Improving documentation of VTE prophylaxis prescriptions in surgical ward round notes

Dr Katie Prior & Dr Sarah Burge, Royal United Hospital Bath

Introduction

• Hospital admission and surgical intervention are well-documented risk factors for thromboembolic events1

• Systems exist to ensure patients are prescribed appropriate venous thromboembolism (VTE) prophylaxis on admission. However, surgical patients may require alteration of their VTE prophylaxis.

• Without ongoing measures to monitor VTE prophylaxis, surgical patients may be at increased risk of omitted VTE prophylaxis.

• Local guidelines recommend that if VTE prophylaxis is withheld, this should be documented2

• Guidance given to new foundation doctors suggests that VTE prophylaxis status should be a routine part of ward round documentation3. However, this is rarely monitored.

Aims

To audit and improve documentation of VTE prophylaxis in surgical ward round notes

Methodology

Baseline data: We examined ward round entries on 3 wards and recorded how many times VTE prophylaxis was documented over a period of seven days.

PDSA cycle 1: Intervention targeted at F1s working in general surgery, highlighting the importance of checking and documenting VTE prophylaxis when preparing ward round notes.

PDSA cycle 2: Intervention extended to registrars.

Intervention involved both written and verbal explanations of our project to the target group. Post-intervention data was collected one and three weeks after each cycle.

Planned to target our intervention towards general surgical F1s as they are most commonly responsible for ward round documentation

We found peer to peer intervention resulted in a mild improvement in VTE documentation. For PDSA cycle 2 planned to extend our intervention to registrars

Results

Message sent to F1s on general surgery about the importance of checking VTE prescriptions and encouraging documentation

Examined ward round notes 1 and 3 weeks after the intervention, and recorded how many times VTE mentioned. This was compared with baseline data

• Baseline data showed poor documentation of VTE amongst surgical specialties. Amongst medical specialities, VTE was documented in at least 75% of notes samples.

• General surgery had the lowest incidence of VTE documentation.

• After PDSA cycle 1, there was a moderate improvement in VTE documentation.

• This varied greatly between individual doctors.

• Specialities with no intervention saw no change in VTE documentation.

• Results following PDSA cycle 2 in progress.

LIPID MANAGMENT FOR SECONDARY PREVENTION OF CARDIOVASCULAR DISEASE IN TORBAY HOSPITAL

Authors: Merson S1, Nakou D2

Introduction

Hypercholesteraemia refers to the elevated levels of low-density lipoprotein (LDL) >3mmol/L or non -high-density lipoprotein (non-HDL) >4mmol/L It is usually the result of unhealthy lifestyle choices It can also bedue to faulty genes, known as familial hypercholesteraemia, something to be considered when total cholesterol >7.5mmol/L or LDL> 4.9mmol/L.Hypercholesteraemia isan importantrisk factor for atherosclerosis and subsequently for cardiovascular disease (CVD) 1

Methods

Aim

This project aims to improve the care of the patients who are admitted on Coronary care unit (CCU) and Cardiac painunit (CPU) in Torbayhospital with acute coronary syndrome (ACS) inline with national guidance for lipid management in secondary prevention of CVD

Act: March 2022 Education

• Present findings andactions at Cardiology

Departmental meeting- Consensus opinion was thatthe management of secondary prevention in CVD should be the remit of GPs

• Cardiology nurses asaboveand write in on improved blood tests recording sheet

• Emergency department and Medical receiving unit to request lipid profileblood test for all ACS patients.

• Junior doctors to add instructions for GP in the care plan summary (CPS)

Study: Results

Current strength:

• 94%(30/32) were prescribedahigh intensity statin (66%), or lower dose statin or ezetimibe with appropriate rational (28%).

Areas for improvement:

• 34%(11/32)had repeat lipid profile.

• 45%(5/11) achieved reduction of non-HDL>40% from baseline.

• 17%(1/6) with reduction of non-HDL<40% GP was advised to consider adding ezetimibe 10mg daily and then PCSK9i.

Please add the following to CPS for all ACS patients.

ALT/AST-

Non HDL Cholesterol -

LDL Cholesterol -

(LDL cholesterol may not be available in which case fine to just mention non HDL cholesterol)

GP-please measure full lipid profile and AST/ALT again after 3 months (non-fasting). High intensity statin treatment should achieve reduction of non-HDL-C > 40% from baseline. For this patient aim for Non HDL Cholesterol of less than …………………….

If this is not achieved after 3 months then please follow the National Guidance for Lipid Management for Primary and Secondary Prevention of CVD

NHS Accelerated Access Collaborative » Summary of national guidance for lipid management (england.nhs.uk)

Next Phase Of Project

Plan: February 2022

• Patients admitted to CCU and CPU with ACS between 01/07/21-30/12/21 with LDL

≥ 3mmol/L

• 32 patients in total

• Male to female ratio 2:1

Do: Is the following happening?

• Prescribeahigh-density statin: Atorvastatin 80mg daily.

• Repeat lipid profile after 3 months

• Achieve reduction of non-HDL>40% from baseline in 3 months

• If non-HDL<40% add ezetimibe 10mg daily or monotherapy if statin intolerance

• If non-HDL remains >2.5mmol/L consider injectable therapies (Inclisiran or PCSK9 inhibitors)

Conclusion

Optimisinglipid management isan essential component of secondary prevention of CVD.

Initiating highdose statins is performed well in Torbay

Improving further monitoring and management is challenging, factors include:

• Transient and rapidly changing team of junior doctors who populate the CPS.

• Hand over between secondary and primary care.

• Timely blood tests and medication reviews.

In June 2022 review CPS and follow up lipid profile and management for patients with ACS discharged in March

If GPs are not consistently followingfollow up guidelines then considercardiology based follow up