Streamlining electronic venous thromboembolism (VTE) risk assessments and enhancing safe prescribing in acute admission units.

Hui Mei Wong, Foundation Year 1 Doctor, Whittington Hospital

Venous thromboembolism (VTE) accounts for about 5-10% of deaths in hospitalized patients and causes significant morbidity in non-fatal cases. In response to this, a key NHS quality requirement is to assess for venous thromboembolism (VTE) risk in 95% of all inpatients aged 16 and above.1 In the 2020/2021 year, the Whittington Hospital did not achieve this requirement and it was a priority for the Trust to increase VTE risk assessment compliance to a national standard of 95%. The Whittington Hospital uses an almost fully electronic system comprising multiple different online platforms; this includes the VTE risk assessment form, which is audited annually to assess whether the trust meets national quality requirements.

All medical documentation including clerking and post take ward round proformas are recorded on CAREFLOW*, electronic prescribing is done on JAC* and the VTE risk assessment form is done on ICE*. Hence, for the clerking doctor to admit the patient and complete VTE risk assessment and prescribing, they would have to open three separate systems. This is inefficient and ill-suited to a busy admissions shift and allows for multiple gaps where human errors can occur, compromising patient safety (eg: forgetting to prescribe VTE prophylaxis or prescribing inappropriate VTE prophylaxis.) (*These acronyms are various brand names of electronic software)

Aim:

The primary aim is to increase uptake of mandatory VTE risk assessments to the national target of 95% within one acute medical admissions unit and one acute surgical admission unit. The secondary aim is to increase the number of appropriate VTE prophylaxis prescribing.

Method:

Pre-intervention data was also collected for a week prior to the first intervention for baseline data. Feedback was also collected via a questionnaire regarding the existing VTE risk assessment system on ICE to identify key issues and to gather suggestions on how to further improve the current system.

QIP data was collected from each Wednesday and Friday over 18 weeks (11/8/2021-17/12/2021) to quantify the number of VTE risk assessment forms completed and the number of VTE prophylaxis prescriptions completed. VTE prophylaxis prescriptions were also assessed to check if the prescription was appropriate for renal function, weight or if the patient was already on other anticoagulation therapy.

Image 1: 2 mandatory ‘tick box’ prompts on CAREFLOW proforma

Insights and feedback from the preintervention questionnaire

• An anonymous, online questionnaire was distributed to doctors of all grades within the Trust via a generic mailing list. This questionnaire was also flagged up during a Foundation School teaching session. 19 doctors responded to this questionnaire.

• 73.7% of respondents reported that they did not find the separate VTE risk assessment form useful

• 89.4% of respondents reported that they do not regularly complete the separate VTE risk assessment form

Image 2: Integrated risk assessment form on proforma

ACT: Intervention did not improve assessments; did not circumvent issue of multiple systems/forgetting to complete form

STUDY: n=186 11/8/2021-27/9/2021

PLAN: Raise awareness through mandatory Foundation teaching session

DO: 11/8/2021

Anticoagulation teaching session and how to access the risk assessment form was carried out

ACT: Slight improvement but still below target of 95% assessments; did not circumvent issue of having multiple systems

STUDY: n=196 28/9/2021-14/11/2021

PLAN: Include 2 mandatory ‘tick box’ prompts on clerking/Post Take proforma (Image 1)

ACT: Significant improvement in completed assessments but still below target as only implemented in Medical proformas

ACT: Significant improvement in completed assessment; but still below national target of 95%. 1 2 3 4

DO: 28/9/2021

Modified version of the CAREFLOW clerking/post take proforma was released to include these prompts: Q1: Has VTE assessment been completed? (Yes/No); Q2: Has VTE prophylaxis been prescribed? (Yes/No)

STUDY: n=95 15/11/2021-7/12/2021

PLAN: Integrate VTE risk assessment form into the MEDICAL clerking/post take proforma (Image 2)

DO: 15/11/2021

Medical CAREFLOW proformas was modified to include VTE risk assessment form. ICE risk assessment form no longer in use.

STUDY: n=69 8/12/2021-17/12/2021

PLAN: Integrate VTE risk assessment form into both MEDICAL & SURGICAL clerking/post take proforma

DO: 8/12/2021

Surgical CAREFLOW proformas was modified to include VTE risk assessment form.

CONCLUSION AND KEY LEARNING POINTS

Streamlining systems and integrating the VTE risk assessment tool into the clerking and post take proforma improves overall patient care by enhancing appropriate VTE prophylaxis prescription. Following the 4 PDSA cycles, the overall VTE assessment improved from 20.0% to 85.5%. The overall appropriate prescription of VTE prophylaxis increased from 88.0% to 95.7%.

