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Dr Oweikumo Eradiri
Quality Assurance & Clinical Governance
Colchester Hospital, UK
Venous thromboembolism (VTE) is responsible for over 25,000 deaths a year in the UK, including 10% of hospital inpatient deaths. A House of Commons report in 2005 led to the development of guidance by the National Patient Safety Agency (NPSA), the National Institute for Health and Clinical Excellence (NICE) and the Chief Medical Officer, for the safe use of anticoagulants and other measures to prevent VTE (deep vein thrombosis and pulmonary embolism). VTE prevention is a patient safety priority for the National Health Service (NHS).
The use of anticoagulants in VTE prophylaxis offers pharmacists, as the experts in medicines, a range of opportunities for involvement.
VTE risk assessments
The NICE 2010 guidance (CG92) requires that all adult hospital inpatients undergo a VTE risk assessment (RA) using a standardised national VTE RA template – upon admission, again 48 hours later, and whenever the patient’s clinical condition changes.
Based on the national template, clinicians at Colchester Hospital University NHS Foundation Trust (CHUFT) pioneered an electronic VTE RA tool that enables the assessment to be completed in 30 seconds. This tool has the added benefits of calculating the risk of VTE and recommending appropriate prophylaxis using a pharmacological and/or mechanical agent. This decision support tool is web-based and is now available to any organisation across the globe. The tool and the VTE prevention programme at Colchester Hospital won the 2010 NHS Innovation Award for Patient Safety.
Commissioning for quality
In the UK, hospital trusts are commissioned by primary care organisations to provide clinical services, with financial remuneration following the satisfactory achievement of agreed targets. In 2009, the UK Department of Health set a Commissioning for Quality and Innovation (CQUIN) payment framework to guide the process. The goal is to enable commissioners to reward excellence by linking a portion of provider income to local quality improvement goals. In addition to local priorities, the NHS Operating Framework sets national targets. For 2010/11 and 2011/12 the two national targets are to:
For the VTE target, commissioners will be able to withhold up to 1.5% of a provider’s annual income if “at least 90% of all adult inpatients have not had a VTE risk assessment on admission to hospital, using the clinical criteria of the national tool”.
Our electronic tool replicates the national tool exactly, and the matrix employed in calculating risk and contraindications is based on NICE CG92. In addition, the census approach mandated by the CQUIN requires a record of all risk assessments completed (“numerator”) as a percentage of all adult patients admitted (“denominator”), rather than the audit approach of sampling a representative proportion of patients. Our audit tool links to an electronic database that records each patient’s VTE RA in a simple and efficient way, and therefore provides ready data for the monthly Unify2 national data collection exercise for NHS Acute Trusts.
The overall effectiveness of this electronic tool depends on its use by clinicians. Hence, our VTE Champions programme was developed to engage colleagues in using a quick, simple and reliable tool to assess a patient’s risk of developing VTE, and in prescribing and administering appropriate measures to ensure VTE prophylaxis. A valuable way to achieve this is by using the Five Pillars Model.
The Five Pillars Model
This approach was applied by the multidisciplinary VTE project board at Colchester Hospital, and illustrates the key elements of our VTE prevention strategy:
1. VTE team structure
The variety of clinical practice and the work necessary to achieve thromboprophylaxis warrants a committee structure, with committed individuals representing all relevant clinical disciplines. As clinicians, pharmacists should play a lead role in the safe use of medicines. At CHUFT, the Medication Safety Pharmacist initiated the thromboprophylaxis committee (now the VTE project board), and contributes to decisions at the fortnightly meetings.Pharmacists can champion the safe use of anticoagulants at ward level and an extension of this role will be to serve as the VTE Champion for a particular ward or specialty. The Pharmacist running the orthopaedic pre-admission clinic at CHUFT risk assesses the patients and prescribes prophylaxis, trained nurses perform risk assessments and either prescribe or print off the completed RA form for the doctor to sign, and the doctors also complete the RA tool when admitting patients.
2. System tools
A number of materials are needed to provide ready guidance and support the implementation of thromboprophylaxis. At the onset, the Department of Health paper form was not readily available in all areas of our hospital and, even when available, some clinicians viewed it as another bureaucratic exercise, complaining that it was laborious and did not provide consistent recommendation of preventive measures to be applied. These were the main drivers for developing the web-based electronic tool, which is now available on all Trust computers. However, as computers were in short supply in some areas, the Trust Board agreed to provide at least four computers and networked printers on each ward. A wireless system has since been installed and, as a next step, mobile computer devices are being considered.
