risk of VTE, but only 37% received American College of Chest Physicians (ACCP)-recommended thromboprophylaxis.3 Lack of awareness and an uncertainty about which patients are at risk of VTE are the main reasons accounting for this gap.3 4
In 2006, a baseline audit was carried out within Acute Medicine at St Thomas' hospital. At that time, there were no Department of Health or local trust guidelines available; hence the 2004 ACCP guidance was used as an audit standard. Data were collected across eight medical wards. The medical notes and drug administration charts of 143 patients were reviewed. Of the 143 patients, 84 were eligible for VTE prophylaxis. Of this group, only 34 patients received treatment in accordance with the guideline. Of the 56 patients not eligible for prophylaxis, 10 were receiving treatment. Overall, the audit revealed an adherence rate of 56% to ACCP guidelines.
This paper describes how we established a VTE prophylaxis culture within the Trust and in doing so significantly improved the rate of adherence to VTE prophylaxis guidelines for patients admitted as medical emergencies.
Method
GSTFT is a large multisite teaching hospital in London. The Acute Medicine service admits approximately 20 000 patients per annum, almost all as emergencies. In May 2007, the GSTFT ‘Thrombosis & Thromboprophylaxis (T&T)’ committee was established. This committee is made up of doctors, pharmacists and nurses from a wide range of clinical specialties. One of the primary aims and objectives of the committee was to develop an explicit guideline to guide VTE risk assessment and thromboprophylaxis within Acute Medicine. A short-life VTE prophylaxis improvement group (CLOT) was formed, and an anticoagulation improvement pharmacist appointed to monitor the effectiveness of the guideline implementation.
Every 3 years since 1986, the American College of Chest Physicians (ACCP) has published comprehensive guidelines for the prevention of VTE, the most recent published in 2008.5 These evidence-based recommendations are considered to be the gold standard of care for Deep Vein Thrombosis and Pulmonary Embolism prevention. The GSTFT guideline for medical VTE prophylaxis (2007) was adapted from the ACCP recommendations of 2004.6
The guideline was approved for use in May 2007 (figure 1). One of the main aims was to improve the recognition and stratification of at-risk patients. To achieve this, the guideline is made up of two components: (1) an individual patient risk assessment; and (2) a treatment flow chart recommending appropriate thromboprophylaxis based on individual patient factors and the outcome of the risk assessment. The guideline follows an ‘opt-in’ approach, that is, patients are prescribed thromboprophylaxis if they fit specific criteria.
Venous Thromboprophylaxis in Acutely Ill Adult Medical Inpatients Guideline.
It was recognised that even though guidelines are tools designed to improve quality of care in daily practice, bridging the gap between the existence of a guideline and its use in everyday clinical practice is not as easy as it seems. Well-designed guidelines have been shown to lead to improvements in care, only if accompanied by specific strategies to put them into practice.7
Guideline launch and implementation
An overview of 41 systematic reviews found that the most promising approach to improving clinical guideline adherence was to use a variety of interventions including audit and feedback, reminders and educational outreach.8 A further systematic review looked at 12 studies using multiple strategies to increase the uptake of VTE prophylaxis.9 Adherence to guidelines and adequacy of prophylaxis improved in all the studies where multiple strategies were used.9 The studies with the best outcomes used audit and feedback to guide refinement of either prophylaxis policy or implementation strategy and/or used a documentary aid such as a paper-based reminder system.9 In 2007, the GSTFT antibiotic guidelines were successfully launched using a multidisciplinary and multiple intervention approach. We felt that implementation of the medical VTE prophylaxis guideline should involve a similar multiple intervention approach. All implementation strategies were utilised concurrently from the time of the guideline launch to the announcement of the 2009 audit results.
Targeting clinicians
The first target for guideline implementation was clinicians. Clinician adherence to practice guidelines can be affected by a variety of barriers. An overview of systematic reviews looking at quality assurance interventions to change clinician's behaviour suggested that implementation of guidelines may be suboptimal because clinicians are typically slow to change their established practice.10 The review covered a wide range of interventions and behaviours, and found that passive approaches are generally ineffective and unlikely to result in behaviour change. Promising approaches included educational outreach and reminders.10 In addition, unlike surgical patients for whom the need for VTE prophylaxis is more clear-cut, implementation of VTE prophylaxis in medical patients is more challenging.6 Acute Medicine has a large number of prescribers with a rapid staff turnover. Patients are admitted 24 h of the day, resulting in a combination of distraction and exhaustion. As a result, VTE prophylaxis is often in a therapeutic ‘grey’ zone and is rarely a primary treatment aim of a medical admission. To achieve recognition of the importance of VTE prophylaxis, it was essential to increase awareness of the extent of the clinical problem and the effectiveness of prophylaxis.
