Background

Hospital-acquired VTE comprises all occurrences of VTE that develop while an in-patient or in the 90 days following discharge from hospital.2 8 Hospital-acquired VTE is associated with significant morbidity and mortality, currently estimated to account for 5%–10% of all deaths among hospitalised patients.3 As a potentially preventable problem, strategies to improve rates of VTE prophylaxis prescription in patients admitted to secondary care have been demonstrated to reduce morbidity, mortality and healthcare costs.3 11

In 2005, a report issued by the House of Commons Health Committee highlighted that an estimated 25 000 people die from preventable HAT each year in the UK. In addition, the cost to the National Health Service (NHS) of treating non-fatal symptomatic VTE and the long-term complications is calculated at £640 million per year, demonstrating that this is an expensive, nationwide problem.12

NICE published guidelines on the prevention of VTE in hospitalised patients in 2010, which was subsequently updated in 2018. This highlights clinical and cost-effective measures for VTE prophylaxis and in addition taking patients’ preferences and risks of treatment into consideration. The Commissioning for Quality and Innovation framework endorsed these guidelines and suggested there ought to be a 95% compliance rate with VTE risk assessment using a national tool.12 VTE prophylaxis via mechanical and pharmacological measures has been shown to reduce the incidence of deep vein thrombosis (DVT) and subsequent VTE.11 12

The NICE guidelines focus on all patients over the age of 16 years admitted to hospital presenting to a variety of different specialties. In the context of patients admitted under general medicine, the guidelines stipulate that all medical patients should be risk assessed for VTE as soon as possible after admission using a tool published by a national UK body, most commonly the Department of Health VTE risk assessment tool will be used.2

The benefits of MDT working are well established. For healthcare professionals, MDTs assist in increased rates of care provision in accordance with clinical guidelines, the development of streamlined treatment pathways, improved interdisciplinary coordination, communication and improved education of staff.13 For the patient, the benefits of MDT collaboration also include the increased access to treatment in accordance with evidence-based medicine, which will be of benefit to the patient, as well as improved access to information and consequently greater levels of patient satisfaction.14 Multidisciplinary quality improvement initiatives have previously been shown to be effective in different clinical environments.13 15 16

Measurement

The project adopted standard quality improvement methodology with the use of Plan-Do-Study-Act (PDSA) cycles to develop and measure the effect of interventions. Information was obtained via the review of patients’ medical notes (in the form of paper records that are available on the ward) and the drug charts, with anonymised patient information by two members of the team (one doctor and one pharmacist).

Initial data were collected using a standardised data collection tool designed by the MDT; this was used to document rates of VTE risk assessment within 24 hours of admission, VTE prophylaxis dose adjustment for patient’s weight and VTE prophylaxis dose adjustment for renal function. In the context of this study, local guidelines recommended the use of low-molecular-weight heparin (enoxaparin) for VTE prophylaxis adjusted for a total body weight of less than 50 kg or more than 110 kg and an estimated glomerular filtration rate of 15–30 mL/min.

The previously mentioned measures were selected as they would allow the team to establish whether VTE prescription was in line with national and local guidance and whether safe prescription accounting for patients’ weight and renal function was being carried out. Quantitative data would allow direct comparison following each intervention. Data would be collected on all patients on the selected wards (wards 12 and 14, two medical wards in our hospital) at 3-month intervals (after each PDSA cycle). The wards selected manage patients with a range of general medical problems and as such a variety of risk factors for VTE. The data would be collected by the same two members of the team to avoid interpersonal variation. A short survey would be carried out at the end of the final cycle to identify any benefits of the multidisciplinary approach to this work.

In order to ensure that any improved outcomes were attributed to the interventions made, we would ensure that only one project with defined interventions was being carried out at one time. Data were collected on the ward by the study team on a random day to avoid the Hawthorne effect. The random days were selected at the beginning of the study period using a random calendar date generator.17

Baseline data were collected on 39 patients revealing that only 20 of 39 (51%) patients had a documented VTE risk assessment carried out within the first 24 hours. Appropriate dose adjustment of low-molecular-weight heparin for weight and renal function was achieved in 27 of 39 (69%) and 30 of 39 (80%), respectively (table 1).

Design

A MDT consisting of three doctors, a pharmacist, a charge nurse, a member of the patient experience team, a clinical nurse practitioner and a physiotherapist was formed under the supervision of a ‘core team’ including the Associate Medical Director who was clinical lead for the MD QIT work, the Head of Nursing for medicine, a quality improvement facilitator and a Senior Pharmacist. Engagement of the entire team at the planning stage ensured stakeholder contribution and reduced parallel working streams. The delivery of sound patient care relies on good interdisciplinary working and thus by using an MDT approach, the team aimed to ensure that all members would feel valued and would work positively to achieve the end goal. Doctors, pharmacists and student nurses frequently rotate through different wards and hospital, therefore, by ensuring that permanent ward staff were involved in the project would help to facilitate sustainable changes being achieved by the project.