Pharmacists on Medicines Management Committees determine which pharmacological thromboprophylaxis agents to add to the hospital’s formulary, after reviewing evidence and reports for each. These committees also provide guidance for the use of these thromboprophylaxis agents in a safe, consistent and effective way, and pharmacists can be involved in publicising and enforcing these guidelines.
At Colchester Hospital, a major consequence of the VTE prevention work was the revision of the Trust’s drug chart. The chart has pre-printed low molecular weight heparin (LMWH), a VTE risk assessment check box on the front, and separate sections for other high-risk medicines, such as insulin and antibiotics. The printout from the electronic VTE RA tool is attached to the back of the drug chart as evidence of completion; this provides a monitoring opportunity for pharmacists, who review the drug charts daily for clinical accuracy of prescribing and administration, and can ensure that risk assessments are completed.
Prior to the availability of the national e-learning VTE package, the Medication Safety Pharmacist at CHUFT developed a VTE training module for nurses, as part of the ‘Foresight’ training under the ‘Patient Safety First’ campaign for England. This course was delivered on a fortnightly basis by a team of pharmacists. Pharmacists can complete the online e-VTE package or undertake more formal courses such as the ‘Thromboprophylaxis for VTE Champions’ course offered by the University of Hertfordshire, England.
Pharmacists clarify doses and duration of treatment and can reconcile the VTE risk assessment with prescribing guidelines for thromboprophylaxis. They are well placed to communicate VTE priorities to clinical colleagues and can flag up those patients who have not been risk assessed, those who have been risk assessed and not prescribed, and those not administered prescribed prophylaxis. They can also assess the appropriateness of prescribed prophylaxis according to the patient’s clinical need, and can identify those patients who need a repeat assessment when their clinical need changes.
From this vantage position, pharmacists can also be involved in root cause analysis, identifying the cause of VTE in patients developing the condition while in hospital or soon after discharge. Pharmacists are equally well placed to advise patients on the indications, contraindications and side effects of their medicines. This role is particularly useful when dealing with high-risk medicines, such as LMWH.
Pharmacists can provide patients with information on additional measures to ensure thromboprophylaxis whilst in hospital, such as drinking fluids and keeping mobile. For those who may require extended prophylaxis at discharge, the pharmacist can facilitate adequate supplies and ensure discharge letters to the patient’s general practitioner are accurate, thus ensuring treatment continues as necessary.
5. Performance management
There are several points at which a pharmacist can contribute to ensuring effective VTE RA and appropriate prophylaxis. Membership of the VTE Project Board affords the opportunity for broad oversight, to monitor audit reports and to review performance in all specialties. Being on the ward daily gives a local view, and involvement in audits offers yet another prospect.
At CHUFT, VTE prophylaxis has increased from less than 50% in 2007 to 99% in 2011, with the pre-printing of LMWH on the drug chart. Documented VTE risk assessment has increased from 0% to 93% in the same period, as pharmacists identify any unsigned risk assessment boxes. The Pharmacist running the orthopaedic pre-admission clinic risk assesses and prescribes prophylaxis for 100% of elective patients. Unsigned or non-administered prescriptions are challenged daily.
The multiplier effects of pharmacists working with multidisciplinary clinical colleagues on VTE prophylaxis are enormous. It provides another platform to highlight and tackle patient safety incidents, creates and strengthens communication with clinical colleagues and, at CHUFT, it has led to the redesign of the drug chart with multidisciplinary buy-in, and an opportunity to incorporate NPSA recommendations for prescribing and administering high-risk medicines.
Colchester Hospital was the fifth NHS Acute Trust to be awarded ‘VTE Exemplar Centre status’ by the Department of Health in November 2008, and won the ‘2010 NHS Innovation Award for Patient Safety’, for its Electronic VTE RA tool and the VTE Champions programme. The web-based tool has been adopted by the East of England Strategic Health Authority (EoE SHA), and is available to any healthcare organisation. For its efforts, the EoE SHA has recently become the second SHA in the country to be awarded VTE Exemplar status.
There are numerous opportunities for pharmacists to contribute to VTE prevention either as catalysts or team players. Patients and the healthcare system will benefit greatly if pharmacists rise up to meet this challenge, which is vital to patient safety.