Development, implementation and audit of a prompt and safe response to NICE guidance Venous Thromboembolism- Reducing the Risk (January 2010), recommending 28 days extended pharmacological prophylaxis for all patients undergoing major cancer surgery in the abdomen and pelvis. Despite no changes to existing infrastructure or additional funding, a multi-departmental team coordinated provision, monitoring and audit of extended thromboprophylaxis in both inpatient and outpatient settings within 9 months of publication. Dr N Quaife, FY1; Dr H Hardisty, FY1; Dr R Maclean, Consultant Haematologist; Dr R Oliver, General Practitioner; Miss L Hunt, Consultant Colorectal Surgeon at Sheffield Teaching Hospitals (STH).
Sheffield Teaching Hospitals 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?
To promptly develop a safe local policy for extended thromboprophylaxis and heparin-induced thrombocytopaenia (HIT) monitoring for patients undergoing major abdominal and pelvic surgery for colorectal cancer. The STH team included haematologists, surgeons, pharmacists and nursing staff, who appreciated the importance of implementing the Guidance to prevent avoidable morbidity and mortality from thromboembolism after hospital discharge. A move locally to enhanced recovery and early post surgery hospital discharge reduced pharmacological thromboprophylaxis to as little as two doses in hospital, adding an even greater imperative to the need for extended prophylaxis outside hospital. Such a multi-disciplinary service would demand careful planning and clear communication with primary care colleagues to coordinate the service. Our concern was that no patient was put at increased risk because of failure to promptly identify HIT or bleeding. Progress of the new service would be assessed from the outset by Prospective Interface Audit of hospital and community care, and the interface between the two. Formal patient and GP feedback surveys were used to identify successes, barriers and practical problems to enable prompt and targeted change to current practice. 1) To deliver training for all existing and new medical staff within the Colorectal Surgical Unit at STH. 2) To identify all patients appropriate for extended pharmacological thromboprophylaxis and ensure this is made clearly visible in those patients records so that all medical and nursing staff involved with their care are aware. 3) To designate pharmacist and nursing leads on colorectal wards to ensure patients are trained in enoxaparin self-administration if required. 4) To ensure clear communication with primary care teams for safe administration of enoxaparin and HIT screening follow-up. 5) A Prospective Interface Audit from day 1 of implementation, regular re-audit and patient and GP surveys to identify barriers to implementation and target future changes to practice to specific needs. 6) To ensure provision of the service should not delay discharge from hospital.
The colorectal team at STH had previously investigated providing extended prophylaxis as patients presented with thromboembolism after discharge from hospital. Prior to publication of CG92, this had not been possible due to perceived cost constraints within the community. Guideline publication made delivery of this service possible. Prior to service introduction, patients who had undergone major abdominal cancer surgery received enoxaparin thromboprophylaxis only during their inpatient stay (as little as 3 days with enhanced recovery). Providing extended thromboprophylaxis for 28 days in this patient group has demonstrated a 60% relative risk reduction (8% vs. 12%, n=343, 95% CI 10%-82%) in venous thromboembolism, with no significant increase in post-operative bleeding. Such evidence is reflected in CG92, advising provision of extended thromboprophylaxis to candidate patients. Extended thromboprophylaxis carries a risk of HIT, thus necessitates monitoring between days 5-7 and 10-14 of thromboprophylaxis. Implementation of the service would require thorough education to staff of several health disciplines, and patients, for whom guidance and understanding were essential to optimise compliance. We perceived the following significant possible barriers to implementation: - Failure by surgeons to identify all appropriate patients. - Failure of in-hospital training for self-administration of enoxaparin. - Training patients to self administer could result in extra hospital stay. - Possible failure of General Practitioners to engage with HIT monitoring. - Poor patient compliance especially the elderly or patients with co-morbidities. Structured advance planning and a committed team ensured the following methods were understood prior to implementation of extended thromboprophylaxis in October 2010. This planning aimed to establish an efficient service from day one and minimise any risk of the treatment delaying patient discharge.
