Best Project Award in Clinical category Venous Thromboembolism (VTE) Prevention Audit Project Al Dhafra Hospitals (Al Gharbia)
Content Main Information.3 The first criteria: Study and define project objectives...4 The second criteria: Project Team...7 The third criteria: Resource Management and Control.7 The fourth criteria: Risk Management and Project sustainability...7 The fifth criteria: Project execution...8 The sixth criteria: Results...9 Appendices...12 2
Main Information Project Name Venous Thromboembolism (VTE) Prevention Audit Project A summary of the project and its reasons VTE is the formation of a blood clot (thrombus) in a vein which may dislodge from its site of origin to travel in the blood, a phenomenon called embolism. Venous Thromboembolism is an important cause of death in hospitalized patients and treatment of non-fatal symptomatic VTE and related long-term morbidities is associated with a considerable cost to health service. Al Dhafra Hospitals (excluding Madinat Zayed Hospital) have not been conformant to VTE guidelines in their clinical intervention leading to unsatisfactory patient care. Hence it is imperative to conduct evidence based VTE Prevention Audits for Al Dhafra Hospitals to ensure consistency in compliance. Project is based on SMART compliance and performance metrics to ensure valid recommendations for improvement. VTE Prevention Audit project includes baseline assessment and after-project performance to quantifiably illustrate compliance trends. Project team comprises of multidisciplinary heads from medical affairs and operations department to ensure successful execution. Department (section): Total Quality Management, Operations Department Project Manager (Name and designation): Name Role Mobile Email Dr. Ahmed Taheri Principal Health Officer 0202121050 attaheri@seha.ae Mohd Omer Nasser Senior Clinical Auditor 0205255050 moonasser@seha.ae Main members of the project team (Name and role) Name Role Mobile Email Dr. Ibrahim Hatab Chief Nursing Officer 050-8007509 ihatab@seha.ae Project Starting Date 01/07/ 2017 The person who can be contacted in with any issues related to the project submission : 3
Name Telephone Mobile Email Abdul Manzoor 028071265 0215055005 Abdulmanzoor@seha.ae The First Criteria: Study and define project objective 1. Identify and set goals and project document The goals of the project are as following: 1.1 To identify current VTE assessment practices 1.2 To understand staff knowledge of the requirement of VTE assessment and thromboprophylaxis (pharmacological and/or mechanical) 1.3 To determine the use of VTE trigger tools to identify patients in need for VTE assessment and thromboprophylaxis (pharmacological and/or mechanical) who may or may not have received the clinically indicated thromboprophylaxis (pharmacological and/or mechanical) 1.4 To determine the use of appropriate/recommended thromboprophylaxis when thromboprophylaxis was indicated(pharmacological and/or mechanical) 2. Project Plan and Execution VTE comprises both deep vein thrombosis (DVT) and pulmonary embolism (PE). DVT occurs when an abnormal blood clot forms inside a vein deep in the leg, causing leg pain and swelling. A blood clot in a leg vein can grow, break off, and travel to the lungs, resulting in shortness of breath, chest pain, and, in some cases, death. A clot that travels to the lungs is called a pulmonary embolism. Almost all hospitalized patients are at risk for VTE and most have multiple risk factors 1. The rate of asymptomatic, hospital acquired VTE, if thromboprophylaxis is not used, is 10 to 40 per cent after general surgery and 40 to 60 per cent after hip surgery. 2 The rate of symptomatic VTE is up to 5 per cent (or more) of medical and surgical patients if thromboprophylaxis is not used (Geert s et al., 2008). Adverse consequences of hospital-acquired VTE include: symptomatic DVT and PE, fatal PE, prolonged hospital stay or readmission, harm of therapeutic anticoagulation, 4
