An inspired innovative solution where common sense met idealism to produce a robust, user friendly and comprehensive electronic system for VTE risk assessment. This produced a positive impact on patient outcomes. An existing computer system was taken and adapted to replace a cumbersome paper-based system which was not fit for purpose. This was in no small way due to the creation of an enthusiastic, integrated, focused, cross-discipline team, with a core belief that anything was possible. Viewing the attached Video clip of the electronic VTE assessment prior to reading the submission material will give you a much greater understanding of how the system works. Please copy and paste this link into your browser: http://www.youtube.com/watch?v=zD6plH-So_A
Whittington NHS Trust
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?
Our primary aim was to develop an electronic risk assessment method that was NICE compliant and would allow simple collection of data for the Venous thromboembolism CQUIN target. We recognised that the CQUIN target would not end with a 90% target for Risk Assessment (RA) in hospital admissions, and ultimately good clinical practice would require the 24-hour repeat risk assessment and appropriate prescribing to be documented. This electronic assessment had to: 1. Be clinically effective 2. Allow already overstretched junior doctors and nursing teams to complete risk assessment without adding additional paperwork or new technology. 3. Simple data capture on all aspects of risk assessment with regards a. Identified risk factors for thrombosis b. Identified risk factors for bleeding and contraindications c. Appropriate prescribing d. Which clinical teams and areas were compliant with assessment and which areas were not, so that targeted training could be undertaken. 4. The risk assessment had to communicate seamlessly with other trust technology such as PAS to identify admissions that needed to be risk assessed.
Initially paper based RA were developed during 2009 which were part of the admission documentation, The Drug charts were modified to encourage RA with a tick box in place of risk categories, to serve as a reminder for staff to complete the risk assessment. Compliance was poor as indicated by paper audits. Audits in early 2010 assessing the acute medical admission unit persistently showed poor compliance with completion of RA, with 63% of patients receiving prophylaxis but only 27% having a documented RA that was NICE compliant. On surgical wards the situation was worse with 0% compliance with paper based RA. In addition, since risk assessments were so poorly performed, it was not possible to assess whether the junior doctors were prescribing the correct dose according to the patients risk category. The poor compliance with paper-based assessment prompted the thrombosis team to assess feasibility of how data would be collected to feed back into the CQUIN target. It was felt that regular audit across the Trust would be required, with the coding department?s engagement. Additional staff would be needed to support this initiative. It was decided that an electronic system was needed to support this initiative. The Electronic RA would facilitate: 1. Greater ease of data collection to enable reporting of more accurate figures. 2. Verification of data accuracy, with physical paper audits undertaken in all clinical areas. 3. Quick identification of patient cohorts and/or clinical areas delivering lower risk assessment rates, enabling us to target our resources more effectively to those areas needing more input and support 4. Cross checking and referencing with other computer systems such as PAS and Coding records for clearer identification of low risk cohorts.
The Trust changed it pathology-reporting system to Sunquest ICE in 2007 and had recently moved to electronic test requesting for all clinical staff. A haematology biomedical scientist was the lead for site-specific issues. The 'Blue Sky' idea of using the existing pathology system for RA was provoked by a corridor conversation between the thrombosis lead and biomedical scientist regarding how to improve data capture and compliance. The RA was built in as a 'test request' and placed on all the inpatient test request pages on Sunquest. Initially very simplistic but over the months several modifications were built in to ensure that all aspects of VTE were covered. As new junior doctors rotate and would be unfamiliar with trust guidelines a 'book' link was added next to the test request, which would directly lead to the relevant VTE guideline. The request has to be actively chosen as a test and cannot be mandatory. This has meant that clinical engagement was critical to ensure completion of assessment. Factors that were critical to successful implementation were: 1. Multidisciplinary discussions with IM&T, Clinicians, and the coding department to clarify what data would be useful. 2. Engagement with clinical staff to better understand patients, clinical mechanisms and barriers to undertaking electronic VTE assessments. 3. Pharmacy support on wards to encourage RA and challenge poor prescribing. 4. Data feedback to clinical teams on performance on a monthly basis initially and then weekly feedback. 5. Daily audit of admissions in poor performing areas to identify reasons for failure and encourage change. 6. Development of a white Board symbol to identify patients who had been assessed in clinical areas. 7. Link nurses and VTE champions in clinical areas. 8. VTE working group- a multidisciplinary group comprising IMT, Haematology technical staff, Clinical nurse for VTE, matrons from Surgery and medicine, and pharmacists.
In order to report accurate VTE figures for the Trust, IM&T staff successfully meshed multiple data sources into a single reporting framework resulting in increased report production efficiency. Electronic records reduced the need for reporting based on physical audit. Monthly reports on VTE RA rates are sent Trust Wide to all ward managers and directorates. Data is reported in a graphical form on a spreadsheet with a traffic light system, to identify poor performance. Areas of poor performance are discussed at the working group meeting held fortnightly and consultations undertaken with ward managers and clinical staff to identify limitations/ hindrances to electronic assessment. This has prompted more robust identification of low risk cohorts by surgical and obstetric colleagues in addition to those defined by the DOH. This has been a work in progress and only achieved by clinician engagement once VTE assessment rate figures were reported per directorate and consultant. We have significantly improved monthly assessment rates in all areas across the Trust during the year, currently at 80% Trust Wide with many areas at 90% or higher. The CQUIN target has been successfully met for all three quarters so far. Engagement by all staff groups has improved with regards VTE prevention. Audits are currently ongoing to assess rates of Hospital acquired VTE in the pre and post electronic risk assessment era.
Sunquest ICE is a system that is commonly used in Acute Trusts in the UK. Any system that can have test requests built into it can probably be modified to allow electronic VTE risk assessment to be built in. Utilising a Multi Disciplinary team is highly beneficial. For example, the information team was able to interrogate data and inform clinical and management staff involved. Laboratory Scientists who were using the existing pathology diagnosis and reporting system were able to build a test request for the VTE risk assessment tool. It is important to engage as many people as possible to identify innovative ways to using technology. Engaging in discussion and encouraging feedback promotes a greater chance of identifying how technology can modified/ adjusted or utilised to meet clinical needs in a more robust way. Reporting data should always be presented as clear and simple to understand and as clinically relevant as possible, which increases usability by the people it is designed to target and motivate. Critically important is learning about the processes that happen in clinical areas around admission to see if RA or review of RA can be built into a part of the process e.g. we identified the admission process on our maternity admission unit following discussion with relevant clinical teams and have successfully been able to identify key people who can help ensure VTE assessment is completed on all patients who are admitted and not on those who are in for simple assessment. This allows the RA to be done within the 24-hour window.
Dr. Farrukh SHAH
Whittington NHS Trust
Is the example industry-sponsored in any way?