Shared learning database

 
Organisation:
Oxford Health NHS Foundation Trust
Published date:
March 2013

This is an audit cycle that took place between 2011 and 2012. The audit was aimed to investigate whether physical health assessment and VTE risk assessment were routinely completed and documented in the inpatients clinical notes.The results will be used to develop plans around the prevention and management of VTE in inpatients, in conjunction with the Medicines Safety Group committee.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
No
Does the example relate to a specific implementation of a specific piece of NICE guidance?
Yes

Example

Aims and objectives

The audit was aimed to investigate whether physical health assessment and VTE risk assessment were routinely completed and documented. The results will be used to develop plans around the prevention and management of VTE in inpatients, in conjunction with the Medicines Safety Group committee.

Reasons for implementing your project

An estimated 25000 people in England die from preventable hospital-acquired Venous Thromboembolism (VTE) every year. There have been several adverse incidents involving venous-thromboembolism (VTE) on inpatient adult and older adult wards. Though VTE is not common, it can be fatal and it is therefore important that clinical practice in Oxford Health NHS Foundation Trust is in line with best practice guidelines. The recently issued NICE guidelines give a framework for assessment and management of VTE risk, and this has recently been introduced to Oxford Health NHS FT. This is a re-audit followed by an initial audit carried out in Sep 2011.

In July 2012 the National Safety Thermometer is being introduced on the Older Adults wards which also assessed the VTE Risk assessment. The planned re-audit in 2012 will compare the audit results with the Safety Thermometer results for Older Adult wards.

There has been a recent focus on the importance of documenting VTE risk within Oxford Health NHS FT and this is reflected high rates of completion of VTE risk assessment.

How did you implement the project

The audit was completed in May 2012 using the electronic patient information system, PCIS/ RiO and where needed paper notes available on the wards were also reviewed. Data collection focussed on assessing evidence that the physical health proforma has been completed and VTE risk identified. An audit tool (Appendix 1) was used for data collection with minimal patient details (RIO / NHS number) to ensure patient confidentiality.

1.4 Standards:
1. All patients admitted to inpatient wards should have a physical health assessment on admission.
2. The physical health assessment should be clearly documented within patient notes.
3. The physical health assessment should include documentation of VTE risk (and appropriate management where necessary).
1.5 Sample Size:
Majority of the adult and older adult wards in Oxfordshire and Buckinghamshire were included. In total 144 adult and 65 older adult inpatients records were audited.

Key findings

3. Detail of Findings

Good Points:
- Completion of physical health assessment has improved (97%) as compared to initial audit (91%).
- Where completed, 100% of the physical health assessments were documented.
- VTE risk assessment has improved (82%) as compared to the initial audit (79%).
- Where a VTE risk assessment has been completed, 99.41% showed appropriate management.

Areas for Improvement:
- Physical health assessment completion needs to improve until 100% is achieved.
- After completion, physical health assessment for every patient needs to be recorded on RiO Physical health assessment section.
-Ensure that VTE risk assessment is completed for every patient on the ward.

Key learning points

-Physical health assessment completion needs to improve until 100% is achieved.
-After completion, physical health assessment for every patient needs to be recorded on RiO Physical health assessment section.
-Ensure that VTE risk assessment is completed for every patient on the ward.

Contact details

Name:
Hasanen Al-Taiar
Job:
Specialty Registrar in Psychiatry
Organisation:
Oxford Health NHS Foundation Trust
Email:
hasanen.al-taiar@oxfordhealth.nhs.uk

Sector:
Secondary care
Is the example industry-sponsored in any way?
No