patient anxiety, additional costs to diagnose and treat, and long-term consequences such as post-thrombotic syndrome. There is strong evidence that providing appropriate thromboprophylaxis to hospital patients at risk for VTE results in a significant reduction in clinically-relevant hospital-acquired VTE. 3 Following, the success of VTE risk assessment and thromboprophylaxis QI project in Madinat Zayed Hospital in 2016, it was decided to assess the VTE assessment/thromboprophylaxis practices through the implementation of the VTE prevention audit project in 5 other peripheral hospitals of Al Dhafra region that were not implementing VTE risk assessment and thromboprophylaxis on consistent basis. The VTE audit was designed to include patients from medical, surgical and ObGyn units, with at least 10 patients from each unit included in the audit. The project team included the senior clinical auditor, the quality and patient safety officers of the hospitals being audited and a physician with quality background. A VTE data collection and reporting tool was developed for the project that was based on the Agency for Health Care Research and Quality (AHRQ) framework for VTE. Patient electronic records were accessed for the purposes of the audit. The project team also interviewed the relevant clinical staff in the facilities and used facility specific KPI reports to determine current VTE assessment and thromboprophylaxis status. Policy Manager Platform was also accessed to determine the availability of clinical VTE assessment and prophylaxis guidelines while evidence of staff training on the VTE guidelines were located directly from the medical directors and heads of departments in the facilities. The baseline audit was conducted two times in the month of June 2017. The subsequent compliance audits will be conducted in the months of August, September and October 2017. 5
Using the VTE Data Collection and Reporting tool, teams audited electronic patient records to gather the following information: 2.1 Is there a standardized, approved VTE risk assessment tool available to all clinical staff? 2.2 Was the patient risk assessed for VTE within 24 hours of admission and thereafter as clinically indicated? 2.3 Was an electronic order set (including VTE prophylaxis) used on admission or after surgery? 2.4 What type of thromboprophylaxis was ordered for the patient? 2.5 Is the patient receiving the recommended thromboprophylaxis? 2.6 Are Patients/carers are informed of VTE risks and treatment options? The project team based on the results of the findings continue to work with hospital patient safety and quality teams to drive the necessary improvements. 3. Develop an organized and comprehensive plan for internal and external communication Once the project team completed the VTE audit, the results were shared with the TQM team and the hospital leadership that subsequently disseminated the results with the heads of the relevant departments and service chiefs and hospital quality and patient safety teams to institute pertinent improvements to improve VTE risk assessment and the use of approved clinically indicated thromboprophylaxis for the patients. 4. Develop a quality assurance plan The audit tool and trigger matrix were pilot tested before the start of the project to ensure reliability and inter-rater consistency. After completion of the project, the audit framework including both the data collection and reporting tool as well as triggers will be shared with the hospital quality and patient safety teams for use during their periodic VTE assessment and thromboprophylaxis practices. 6
The audit team will continue to use the VTE trigger matrix to periodically audit VTE assessment and thromboprophylaxis practices in the facilities and plot trends to provide candid assessment of the impact of the improvement measures by the hospital leadership and quality and patient safety teams. The Second Criteria: Project Team Manage and Lead Project Team The Chief Operations Officer will serve as the project lead. The project team will continue to provide list of patient records using the VTE trigger matrix for auditing by the project team and will be analyzing/plotting trends and sharing the results with the TQM team for pertinent action and improvement. Third Criteria: Resource Management and Control Manage financial resources related to the project There are no financial resources allocated to the project. Manage and direct knowledge resources and identify a systematic and comprehensive plan The project audit team consisted of clinical and quality staff members. No external capacity was required for this project. Manage and direct suppliers The project is not deemed to necessitate any supplies or direct/indirect involvement of any suppliers. Assure optimum Resources use To manage the resources optimally, the project used Gantt chart with specific timeframes and responsibilities for project team members. Fourth Criteria: Risk Management and Project sustainability The project data will only be shared internally within the TQM team and hospital medical leadership and patient safety and quality teams for the purposes of instituting necessary improvements. 7