Based on this evidence, in order to achieve maximal adherence with the guideline, it was important to develop a thromboprophylaxis culture as well as redesign the process to facilitate higher-level adherence.
Education
To target clinicians, reminders and educational outreach techniques were used, as they have been shown to achieve improvements in uptake of guideline recommendations.10 11 Fassiadis and colleagues evaluated the change in VTE prophylaxis during a 6-month period after local prophylaxis guidelines were put into practice. Prophylaxis utilisation remained suboptimal after the institution implemented prophylaxis guidelines without an education component.12 As a result, education was a key component to the success of our guideline implementation. Our educational programme included a group of presentations which are ongoing to medical and pharmacy staff focusing on the following issues: (1) the risk of developing VTE and the underutilisation of VTE prophylaxis in hospitalised medically ill patients; (2) how to risk assess a medical patient to determine their need for VTE prophylaxis; and (3) the appropriate management of patients who have been identified as ‘at risk’ of VTE.
Thromboprophylaxis was incorporated into the top 10 safety themes for induction of new medical staff.
Evidence also suggests that adherence to a guideline can be improved by highly influential and respected individuals (opinion leaders) who can be responsible for disseminating the guidelines and driving implementation.13 Our campaign was supported and promoted by the Clinical Director and Clinical Lead for Acute Medicine as well as all of the physicians involved in the medical take.
Reminders
Paper-based reminder systems have been shown to be effective in increasing the uptake of VTE prophylaxis.10 At GSTFT, a record sheet is completed for every patient seen on the medical Post-Take Ward Round (PTWR) (the first consultant lead ward round which takes place within 12 h of admission). A separate VTE prophylaxis check was added to this sheet. The medical team must document whether VTE prophylaxis has been initiated and, if not, the reasons why. This has acted as an effective reminder to the team to complete a risk assessment and consider VTE prophylaxis for all medical patients.
Communication using IT
IT has played a pivotal role in the launch and implementation of the guideline. Computerised reminders, screensavers and email communication (after establishing an effective email-based communication with all medical staff) were utilised. These are displayed at regular intervals and allow periodic reminders and quality alerts around incidents and case review. The guideline is also available on the Trust intranet and can be accessed at any time and from any location within the hospital.
Pocket-guide
Based on the success of the pocket-sized version of the antibiotic guidelines, a similar version detailing the management of patients on anticoagulants was designed and distributed to all clinical staff. This guide contains a copy of the medical VTE prophylaxis guideline. The guide acts as a portable reminder for existing clinical staff, but it also has proven invaluable for new staff who may be unfamiliar with local practice.
Pharmacist contribution: reliable design
Research has shown that pharmacists can effectively contribute to and optimise treatment at the prescribing stage on the PTWR.14 In fact, Bond et al showed an increase in deaths of patients who were treated in hospitals without pharmacist-provided heparin and warfarin management.15 It was recognised that pharmacists could play a key role in VTE risk assessment and could greatly assist guideline adherence.
A pharmacist has been attending the morning and evening medical PTWR at GSTFT on a permanent basis since 2000 and is acknowledged as being pivotal in the success of guideline implementation and adherence. Since introduction of the guideline, VTE prophylaxis is one of a list of key priorities for the pharmacist on the PTWR. The pharmacist has an explicit role in determining whether patients who need VTE prophylaxis have had it prescribed (recognition of failure) and then prompt prescription (a two-stage process using the principles of reliable design). Regular surveillance of practice by the ward pharmacist and nurses has also helped to ensure prophylaxis has been considered for all medical patients, particularly those who deteriorate while an inpatient.
Results
In July 2007, 3 months following guideline launch and implementation, a prospective drug administration chart review took place across all medical wards to determine whether VTE prophylaxis was being utilised in accordance with the trust guideline. The medical notes of 100 medical patients were examined to determine eligibility for VTE prophylaxis. The drug administration charts were reviewed to establish adherence to the guideline. Where the guideline was not adhered to, a reason was sought. Of the 100 patients, 49 were eligible for VTE prophylaxis. Of this group, 34 patients received treatment in accordance with the guideline. Of the 51 patients not eligible for prophylaxis, six received treatment. Overall, the audit results revealed a guideline adherence rate of 79%—an increase of 23% after implementation of the guideline. Results of this audit were fed back to medical, pharmacy and nursing staff with particular emphasis on the need for clear documentation of deviation from the guideline as well as the need for further improvement with an aim of achieving a 95% guideline adherence rate.
