27 th May 2011 Anticoagulation in Practice. Dr Jennie Wimperis Consultant Haematologist

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1 Dr Jennie Wimperis Consultant Haematologist

2 What is Click for Clots? Why we set it up? How we set it up? More details of what it contains Thrombosis Risk Assessment Hospital aquired/associated Thrombosis

3 Norwich London

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5 NNUH PFI hospital opened in 2001 Queen officially opened 2004 UEA medical school 2002 Foundation status 2008 National VTE Exemplar site 2010

6 Norfolk and Norwich University Hospital ~1010 beds ~70,000 adult discharges / yr ~70,000 adult day cases / yr

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8 What is Click for Clots? Hospital Intranet website Links into information relating to Thrombosis and Anticoagulation Accessed through an icon on the front page of the Trust Intranet

9 Why did we set it up? Thrombosis prevention and treatment vital part of medical care Important all health care professionals are well informed Information relating to Thrombosis and Anticoagulation difficult to find Need to raise Trust awareness of Thrombosis and Anticoagulation Ease of access to national reports, guidance and educational resources

10 Solution Dedicated Hospital Intranet website Linking into all relevant information Accessed through an icon on the front page of the Trust Intranet

11 How did we set it up? Much discussion at T&T committee Design of Logo Name - Click for Clots shortened to C4C Contents Persuade Trust for logo (portal) on front page Engagement of Trust web team for design and execution and maintenance T&T = Thrombosis and Thromboprophylaxis

12 Thrombosis & Thromboprophylaxis Committee Medical staff representation medicine for the elderly (chair); haematology; cardiology; respiratory; general, orthopaedic and plastic surgery; obstetrics & gynaecology, anaesthetics Anticoagulation nurse specialists Laboratory staff Pharmacy Administrative support Primary care representation Meets bimonthly

13 Launch of Click for Clots February 2010 Information stand outside the staff restaurant Click for Clots T-shirts Click for Clots badges Announced at the Trusts Grand rounds Report in the Hot news section of the Trusts intranet Report in the Trusts magazine (Pulse)

14 What does it look like?

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18 Unfractionated Heparin chart

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26 What s in a HAT report? Summary broken down into speciality of TRA completion audit traffic lights HATs fatal and non-fatal RCA analysis of cause of HAT Take home message also sent around by to all medical staff, senior nurses, pharmacists, senior managers TRA = Thrombosis Risk Assessment; HAT = Hospital Acquired/Associated thrombosis; RCA = Route Cause Analysis

27 Thrombosis Risk Assessment Goal >90% - Trust wants 100% Tool on front page drug chart completed by admitting clinician/assessing nurse (cardiology/ pre assessment unit) Monthly audit 10 patients each ward area by pharmacy staff (how completed what TP given) CQuins - census type data all patients Ward clerks completed or not

28 HAT reports What is a HAT? Hospital Acquired (or Associated) Thrombosis DVT or PE during hospital admission What about those who probably had DVT / PE on admission but not initially suspected? DVT or PE within 90 days of discharge We initially chose within 30 days (until April 2010) DVT = deep vein thrombosis; PE= Pulmonary embolus

29 How did we find the HATs? Non-fatal Inpatient anticoagulation (warfarin dosing) service DVT clinic Fatal Pathology Liaison & Bereavement Nurse Death certificates Post Mortem reports (including Coroner s)

30 Root Cause Analysis - RCA Case reviewed sections 1 to 3 completed by members of T&T team.

31 Root Cause Analysis - RCA Partially completed form sent to Consultant responsible for index admission to complete Section 4 Completed RCA form returned to T&T team, data collated and entered onto database. Common themes identified Summary results contribute to monthly HAT report

32 Findings 162 HATs per annum (2010) 125 non-fatal (62 PE / 63 DVT) 37 fatal (31 PE / 6 DVT) ~ 2 / 1000 inpatient episodes

33 Root cause of HAT Patient declined TPX Incorrect risk assessment Anticoagulation reversal Prescription failure Failure to risk assess Omission dose(s) TPX Delay commencement TPX TPX contraindicated / not indicated TPX failure

34 Problems identified & tackled along the way Failure to risk assess Education campaign, drug chart risk assessment Delay in first dose of LMWH Thromboprophylaxis round in the evening on orthopaedic wards Unexplained gaps (missed doses) in LMWH prophylaxis Targeted audit Inappropriately Low-dose LMWH Tinzaparin 3500 units removed from stock Education re. correct dosing in renal impairment Failure to prescribe according to the risk assessment Audit and feedback, re-design drug chart TRA Some VTE events seem to be unpreventable Maintain morale and commitment to VTE prevention Delay in diagnosis and treatment of VTE Education

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36 What have we achieved with Click for Clots? Positive feedback - hits on site remain high approx 700 per month Awareness of Thrombosis higher IP TRA completion 46% in January to 75% in February and is now over 90% More patients now receive appropriate TP Informal feedback has been excellent Directorate Governance meetings use the site to discuss TRA and for education Link nurses are using the site to access the DH evte educational resources IP = In patient; TRA = Thrombosis risk assessment; TP = Thromboprophylaxis

37 Any questions?