The data and results will not be shared externally or publish anywhere without the explicit permission of the project lead. The facility medical leadership and patient safety and quality teams will be provided with the project data collection and reporting tool so they may use it to periodically conduct assessment of VTE risk stratification and thromboprophylaxis practices in the facilities and introduce improvements as necessary. The project will be subsequently expanded to include other key clinical core aspects as part of the compliance and improvement in AGH business entities. The project team will also periodically audit VTE assessment and prophylaxis practices for all the facilities to establish trends and provide facilities with feedback on the impact of the instituted improvements. In order to maintain sustainability, the project team will continue to ensure that 4.1. rates of risk assessment completion are audited periodically (at least annually, or more frequently if compliance is poor) 4.2. rate of provision of appropriate prophylaxis are audited periodically 4.3. results of audit and review are reported back to clinicians to drive change 4.4. clinicians are educated on the need for VTE prevention measures Fifth Criteria: Project Execution The project team conducted the preliminary audit using data for the month of June 2017 for all the target facilities. A total number of 30 patient records that were identified through the use the trigger tool were included in the baseline audit. The facilities KPI reports were also accessed. The results of the preliminary audit will be used as baseline. After implementation of the project, a final audit will be conducted that will cover a period of at least 3 months and the audit results will be compared with the baseline audit results to determine project impact. 8
After the life of the project, the VTE assessment and prophylaxis compliance audits will be conducted on a quarterly basis or sooner as required. Develop a comprehensive plan or methodology to close the project including all aspects of the project Sixth Criteria: Results Project KPIs and results: The following is the baseline assessment findings that was conducted in June 2017. Measure Target GH SL MA DL LW VTE Assessment completed within 98% 76% 82% 79% 90% 70% 24 hours for Medical patients VTE Assessment completed within 98% 70% 86% 84% 87% n/a 24 hours for Surgical patients VTE Assessment completed within 98% 60% 89% 62% 89% n/a 24 hours for Obstetrics patients 90% 10% 35% 38% 50% 60% hours for Medical patients 90% 8% 67% 42% n/a n/a hours for Surgical patients hours for Postnatal patients 90% n/a n/a n/a 100% n/a The results clearly indicate a gap in VTE risk assessment and thromboprophylaxis compliance and a drastic need for improvement. The project team in coordination with the facilities medical leadership and the patient safety and quality teams led specific improvements that is measured in the subsequent compliance audit in the months of August, September and October 2017 as below: August Measure Target GH SL MA DL LW 9
VTE Assessment completed within 24 hours for Medical patients VTE Assessment completed within 24 hours for Surgical patients VTE Assessment completed within 24 hours for Obstetrics patients hours for Medical patients hours for Surgical patients hours for Postnatal patients September 98% 97% 100% 100% 100% 88% 98% 100% 100% 100% 100% n/a 98% 100% 100% 100% 100% n/a 90% 57% n/a% 100% 100% 50% 90% 100% 67% n/a n/a n/a 90% n/a n/a n/a 100% n/a Measure Target GH SL MA DL LW VTE Assessment completed within 24 hours for Medical patients 98% 98% 100% 100% n/a 100% VTE Assessment completed within 98% 100% 100% 25% 100% n/a 24 hours for Surgical patients VTE Assessment completed within 24 hours for Obstetrics patients 98% 100% 100% 36% 100% n/a hours for Medical patients 90% 91% 100% 100% n/a 100% hours for Surgical patients 90% n/a 50% 100% 100% n/a hours for Postnatal patients 90% 100% n/a n/a n/a n/a October Measure Target GH SL MA DL LW VTE Assessment completed within 98% 93% 100% 100% 100% 88% 24 hours for Medical patients VTE Assessment completed within 98% 91% 100% 100% 100% n/a 24 hours for Surgical patients 10