1) A group was formed, of a consultant haematologist and colorectal surgeon, pharmacists, junior medical and senior nursing staff. Formal consultant-consultant and junior-junior training was provided, and the surgical team had representatives on the thrombosis committee. 2) Training leads for each professional group ensured continuity of training for new staff. 3) The operating surgeons identified candidate patients in the post operative instruction section of their operation note. 4) Junior doctors ensured provision of enoxaparin during inpatient stay and after discharge and a thromboprophylaxis information leaflet. Where doses were needed to complete the 28-day course, patients were supplied with pre-loaded enoxaparin syringes and a sharps bin. 5) The nursing lead and pharmacy staff established and delivered either early patient training on administration or immediate referral to district nursing services for administration or ongoing training in the community. 6) A clear template letter was produced, to be completed by medical staff upon discharge and faxed to GPs. It specified patients' individual need for extended thromboprophylaxis and HIT screening. This communication aimed to establish GPs understanding and support of the service and their role as facilitator following patients' discharge. 7) A Prospective Audit was undertaken, which covered hospital treatment, community treatment and the interface between the two. This took place for one month from day 1 of implementation. 8) Regular consultation with individual leads from pharmacy, nursing and medical specialties, and follow-up surveys by phone with patients and GPs identified barriers to implementation in inpatient and community settings respectively. The project required no changes to infrastructure or additional funding.
Prospective audit showed: In the first month of implementation 20 patients had major abdominal or pelvic surgery for cancer. 17 had notes available and were discharged from hospital before post-operative day 28. Operating surgeons recorded 28 days enoxaparin in the post-operative instructions of only 4 (24%). Despite this 28 days of enoxaparin was successfully administered to 12 (75%) of 16 patients whose full records were available. For 12 (70%) of 17 patients whose GP records were available, the HIT monitoring information letter was correctly faxed and acted upon by the GP. HIT monitoring fell short of full compliance. Of the 17 patients who were in hospital on post-operative day 5, only 12(70%) had correct HIT monitoring. Furthermore, of the 14 patients who were at home on days 10-14 only 9(64%) had correct HIT monitoring. Compliance with HIT monitoring in the community improved during the audit period: 0% 1st 7 days, 33% 2nd 7 days and 100% 3rd 7 days. There were no recorded delays in hospital discharge. Results demonstrate an initial significant shortfall in safe service provision. Formal feedback was obtained from patients, primary care and nursing staff to identify barriers to delivery. Patient surveys revealed lack of understanding about enoxaparin, self-administration and blood tests, and some patients, a wish to comply but failure to do so. Others had difficulties disposing of used sharps bins. Discussions with senior nursing staff revealed some nurses had concerns about teaching self-administration. Feedback from primary care colleagues indicated discharge letters were often not being seen in time to arrange HIT screening within the necessary timescale.
This guideline demands multidisciplinary input, clear communication and preparation of both patients and staff. Our experience has led to the following learning points: 1) The operating surgeon must document on the operation note: the need for extended thromboprophylaxis, the days HIT screening is due and requirement for a specific discharge letter. We now identify candidates on the pre-operative assessment form and the inpatient drug prescription chart. 2) Elective candidates are now identified in the outpatient clinic and patient education begins in the pre-operative assessment clinic. We are developing an extended thromboprophylaxis information leaflet to improve understanding and compliance at an early stage. 3) Delivery of improved training to new pharmacy and junior medical staff ensures continuity, and that there are more staff to identify candidate patients should this information be omitted elsewhere. This is particularly important for emergency patients. 4) Flow charts on wards increase awareness of the programme. 5) Nurses administering enoxaparin should make each dose administration a patient training opportunity. 6) Identification of those likely to fail at self-administration allows early intervention by the district nursing team. 7) A clear template letter makes it easier for junior medical staff to convey the necessary information to all GP practices. We are now also contacting GPs by phone in anticipation of discharge to ensure continuity of HIT screening. Identification of a key community lead can help facilitate and maintain contact between primary and secondary care. 8) We offer disposal of sharps bins at the next outpatient appointment. 9) Having a team with leads from individual specialties ensures structured and coordinated implementation. Clear communication and support between departments ensures prompt implementation and optimal service provision, avoiding discharge delay.
Miss L Hunt
Consultant Colorectal Surgeon
Sheffield Teaching Hospitals NHS Trust
Is the example industry-sponsored in any way?