Initial interventions included the introduction of a ‘VTE sticker’ that would prompt prescribers to carry out the risk assessment: this would be accompanied by education for all members of the MDT. It has been well documented in previous studies that patients, given the option, would choose to be educated about VTE via direct discussion with the healthcare professional, and thus ensuring that clinicians were provided with the opportunity to consolidate their knowledge was considered a priority.18 The education comprised sessions run in the medical department weekly teaching, in which staff from all areas of the MDT were invited. The sessions included a Powerpoint presentation with didactic teaching followed by some simple case scenarios that covered more complex VTE prophylaxis decisions and allowed the opportunity for discussion. There was a reminder on how to access the hospital guidelines and the opportunity for questions. Shorter sessions were also run for three consecutive weeks on the ward during the nursing and doctor handover that included the indications, risks and two case scenarios surrounding VTE prophylaxis. The rationale behind the shorter sessions in handover was that as large a percentage of the ward staff could benefit from the teaching despite the constraints on time that can pose a challenge to staff leaving the ward for longer sessions.

The intended use of the sticker was such that if it was noted by any member of the MDT that risk assessment had not occurred, a sticker would be placed in a designated place in the medical notes, where it would come to the attention of the doctors even under time-pressured circumstances. Preprinted stickers would be in an accessible location to pharmacists and nurses to promote their uptake. During the implementation, the team would meet on a 2 weekly basis to discuss progress and provide informal feedback. By promoting MDT involvement, we hoped this would allow for positive changes to the interventions as part of the PDSA cycles and also to encourage compliance.

After the initial cycle was complete, data would be recollected and presented to the ‘core team’ allowing advice and leadership to be provided by senior colleagues with a good understanding of quality improvement methodology.

At this early stage, it became apparent that it was difficult to hold frequent meetings with all members off the ward due to the demand for clinical commitments. Therefore, it was decided that all meetings would be held in the ward manager’s office within the clinical environment to allow maximum attendance and the agenda was strictly abided to ensuring that the meetings met their objectives in a timely manner. Larger meetings at monthly intervals with the ‘core team’ were held in a more protected environment allowing the longer discussion to take place.

Further interventions were determined using feedback at each stage and included educational posters, bilingual patient information leaflets and electronic public displays. The educational posters that were displayed were those developed as part of the 1000 Lives (now Improvement Cymru) ‘Ask about Clots’ campaign, with permission. These resources were used to ensure that validated information was being disseminated. The bilingual patient leaflets were developed in conjunction with the patient experience team and their expertise was valued with respect to ensuring that the messages within the content were clear and available in both the Welsh and English language. They combined some of the figures from the 1000 Lives campaign combined with text developed by the team.

The work would initially be held on two wards in the hospital and if improvement was demonstrated, then the project would be extrapolated to other wards.

Strategy

Our aim was to increase the percentage of risk assessments for VTE prophylaxis in patients being admitted to a medical ward within the first 24 hours of their admission, evidenced by an 85% compliance within a 3-month time frame.

Cycle 1 (carried out between October and January) had two main focuses: first, the education of staff regarding VTE and VTE prophylaxis and second, ‘VTE stickers’ for the use in the medical notes to act as a visual cue and prompt to VTE risk assessment in the clinical setting.

With respect to healthcare professional education, our first intervention was the development of a VTE teaching session that was delivered to doctors, pharmacists and nursing staff highlighting best practice as outlined within local and national guidelines. This education also provided staff practical advice on how to access local VTE prophylaxis guidelines via the hospital intranet.

With respect to the ‘VTE sticker’, the MDT designed a sticker that could be placed in the medical notes following admission to act as a prompt to prescribers to carry out a risk assessment for VTE prophylaxis if this had not yet been performed. This action was largely led by pharmacy and nursing colleagues and was designed to prompt timely risk assessment.

This cycle focused on improving care in a defined clinical area covering two general medical wards (wards 12 and 14) at the RGH. Data using the standardised data collection tool described were recollected at this stage using the same approach as described earlier.

A further cycle of improvement (cycle 2, February–April) was carried out after modification of the sticker design in response to feedback gained from users and the ‘core team’ that was aimed at simplifying the VTE sticker for ease of use. In addition, cycle 2 also focused on patient-centred education. Education materials and literature developed by 1000 Lives during their ‘Ask about Clots’ campaign were displayed in clinical areas.19 We also worked with the patient experience team to use a modified poster to display on electronic public information screens. In addition, a bilingual patient information leaflet, in both English and Welsh, was designed for patients to raise awareness of HAT, encouraging patients to remain as mobile as possible and facilitating informed shared decision making. The expertise of the patient experience team was valued in ensuring that the messages the team were trying to covey were clear. Data were recollected following cycle 2 using the standardised collection tool.

Following an observed and sustained improvement in this defined clinical area (wards 12 and 14), the third cycle of the Quality Improvement Project (QIP) was to extend our project to another clinical area to try to improve practice across a wider area. Cycle 3 (May–July) focused on two acute general medical wards (wards 4 and 6). Prior to implementation, baseline data were collected in the same manner as on the previous wards by the study team.

At the end of the final cycle, appropriate statistical tests have been used to establish whether improvements are statistically significant. In addition, a short survey would be distributed to the members of the QIT to establish the benefits of the multidisciplinary approach to this work. This would be an anonymous questionnaire that would be distributed at the QI meeting and then inserted into an envelope by the participant. The results were then revealed and analysed by one of the study teams.