VTE Assessment completed within 24 hours for Obstetrics patients hours for Medical patients hours for Surgical patients hours for Postnatal patients 98% 88% 100% 50% 100% n/a 90% 78% 100% 100% 100% 67% 90% 100% 50% n/a 100% n/a 90% 100% n/a n/a 100% n/a It is worth mentioning that the facilities have different scopes and case mix index as is indicated in VTE compliance patterns. The table below summarizes the overall improvement in the VTE compliance over the target period in the facilities audited. Facility VTE Performance August - October 2017 Compliance audit criteria Ghayathi Hospital Silla Hospital Marfa Hospital Delama Hospital Liwa Hospital Baseline Avg Baseline Avg BaselineAvg BaselineAvg BaselineAvg VTE Assessment completed within 24 hours for Medical patients 76% 96% 82% 100% 79% 100% 90% 97% 70% 87% VTE Assessment completed within 24 hours for Surgical patients 70% 97% 86% 100% 84% 75% 87% 97% n/a #DIV/0! VTE Assessment completed within 24 hours for Obstetrics patients 60% 96% 89% 100% 62% 62% 89% 97% n/a #DIV/0! hours for Medical patients 10% 75% 35% 100% 38% 100% 50% 83% 60% 69% hours for Surgical patients 8% 100% 67% 56% 42% 100% n/a 100% n/a #DIV/0! hours for Postnatal patients n/a 100% n/a #DIV/0! n/a ###### 100% 100% n/a #DIV/0! Legend: n/a refers to no relevant cases in the period Conclusion: Thromboprophylaxis is an important patient safety area. The audit project led to clear improvement in the implementation of VTE prophylaxis with the need for concurrent monitoring. References 11
1. Gangireddy C, Rectenwald JR, Upchurch GR, et al. Risk factors and clinical impact of postoperative symptomatic venous thromboembolism. J Vasc Surg 2007;45:335-342 2. Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008; 133 (6 Suppl): 381S 453S. doi: 10.1378/chest.08-0656. http://journal.publications.chestnet.org/article.aspx?articleid=1085923 3. Maynard J Hosp Med 2010;5:10; Zeidan Am J Hematol 2013;88:545; Roberts - Chest 2013;144:1276; Lester Heart 2013;99:1734 Abbreviations: VTE: Venous Thromboembolism PE: Pulmonary Embolism DVT: Deep Vein Thrombosis KPI: Key Performance Indicators 12
Appendices Appendix 1: Venous Thromboembolism (VTE) Prevention Audit Tool Appendix 2: Facility VTE Performance August - October 2017 13
Appendix 1 14
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Appendix 2 Facility VTE Performance August - October 2017 Compliance audit criteria Ghayathi Hospital (GH) Baseline Aug Sept Oct Average VTE Assessment completed within 24 hours for Medical patients 76% 97% 98% 93% 96% VTE Assessment completed within 24 hours for Surgical patients 70% 100% 100% 91% 97% VTE Assessment completed within 24 hours for Obstetrics patients 60% 100% 100% 88% 96% hours for Medical patients 10% 57% 91% 78% 75% hours for Surgical patients 8% 100% n/a 100% 100% hours for Postnatal patients n/a n/a 100% 100% 100% Compliance audit criteria Silla Hospital (SL) Baseline Aug Sept Oct Average VTE Assessment completed within 24 hours for Medical patients 82% 100% 100% 100% 100% VTE Assessment completed within 24 hours for Surgical patients 86% 100% 100% 100% 100% VTE Assessment completed within 24 hours for Obstetrics patients 89% 100% 100% 100% 100% hours for Medical patients 35% n/a% 100% 100% 100% hours for Surgical patients 67% 67% 50% 50% 56% hours for Postnatal patients n/a n/a n/a n/a #DIV/0! Compliance audit criteria Marfa Hospital (MA) Baseline Aug Sept Oct Average VTE Assessment completed within 24 hours for Medical patients 79% 100% 100% 100% 100% VTE Assessment completed within 24 hours for Surgical patients 84% 100% 25% 100% 75% VTE Assessment completed within 24 hours for Obstetrics patients 62% 100% 36% 50% 62% hours for Medical patients 38% 100% 100% 100% 100% hours for Surgical patients 42% n/a 100% n/a 100% hours for Postnatal patients n/a n/a n/a n/a #DIV/0! Compliance audit criteria Delma Hospital (DL) Baseline Aug Sept Oct Average VTE Assessment completed within 24 hours for Medical patients 90% 100% n/a 100% 97% VTE Assessment completed within 24 hours for Surgical patients 87% 100% 100% 100% 97% VTE Assessment completed within 24 hours for Obstetrics patients 89% 100% 100% 100% 97% hours for Medical patients 50% 100% n/a 100% 83% hours for Surgical patients n/a n/a 100% 100% 100% hours for Postnatal patients 100% 100% n/a 100% 100% Compliance audit criteria Liwa Hospital (LW) Baseline Aug Sept Oct Average VTE Assessment completed within 24 hours for Medical patients 70% 88% 100% 88% 87% VTE Assessment completed within 24 hours for Surgical patients n/a n/a n/a n/a #DIV/0! VTE Assessment completed within 24 hours for Obstetrics patients n/a n/a n/a n/a #DIV/0! hours for Medical patients 60% 50% 100% 67% 69% hours for Surgical patients n/a n/a n/a n/a #DIV/0! hours for Postnatal patients n/a n/a n/a n/a #DIV/0! Legend: n/a refers to no relevant cases in the period 16