BC QUALITY FORUM CONFERENCEFebruary 28th 2013,

Melanie Basso, RN, MSN, PNC(C)Senior Practice Leader-Perinatal

Dorothy Shaw, MBChB, FRCSCVice President, Medical Affairs

BC Women’s Hospital and Health Centre

Venous Thromboembolus (VTE) Prophylaxis: Using ImPROVE Methodology to Implement an

Accreditation Canada Standard

Objectives

Primary project objective:Ensure 100% of women who deliver at BCW, receive a VTE risk assessment

Presentation objectives:Describe the use of ImPROVE - RPIW methodology to strengthen the implementation of a pre-existing protocol on Venous Thromboembolism (VTE) ProphylaxisIdentify the interventions used to sustain this accreditation Canada standardDescribe our lessons learned along the way

Disclosure

Images of commercial products in the patient brochure are included as examples for illustration purposes and were obtained from “Google Images”.

These pictures do not represent the products used or endorsed by BC Women’s Hospital and Health Centre, or by the presenters.

Neither of the presenters has any disclosures of conflict of interest

D. Shaw is a member of several Advisory groups for non-profit organizations, none related to this presentation

Background

BC Women’s Hospital has over 7000 births/ year

A lack of VTE prophylaxis protocol was identified as a Best Practice issue for our woman at risk.

In January 2011, we received the 2012 Accreditation Standards which included having a VTE Risk Prophylaxis protocol

Between 1987-2004 there were 35 maternal deaths in BC

51% of obstetric deaths in BC were potentially avoidable

28% were related to blood clot issuesDeveloping a blood clots is a bad outcome.

Patients are on blood thinners for extended periods of time if they get one and are always at an increased risk for additional clots in the future.

BC Statistics

BC Women’s Statistics

Staff Survey: Issues with VTE ImplementationIn person survey of 12 post partum nurses and 2 physicians (April 2nd-4th, 2012) on all BCW Post Partum Units

29% 29% 29%

64%

0%

20%

40%

60%

80%

100%

Prop

ortio

n of

sta

ff w

ho m

entio

ned

issu

es w

ith V

TE im

plem

enta

tion

Series1 64% 29% 29% 29%

Fragmin dose timing When to remove stockings? (mobility) MD Orders Incomplete More Info/Evidence

Chart Audits: Defects in VTE Orders Audits conducted March, 2012 on all BCW Post Partum Units

19%

75%

29%

0%

20%

40%

60%

80%

100%

Def

ects

in V

TE C

hart

Aud

its b

y fr

eque

ncy

of is

sue

Series1 29% 19% 75%

Patient received wrong dose Patients given incorrect protocol Risk Assessment incomplete

Current State & AnalysisProcess Map

What are the system requirements?Average of 19 women arriving to deliver at BCW (takt time) per day. Approximately 9 women will receive the VTE protocolProject Scope All women who deliver at BCW (or are transferred post delivery to BCW)

RPIW Project Form Previously Linked RPIW #:

imPROVE: improve@phsa.ca Revision Date: Oct 31, 2011

Sponsors: Heather Mash/Ruth Dueckman

Process Owners: Pam O’Sullivan/Roane Preston

Team Leader: Melanie Basso Sub-team Leader: Dorothy Shaw

imPROVE Support: Lily Farris Content Experts:Nancy Kent (MFM), Henry Woo (OB), Peter Tsang (Hematology), June Yee

(Pharmacy), Simon Massey (Anesthesia)

Team Members/Dept. Team Members/Dept.

1. Lisa Scigliano (PP RN) 5. Caitlyn Atkinson (Birthing RN) 8. Thea Parkin (RM)

2. Cathy West (AP RN) 6. Sarah Saunders (OB Res) 9. Grace Dublanko (Quality)

3. Kathy Greenberg (FP) 7. Hanna Ezzat (OB)

Primary Objective 100% of women who deliver at BCW, receive a VTE risk assessmentKey Measure % of women who deliver at BCW, receive a VTE risk

assessment. Secondary Measure: % of women who are assessed as high or intermediate

risk receive VTE protocol until discharged or reassessed.

Countermeasures Developed provider information sheet including evidence and implementation details, Revised order forms to

streamline process, and drafted a patient information sheet for VTE.

Current State (Cont.)

Assessment and Treatment: 75% of VTE risk assessment incomplete

Staff process: 64% of staff surveyed mentioned lack of clarity on when to provide fragmin doses

Patients: 0% of patients refused the VTE protocol, 0% of patients received written information on VTE

RPIW 47 & Project Name: VTE Standardization RPIW Week (Date): April 30th – May 4th 2012

BackgroundMaternal mortality and morbidity found to be associated in BC with a lack of prophylaxis

protocol in place. Guidelines being implemented internationally/nationally/provincially and to meet RoP

VSM Name, Date & Related Goal:Accreditation RoP VTEProblem statement: No assessment of risk or prevention of VTE post partum at BCW existed.