A similar audit involving 101 patients carried out in July 2008 revealed a further improvement. Thirty-seven patients were deemed eligible for VTE prophylaxis. Of these, 35 received treatment. Of the 64 patients not eligible for prophylaxis, two patients received treatment. Overall, 96% of patients were managed in accordance with the guideline. However, documentation of deviation from the guideline was again highlighted as an issue in this audit.
In July 2009, a larger audit involving 157 patients was carried out to ascertain whether the improvement in adherence had been sustained. In this audit, 48 patients were eligible, and 109 patients were not eligible for VTE prophylaxis. Of the eligible patients, 47 received treatment in accordance with the guideline. Of the 109 patients not eligible for treatment, 48 patients received it. None of these patients had a contraindication to heparin treatment. A guideline adherence rate of 69% was recorded in this audit.
Discussion
It is clear that adherence to VTE prophylaxis has increased significantly between 2006 and 2008. This is thought to be due to a comprehensive multidisciplinary and multiple intervention approach to guideline implementation resulting in a complete change in culture in relation to VTE prevention. However, there was a significant decrease in the adherence rate in the 2009 audit where a rate of 69% was recorded.
When the Trust guidelines were implemented, our focus was to ensure that patients at risk of hospital-acquired VTE received appropriate prophylaxis. At that time, documented VTE risk assessment was not a requirement. The 2006, 2007 and 2008 audits showed that 18%, 12% and 3% of ‘low-risk’ patients, respectively, received VTE prophylaxis, even though they did not meet the criteria. This figure increased to 44% in the 2009 audit.
In this patient group, the most common reason given for the use of VTE prophylaxis was ‘immobility expected to last >72 h.’ At data collection, this was visibly not the case. It is possible that the absence of a documented VTE risk assessment contributed to this poor practice. However, even though this group of patients did not meet the primary inclusion criteria for treatment (respiratory disease, congestive cardiac failure and immobility expected to last >72 h) all presented with one or more additional risk factors for VTE as stated in the guideline. In addition, none of these patients were contraindicated to heparin, and so its use did not expose them to any unnecessary risk. The primary reason this group of patients received treatment unnecessarily was because a comprehensive VTE risk assessment had not been carried out, and an inappropriate assumption of immobility was made.
VTE prevention has now been declared a national goal as part of the Commissioning for Quality and Innovation (CQUIN) framework, with the NHS Operation Board naming VTE as one of two nationally specified goals.16 The national goal is to reduce avoidable death, disability and chronic ill health from VTE; with the goal defined as ‘the percentage of all adult inpatients who have had a VTE risk assessment on admission to hospital.’ A payment of 1.5% of the contract value will be triggered when trusts meet a goal of 90% of all adult inpatients risk-assessed within the first 24 h of admission and again 24 h later.16
The results of our latest audit suggest that patients are being prescribed VTE prophylaxis in the absence of a comprehensive risk assessment. This demonstrates that even though thorough implementation of the guideline has succeeded in altering prescribing culture and practice, it may also have led to a culture where VTE prophylaxis is prescribed in patients who may not need it. It is essential that we address this issue and take steps to ensure full risk-assessment implementation in line with CQUIN targets.
Conclusions and future work
VTE is a preventable condition associated with significant mortality and morbidity. At GSTFT, a multidisciplinary and a multiple intervention approach has been utilised to improve adherence to prescription of VTE prophylaxis in those at high risk using implementation of an opt-in methodology. The key components of the intervention were (1) a clear guideline; (2) launch and implementation of the guideline using sustained and multifaceted interventions, which included clear clinical leadership; and (3) redesign of the prescription pathway. Repeat audit suggests that this approach has succeeded in influencing the prescribing behaviour of physicians achieving a significant improvement in the number of patients receiving appropriate prophylaxis. However, this high level of adherence was achieved only by treating additional patients who did not strictly fulfil the agreed criteria of the guideline mainly due to poor VTE risk-assessment documentation.
Hospital-acquired VTE has become a clinical priority for quality and productivity for 2010. The significance of this cannot be underestimated. We must ensure best practice is fully implemented. The medical VTE prophylaxis guideline has now been updated to reflect the NICE guidance of 2010. However, we must continue to reiterate the significance of VTE and the importance of prophylaxis among all healthcare professionals. However, our work is not yet done. In order to meet CQUIN targets, steps must be taken to improve risk-assessment implementation. However, we are confident that because of the significant amount of PCT funding the CQUIN target represents, it will concentrate the minds of Trust management to prioritise VTE risk assessment.
References
Footnotes
Funding Thanks to the Guy's and St Thomas' Charity, who provided funding for a senior pharmacist to contribute to this work.
Competing interests Funding for printing of the guideline was provided by ‘Sanofi Aventis.’ BJH has recently received funding from Sanofi Aventis to carry out a research project.
Provenance and peer review Not commissioned; externally peer reviewed.