FOOD FOR THOUGHT: A WORK IN PROGRESS

-This QIP focuses on the medical and surgical acute admission units where patients are referred from ED and clerked by the Take team. Patients who are admitted onto these wards via other routes such as elective surgery, day cases or through maternity use separate proformas and the risk assessment tool has not been integrated in this. Modifying these proformas may help to further improve risk assessments to the target of 95%.

- The integrated risk assessment tool could also include other elements such as patient’s weight & eGFR to enhance safe VTE prophylaxis prescribing. However, the benefits of this must be balanced against creating an inefficient, ‘over bloated’ proforma.

- The final intervention should be re-audited to see if the improvements in VTE risk assessment and prescription are sustained after a longer period of time

“Anyone know how to refer to... ?!”: Improving ease of referral pathways at Homerton University Hospital

Dr Nadia Eden1, Dr Mishka Venables 1

INTRODUCTION: A large part of medical practice is making sure patients are referred to the appropriate speciality in a timely manner. Difficulties in accessing those specialties can lead to delayed diagnoses, prolonged hospital stays and generally a poorer outcome for patients.

When we first started as F1s at Homerton University Hospital (HUH), a busy central London teaching hospital, we soon realised that there was no single point of access to find out how to refer to a specialty and that there were several different methods of referral and the only way to find out was through word of mouth.

AIM: to improve the process and ease of referring to specialties by 25% by August 2021

Cycle 1

METHODOLOGY:

Plan: to identify patterns and barriers to referral, preferred referral pathways and suggestions for improvement

Act: an online referral directory (see Fig 1) was created and distributed via the intranet, email, Whatsapp, F1 Induction talk and included in the updated Acute Care handbook

Feedback and suggestions of the current referral systems:

RESULTS of SURVEY:

• The survey found that all doctors referred at least once a week and 50% of those were referring once a day

• On a scale of 1 to 10, 44.8% of doctors rated the difficulty in referring as a ≤5, (with 10 being extremely challenging)

Do: We designed a qualitative and quantitative survey as a Google Form and distributed it to all the doctors in the hospital via email

Study:

50% indicated that they would prefer a single unifying method of referring to specialties

The other 50% all suggested electronic methods of referring

”a document on how to refer to each specialty”

“It would be easier if there was one referral system for all specialties”

Cycle 2

METHODOLOGY:

Plan:

To evaluate the effect of the referral directory and their experience of using it

• There was afairly even distribution of preferences for the 8different ways of referring:

• Neurology, ENT and Vascular were reported to be the most difficult specialties to refer to

• The process of referring to these specialties at HUH is via paper‘Yellow Boards’ or a phone call, neither of which arein the top three preferred methods of referring.

Act:

To convert the directory into a mobile phone app available to all doctors for free to improve ease of access to the directory (currently in progress)

"It’s amazing!! So so helpful, thank you for making it"

"Excellent resource!

Hugely helpful!"

“Significant stress and ping pong process. Very stressful as unable to provide cleat timeline or clarification to patients.”

RESULTS/REFLECTIONS:

• The improvementin ease of referral went up by 8.2% (from 44.8% to 53%scoring ≤5, with 10 being extremely challenging) with the implementation of the referraldirectory

• 82.3% rated the directory ≥4 outof 5 for ease of use

• 88.2%used the directory when they were unsure how to refer

Do: We sent a follow-up survey asking for people’s opinions on the directory i.e. how much it has helped them/suggestions for improvement

Study: 82.3% rated the directory 4 or above out of 5 for ease of use. Most common improvement suggestion was regarding ease of access to the directory.

"More easily available i.e. intranet or S drive. Could be a good app"

• We did not reach our 25% improvement target, likely due to multiple factors as follows: o Access to the directory

Ø 82.4% were aware of the directory however, feedback on the surveyshowed there is still room for improvement: o Phrasing/scaling of survey questions o Poorer response rate for 2nd survey

Ø Our key question for measuring the outcome: “On a scale of 1-10, 10 being extremely challenging, how easy do you find referring to adifferent specialty?

Ø 40 people responded to the 1st survey and only 17 to the 2nd one

Feedback from Cycle 2 Survey

"Added to more place and posters around the hospital"

CONCLUSION/NEXT STEPS:

• We did not meet our target of improving the process and ease of referring by 25%

• According to our survey, the next steps to try and achieve this would be improving access to the directory

• We are looking into creating an app to be ready to use in time for the new starters in August 2022

% of doctors that rated the difficulty of referring </ to 5 (with 10 being extremely challenging)