Salford Royal NHS Foundation Trust used the NICE Quality Standard on VTE Prevention (QS3) as a catalyst for developing an electronic assessment system to identify cases of hospital-acquired venous thromboembolism (HAT). This enabled the Trust to go above and beyond the CQUIN target for venous thromboembolism (VTE) and identify whether they were actually reducing the number of hospital-acquired blood clots.
Aims and objectives
The Commissioning for Quality and Innovation (CQUIN) target is directed at ensuring over 90 per cent of patients admitted to hospital are risk assessed for HAT. The Trust wanted to go above and beyond this target and combine the CQUIN and the NICE quality standard on VTE prevention to improve outcomes, and to identify whether care was improving through a reduction in blood clots. The Trust set an aim to reduce the number of cases of hospital-acquired clots by 60 per cent. However it proved challenging to identify which clots were associated with a hospital stay and which were not.
Reasons for implementing your project
NICE published its quality standard on VTE prevention in June 2010 to encourage trusts to check all patients admitted to hospital for their risk of developing HAT using clinical risk assessment criteria. The NICE quality standard ties into the national CQUIN for VTE prevention, which calls for hospitals to risk assess over 90 per cent of adult inpatients on admission to hospital. Salford Royal were certainly well on towards achieving this target, but it was not possible to identify if implementing the quality standard was making a difference to patient care by reducing the number of hospital acquired clots.
How did you implement the project
The assessment system was integrated into the prescribing process and included other key admission tasks so that using the admission bundle saved clinician time. This was introduced to staff during their induction and shadowing, and the risk assessment was checked as part of the reliable ward round checklist already in place. Other techniques to support implementation included:
- Weekly feedback of how each area was doing against aim
- Daily check by ward clerks, with reminder magnets on ward board
- Patients cannot leave theatre recovery to go to a ward until a HAT assessment has been completed.
- Posters, screensavers, education sessions in structured teaching Monthly electronic data was collected to inform the national returns, and this was quality assured by a team of doctors and pharmacists.
To identify HAT a system was developed where pathology & radiology flag any positive scan or clot found during a post mortem examination. A monthly 'VTE positive' report is generated, which is checked to see whether clots meet the definition for HAT. The named consultant is then asked to complete a root cause analysis (RCA) which assesses care against the NICE quality standard and reports in to Trust Clinical Governance.
This process was enabled with a local CQIN after discussion with the commissioners - the Trust would receive £40k to set the process up, which was offset against clinical time. Multiple previous attempts to create a system had failed; it was only the collaboration with the CCG that enabled this to happen.
In 2010/11, 93 per cent of patients admitted to hospital were risk assessed for VTE. The national CQUIN target remained the same for 2011/12 but the Trust created a local CQUIN target and achieved 95 per cent and now reliably achieves 96-97 per cent risk assessment without any additional measures.
A total of 52 cases of hospital associated VTE were found in the first 6 months. The Trust now has a rolling programme of root cause analysis where a clot is perceived as 'preventable' if there is any failure in delivering the thromboprophylaxis items of the NICE quality standard (including extended prophylaxis). The system allows for the measuring of real time trust-wide data that can help drive improvements in areas the trust is struggling with. In the first 6 months of the 2013/14 financial year 41 new cases were found - with only 6 where current prophylaxis recommendations not followed reliably - suggesting that implementing the quality standard has already reduced the rate of preventable clots substantially from the figures quoted nationally.
The system is future proof ensuring that the trust can meet the targets of the 2013/14 CQUIN for root cause analysis and identify where assessment failure occur in patients with HAT. The root cause analysis system is now being used to inform process changes to prevent omissions in future cases.