Transcript Welcome 18th March 2009 - Kings Thrombosis Centre

VTE Education, Education,
Education!
Colchester Hospital University NHS
Foundation Trust
J Cronin, S Majeed, E Morley-Smith, K Ganesh, S Ambrozie,
M Wood, A Howard.
Numerous Reports of Poor
Prophylaxis
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Canada
USA
UK
Australia & NZ
UK
USA
USA
UK
USA
- Belch et al 1981
- Conti & Daschbach 1982
- Jones 1991
- Fletcher et al 1992
- Stephens et al 1995
- Audet et al 1998
- Bratsler et al 1998
- George et al 1998
- Alizadeh & Hyman 2005
Questionnaire Audit of
Surgical Doctors
Charing Cross and Hammersmith Hospitals 2002
• Aims - Assess prescription activities of
surgical doctors for DVT prophylaxis
• Questionnaire - 24 questions
• Response rate - 100%
(n=55)
Howard et al EVF 2003
Doctors
13%
24%
27%
36%
House Officers
Senior House Officers
Registrars
Consultants
Howard et al EVF 2003
Surgical Speciality
17%
24%
16%
25%
2% 3%
Gastrointestinal
Breast
Plastics
ENT
Maxillofacial
Orthopaedics
3% 5%
5%
Urology
Neurology
Vacular
Doctors Prescribing
Prophylaxis
87%
13%
0%
Consultant
Middle Grade
Junior Grade
Howard et al EVF 2003
Source of Information
36%
42%
7%
15%
Personal Knowledge
Hospital Guidelines
Literature Guidelines
Consultant Opinion
Howard et al EVF 2003
Uncertainty of Prophylaxis
Amongst Doctors
91%
100
90
80
73
70
60
%
50
40
30
24
20
10
3
0
0
Colleague
Nurse
Literature
Don’t Ask
Action Taken
Howard et al EVF 2003
Thromboembolic Risk
Assessment
• 3 Case Scenarios
– High VTE risk (n=2)
– Moderate VTE risk (n=1)
• 45% correct risk given
• 69% prescribed heparin & stockings
• 96% approved of a single prophylaxis protocol
Howard et al EVF 2003
Education and Awareness
Programme CXH 2002
• Lectures to all surgical HO’s and SHO’s
• Presentations to all surgical departments
(twice)
• New hospital consensus and protocol
AUDIT OF CXH PROTOCOL
Urology, GIT, Vascular and Breast
Surgery
Thromboembolic Prophylaxis
100
90
80
70
60
Percent 50
40
30
20
10
0
92
67
56
54
(p=0.1)
24
18
(n=45) Before Education
STOCKINGS
88
81
SUBCUTANEOUS HEPARIN
(p=0.03)
After Education (n=34)
OTHER PROPHYLAXIS
OPTIMAL PROPHYLAXIS
(p=0.003)
2006 Audit of Compliance
With Hospital Single Protocol
Only 60 patients = 19% [95% CI 14-23%]
2
4
32
n = 324
22
Contra-indicated LMWH & GCS
Wearing GCS & Contra-indicated LMWH
Receiving LMWH & Contra-indicated GCS
Receiving LMWH & Wearing GCS
Failure of Prophylaxis
Application
233 patients
Failed to receive GCS
(72%)
151 patients
Failed to receive LMWH
(47%)
Lessons Learnt!
Sporadic education and audit does not
maintain compliance in VTE
Why?
Silent disease until its too late
Prevention is not exciting
Effective Strategy
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Multifacted
Evidence-based protocols
Education
Risk assessment protocol
Computerised decision support
Audit with feedback
Specific staff for implementation
New Programme 2008
Colchester Hospital University NHS Foundation
Trust
 New Trust guidelines
 Online risk assessment
tool
 e-learning and education
programme
 New Drug charts
 Thrombosis committee
 Audit all Trust inpatients
(pre-launch & ‘rolling’)
 Electronic alerts
VTE CHUFT Website
Laminated Handbook
Education on Risk is Complex
- Online Risk Assessment Tool
• Patient details and date
of admission
• VTE risk factors
• Contraindications to
prophylaxis
• Bleeding risk with
LMWH
• Printed version -> case
notes
Education & Awareness
Programme
E-learning assessment
(http://www.elearning-essexrivers.co.uk)
F1 and F2 teaching sessions
Nurse patient safety teaching sessions
Grand rounds
Clinical governance half-days
Electronic alerts in clinical areas
Education & Awareness
Programme
• E-learning assessment
(http://www.elearningessexrivers.co.uk)
• 70% pass mark
• Certificate of
completion
Education & Awareness
Programme
E-learning assessment results
• 45 completed – 44 doctors, 1 nurse
• F1= 23, F2= 19, SpR = 2
• 25/45 achieved 70% on first attempt
• 43/45 have completed (range 2-4 attempts)
‘Audication’ in VTE
• Audit and vascular surgical department
• 15 patients audited per week
• Immediate feedback of results on wardrounds
• Hospital league table on intranet
page/posters
‘Audication’ in Infection Control
• Hand Hygiene Officer
• 20+ surgical patients per week
• Immediate feedback of results on wardrounds
• Surgical league table on infection control
board
The Clean Practice Protocol
Educational Poster
‘Audication’
Rounds 1 & 3
Clean Practice Score (%)
Round One
Clean Practice Score (%)
Round Three
Vascular
Upper GI
Colorectal
Colorectal
95
95
90
90
85
85
80
75
70
Vascular
Upper GI
83%
83.5%
80
Colorectal
77%
Vascular
Upper GI
75
70
Colorectal
91.3%
Vascular
84.6%
Upper GI
86%
Hand Washing Round 1 & 3
Hand washing before or after seeing patients
100%
90%
80%
70%
60%
Round 1
50%
Round 2
40%
n=182
30%
20%
10%
0%
Vascular
Upper GI
Low er GI
Patient Education
• ‘Stop the Clot’ campaign
• Patient information with hospital TCI letter
• Focus Groups
• Media help
Maintaining Practice
 Maintenance of prophylaxis and risk assessment
compliance
• Continued education and awareness
• Appointment of DVT Nurses for Prophylaxis and
Treatment
• Clinical Governance sessions
 E-learning assessment study
 Improve patient education and awareness
Mr Adam Howard
Dept of Vascular and Laparoscopic Surgery
[email protected]
Mobile 07507646586