NHS Leeds Community Healthcare
We have introduced assessment of venous thromboembolism (VTE) into our Community Intermediate Care Unit (CICU).
CICU is an in-patient ward providing short term medical treatment and rehabilitation to people aged over 60 years who do not need acute hospital care.
Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?
Aims and objectives
To introduce the routine assessment of risk of venous thromboembolism (VTE) into our Community Intermediate Care Unit.
To raise awareness amongst medical and nursing staff of the need to assess the risk of VTE in all patients admitted to the Unit.
To develop and introduce VTE risk assessment screening tools for use by both medical and nursing staff.
To develop a protocol on the mamangement of VTE for use within the Unit.
Alongside the work to implement the NICE guideline, to ensure all of the actions required by the NPSA Rapid Response Report 2010/014: reducing treatment errors with low moelcular weight heparins were also implemented.
Reasons for implementing your project
Before the publication of the NICE guidance, patients were not routinely assessed for their risk of VTE.
There were no tools available to support the decision making of doctors and nurse practitioners providing care.
There was no routine auditing of practice relating to VTE risk assessment.
The experience of patients was not consistent - it would depend on who was the admitting clincian as to whether or not a VTE risk assessment was undertaken.
When VTE risk assessment was undertaken, and a decison made to offer pharmacological prophylaxis, there was variation in the prescribing practice of the clinicians on the Unit.
How did you implement the project
A multi-disciplinary medicines group has been established on the Unit since summer 2008. This group brings together medical, nursing and pharmacy staff working on the Unit, with additional senior nursing and pharmacy support from the Trust Governance and Professional Development Team to discuss medication issues. The NICE guideline was first discussed in February 2010, where it was agreed that this should be introduced for all patients. The group agreed a number of steps to implementation of the guidance:
1. To make modifications to the drug chart to include a screening box for VTE risk assessment.
2. To develop a VTE clinical protocol for use on the Unit.
3. To consider the appropriateness of the VTE screening tool produced by NICE, and to make modifications to increase relevance for the population of patients seen on the Unit.
4. To agree a standardised treatment regimen for when pharmacological prophylaxis was indicated.
The publication of the NPSA Rapid Response Report 2010/014: reducing treatment dose errors with low molecular weight heparins in July 2010 added a further dimension to the work. Although the focus of this alert was on treatment with low molecular weight heparins (rather than prophylaxis of VTE), the actions required were complimentary, and further supported the awareness of medical and nursing staff on the safe use of heparin products.
A small increase in prescribing costs for the Unit was seen within weeks of implementation of VTE risk assessment as patients were identified as requiring pharmacological prophylaxis; however this was deemed acceptable and appropriate relative to the level of care now provided.
The multi-disciplinary medicines group oversaw the project implementation, and continue to monitor and evaluate effectiveness by regular updates from key clinicians. The group will receive regular audits of completeness of application of VTE risk assessment, proportion of patients requiring thromboprophylaxis and therapeutic regimen used. Completing this audit will be a requirement for each F2 doctor during their rotation on the Unit. Initial results show that 100% of patients admitted to the Unit are now assessed for VTE risk on admission, and periodically during their stay if their condition changes. The inclusion of a VTE screening question on the drug chart is a quick and easy method to ensure VTE risk assessment is undertaken when required, and meant that medication was prescribed in a timely fashion. The risk assessment box is reviewed on the daily nursing and weekly medical rounds for completeness. A standardised treatment regimen has been agreed for when pharmacological prophylaxis is indicated. This is included in the induction pack for junior medical staff who work on the Unit as part of their F2 training. The NICE screening tool has been adapted and made more appropriate for the setting, including prescribing information for when pharmacological prophylaxis is needed. This ensures that the agreed regimen is followed, and all relevant information is contained in one document. The clinical protocol developed provides additional supporting information on how and when thromboprophylaxis should be used. The publication of the NPSA Rapid Response Report shortly after the NICE guidance helped to maintain a clinical focus on issues relating to the use of parenteral anticoagulants within the Unit. Patients identified as at risk of VTE and require thromboprophylaxis are now receiving appropriate prophylaxis during their stay on the Unit in a consistent manner, rather than relying on the experience and preferences of the admitting doctor or nurse practitioner.
Key learning points
VTE risk assessment can be successfully delivered in a community setting. Medical staff and nurse practitioners have accepted with enthusiasm the need to undertake this assessment, and have fully embraced being able to improve the care they provide to patients on the Unit. Using the established multi-disciplinary medicines group to lead this work helped to raise the importance of the clinical issue concerned, and provided an appropriate forum for ongoing review of performance against the target that 100% of patients will be assessed for their risk of VTE on admission and during their stay.
The Consultant Geriatrician took a lead in developing this work, including drafting the clinical protocol, and supporting the induction of the nurse practitioners and the junior F2 medical staff to undertake this role. All staff concerned welcomed the clear guidance issued, and the agreement of a standardised regimen to provide the same high level of care to all patients on the Unit. The agreement of a standardised treatment regimen enabled close working between the medical staff and nurse practitioners. This has had other benefits in terms of team working and development of care pathways.
Head of Medicines Management
NHS Leeds Community Healthcare
Is the example industry-sponsored in any way?