Sustainment PlanAudits: Chart auditsAudit Leader: Melanie Basso

Patient assessed for VTE Risk

Patient

Delivers SVD

Patient receives VTE protocol until discharge

Women with pre-existing history assessed as high risk

Women with intermediate risk receive protocol

Patient

Delivers Cesarean

Patient assessed for VTE Risk

Patient receives VTE protocol until discharge

Patient

Ready for Cesarean

TEDs applied to all women

Women with intermediate or high risk receive protocol

25%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% of women who received VTE riskassessment

25%

Pre-Kaizen

Chart Audit: % of patients with

risk assessment complete

Chart Audit: % of patients who

receive appropriate treatment

81%

0%10%20%30%40%50%60%70%80%90%

100%

81%

Pre-Kaizen

RPIW Plan: Goals for the week

Audit and observe VTE process and develop kaizenRevise VTE orders and implementReview audit of oozy wounds and develop kaizen Draft, revise, and implement patient pamphlet Revise “Anticoagulant Chart” CV0700 Appendix C Review Second Trimester Induction orders, develop new process, draft new orders, implement new processDevelop evidence reference and fact sheet (SHORT)Visual cue for Fragmin patients How do we make the standard obvious, self explanatory and mistake proof ?How do we energize staff to have a “standard work” culture? Same practice for everyoneExplore training communication to care team (MD, Nurse, etc.) and patient

How do we make BCWs standard obvious to the providers? (regular staff and others)

Adapted from RCOG Green Top Guidelines

BC Women's Hospital RPIW #47

Chart Audit: Providers Completing VTE OrdersAudit of 12 charts April 20th-May 2nd, 2012

58%

42%

17% 17%

0%10%20%30%40%50%60%70%80%90%

100%

58% 42% 17% 17%

1 2 3 4

Ob/GynFamily Practice

Maternal Fetal Medicine

Registered Midwife

Provider Information (EXAMPLE)

Background: VTE occurs in 0.5 – 3/1000 pregnancies.[1] Pulmonary embolism (PE), along with pre-eclampsia, is the number one cause of maternal death in Canada. Of the 1,054,828 live births in Canada between 1997 and 2000, there were 44 direct maternal deaths, 9 of these were the result of PE. This makes PE the leading potentially preventable cause of maternal mortality.[2] Review of BC women’s data from the past 8 years identified at least 18 postpartum inpatient thrombotic events equally divided between vaginal and c-section births. Of these, 11 were PEs. Even in low risk women, VTE is at least 5 times more common in pregnant than in non-pregnant women. The greatest increase in risk is in the postpartum period. (~22 fold)

Multiple studies have been done to identify patients at greatest risk for VTE. One of the most consistently identified and strongest risk factors is emergency c-section, with a risk for VTE of 0.5% to 2%.[3] Many other patient factors can increase the risk further, hence the basis for stratifying patients into risk categories.

[1] Sultan et al, British Journal of Hematology, 2011 [2] Health Canada. Special Report on Maternal Mortality and Severe Morbidity in Canada- Enhanced surveillance: The Path to Prevention. Ottawa: Minister of Public Works and Government Services Canada, 2004[3] Jacobsen et al, Thrombosis Research, 2004

VTE Patient SurveyComments

Patient 1- The nurse said the stockings are to keep the blood flowing; nurse said ‘you need stockings’; nurse said ‘If you walk more you can take off stockings’Patient 2 – The nurse in delivery suite measured my legs and put on the stockings. She said that the stockings and medication would help me avoid blood clots so I said definitely Patient 3- When the nurse told me that the stockings and meds would prevent clots that made sense to me. I would like a short pamphlet -1 page of bullets on benefits, risks (if there are any). Don’t put it in the prenatal package because I won’t remember it, already too much information.

Workshop Summary

So, what did we accomplish?

We revised all the Prescriber Order Forms related to VTE Prophylaxis Protocol and embedded them in existing practices

Developed Provider Information Sheets (evidence- based)

Developed the Patient Information Sheet Drafted the education roll-out plan

Lessons Learned

Project implementation success is not guaranteed just because it is a “must do”

Need staff buy in –don’t just tell them what to do, they want to have evidence

Patients want answers too, and need resources created for them at the appropriate literacy level

Embedding practice change into existing processes, try not to create additional paper work

Audits keep you honest about how your project is going and identify areas for further development/strategy.

Questions

Thank you

Questions?

Email: Melanie Basso mbasso@cw.bc.ca

Dorothy Shaw dshaw@cw.bc.ca