In accordance with the published NICE guidance CG92: Venous thromboembolism: reducing the risk for patients in hospital, we implemented venous thromboembolism risk assessment of all patients being discharged from our Emergency Department in a lower limb cast.
Aims and objectives
The aim of the project was to initiate venous thromboembolism risk assessment for all patients being discharged from our emergency department with a lower limb plaster cast.
Reasons for implementing your project
We did not carry out a formal baseline assessment prior to the implementation of our risk assessment tool, however normal working practice at that time did not include any form of venous thromboembolism risk stratification for patients being discharged from our emergency department with a lower limb cast.
The project was part of a trust wide initiative to reduce the morbidity and mortality of hospital associated/acquired venous thromboembolism. Patients in the emergency department being discharged with lower limb casts were identified at an 'at risk' group.
How did you implement the project
During the initial phase of implementation a risk assessment form was developed (see supporting documents). This assessment form identified well recognised risk factors in patients and allowed them to be risk stratified into high and low risk based on their current medication, medical and family history. Those deemed at high risk were considered for prescription of pharmacological thromboprophylaxis (based on any contraindications and individual patient preference).
Following initial audit of compliance patient information leaflets and posters were produced (see supporting documents). We also undertook intensive departmental education, this included teaching sessions to specific groups within the department (doctors, emergency nurse practitioners, nurses and health care support workers).
We initially encountered problems with compliance in completion of the risk assessment forms due to poor understanding of the guidelines implementation and a large number of non permanent medical staff who were involved with these patients. We addressed these issues by display of posters within our treatment room (where the majority of below knee plaster casts are applied), departmental teaching sessions and construction of a prominent display that contained risk assessment forms and patient information leaflets at the exit to the treatment room. Patient information posters were also produced (see supporting documents) to encourage patients to initiate discussion with members of staff about reducing their risk of developing thromboembolism.
We did not specifically cost analyse this project at any stage however the costs were likely to have been minimal. Patient information leaflets where printed free by BOE Medical Publishing. Posters (patient/staff information) where printed within the department with pre-existing equipment. Education of staff was undertaken during the authors eductaion/study days.
We undertook three audits during the first year of implementation (see supporting documents). We demonstrated improvement in compliance with our guideline during this time (from 26% to 48%). We have a venous thromboembolism link nurse within the emergency department who continues to support and facilitate the risk assessment process.
Although our audit demonstrates improvement in risk assessment it is more difficult to prove any definitive improvement in patient outcomes (e.g. reduction in numbers of thromboembolic events or decreased mortality).
As part of our Trusts wider implementation of risk assessment all patients who present with venous thromboembolism (deep vein thrombosis and pulmonary embolism) following immobilisation in a lower limb plaster cast have a route cause analysis undertaken on their case facilitated by our DVT nurse specialist.
Since April 2011 only 4 patients have been identified with venous thromboembolic events whilst in a lower limb cast. All underwent risk assessment and had written information prior to discharge (of interest all were deemed low risk using our risk assessment process and therefore not prescribed pharmacological thromboprophylaxis).
Key learning points
From our experience of implementing venous thromboembolism risk assessment it is important to involve all members of staff likely to be involved in the patient's journey. We found our biggest obstacle was dissemination of information to the many clinicians (consultants, specialty trainees, core trainees, foundation doctors and emergency nurse practitioners) who worked in the department, many of whom were not permanent members of staff.
As many of our plaster casts are applied with the involvement of our health care support workers we found that they were a useful asset in instigating reminders for clinicians to risk assessment patients prior to discharge.
Prominently displayed patient information posters in the department prompted patients to ask questions regarding venous thromboembolism.
Provision of a specifically designed and targeted information leaflet for patients allowed us to provide written information to all patients discharged from the department who required immobilisation in a lower limb cast.