Speaker Notes: 60-70% of all VTE is hospital-acquired (i.e. this is a public health issue). Pulmonary embolism is the commonest, preventable cause of hospital death. These facts support the Accreditation Canada VTE ROP which recommends that the team establish measures for appropriate thromboprophylaxis use, audits the implementation of appropriate thromboprophylaxis, and uses this information to make improvements to their services. “ Patients without risk factors for VTE are called outpatients .” G. Maynard (2010)
Speaker Notes: Numerous audit methodologies are available that consider the following: the depth of information desired (snap-shot vs. detailed) timing with respect to a patient’s admission (real-time vs. retrospective)
Speaker Notes: Importantly, the audit methodology (snap-shot vs. detailed) should be consistent with your local VTE prophylaxis policy/guideline.
Speaker Notes: The type of audit your institution chooses to perform will depend upon the resources available to conduct the audit, as well as the type and depth of information sought. Once the audit type has been decided then resources need to be determined and allocated.
Speakers Notes: A VTE prophylaxis audit should assess the proportion of patients receiving recommended or indicated prophylaxis and/or appropriately prescribed prophylaxis (capturing onset, type and duration) Appropriate thromboprophylaxis should be: 1 provided within 24 hours of admission to hospital and within 24 hours following major l surgical procedures involve evidence-based (ACCP recommended) thromboprophylaxis continued until hospital discharge or post-discharge for selected patient groups, if appropriate (at least until hospital discharge in major non-orthopedic surgical patients and at least 10 days for hip/knee arthroplasty or hip fracture surgery) Reference: Geerts WH, et al . Prevention of venous thromboembolism: ACCP evidence-based clinical practice guidelines, 8 th edition. Chest 2008;133:381S-453S.
Speaker Notes: At some point in time each audit methodology, both snapshot and in-depth, should be performed to ensure a complete audit/review of thromboprophylaxis practices is conducted, with the information gained being used for quality improvement purposes.
Speaker Notes: In situations where a pharmacy informatics system is in place, the appropriate pharmacy personnel will/should generate a report indicating patients currently receiving any anticoagulant, including LMWH, LDUH, warfarin, rivaroxaban and dabigatran. All patients that are captured by the DUE report as being on an anticoagulant can be classified as receiving therapeutic or prophylactic anticoagulation. Patients not appearing on the DUE report require a chart audit to determine if they are receiving mechanical thromboprophylaxis or no thromboprophylaxis and whether those decisions are appropriate.
Speaker Notes: Important for any audit is that every patient be accounted for including those who do not require thromboprophylaxis due to a lack of indication. If the entire hospital will be audited consider excluding some patient groups where there are no clear guidelines regarding appropriate thromboprophylaxis: paediatric psychiatric palliative/long-term care rehab
Speakers Notes: On average, an organization wide point-in-time audit in a 400-bed hospital with moderate rates of thromboprophylaxis will require 4-8 hours, depending on audit staff efficiency. With experience, significant improvements in efficiency will be noted.
Speaker Notes: For a snap-shot audit, only patients who are determined NOT to be on an anticoagulant will require a chart review. All patients that are captured by the DUE report as being on an anticoagulant can be classified as receiving therapeutic or prophylactic anticoagulation. Patients not appearing on the DUE report require a chart audit to determine if they are receiving mechanical thromboprophylaxis or no thromboprophylaxis and whether those decisions are appropriate. For each patient who requires a chart review, this review can be used to determine if they have contraindications to a pharmacological agent, received mechanical thromboprophylaxis, or did not have an indication for thromboprophylaxis.
Speaker Notes: The data collection forms should be adapted to fit the policy/guideline of your hospital. These examples are very comprehensive and offer a good start point for designing you own data collection forms. It is important that a SUMMARY section be provided to capture the key point of a patient’s risk and treatment (if any).
Speaker Notes: The data collection table should be adapted to fit the policy/guideline of your hospital. This example is a good start point for designing you own tables.
Speaker Notes: Once the audit is complete a report should be generated. Most helpful is comparisons to previous audits to clearly show successes and care gaps.
Speaker Notes: In this case the success should be celebrated (83%, 10% better than 2010) and the gaps identified (missing 17%). It is important that a strategy be worked out to support continued improvement. Vigilance in awareness and improvements are key to a backwards slide.
Speaker Notes: In order for audit results to drive change toward best practices, it is important that the results be shared/disseminated to stakeholders, including healthcare providers and hospital/institution administration.
Speaker Notes: Next steps to drive awareness and change should be built into the audit report. Care units/wards/service areas should be provided with outcomes from the audit to assist them with improving their patient management.
Speaker Notes: Wide dissemination is key to success. Displaying the results in prominent locations such as the hospital entrances, nursing care unit/ward entrances, staff washrooms, staff locker room or lunch rooms will raise awareness and ensure the majority of staff are made aware of the outcome, successes and gaps.
Speaker Notes: This is the goal. Protection and prevention of VTE in all our patients.
Audits: Introduction and Procedure
Snap-Shot & Detailed Audits:Introduction and Procedure
ACCREDITATION CANADA2010 VTE Prophylaxis ROP1. The hospital has an organization-wide, writtenthromboprophylaxis policy or guideline.2. Identifies patients at risk for VTE and providesappropriate, evidence-based VTE prophylaxis.3. Establishes measures for appropriatethromboprophylaxis use, audit itsimplementation, and uses this for qualityimprovement.4. Identifies major orthopedic surgery patients whorequire post-discharge prophylaxis and providesit.5. Educates health professionals and patients aboutVTE and its prevention.www.accreditation.ca
Why do Audits?Audits and feedback are an effectivestrategy to identify gaps betweenevidence and practice, and shoulddrive change in healthcare settings.
• It will help identify gaps between the evidence(embedded into the local thromboprophylaxispolicy) and what is actually done in practice.• Will be used to guide where to implement qualityimprovement (QI) interventions.• Should assess the proportion of patients at riskfor VTE who are prescribed appropriate(evidence-based) VTE prophylaxis− capturing correct option, dose, onset, compliance and,where possible, duration.What will a VTE prophylaxisaudit tell us?
• Data collection/generation• Computerized pharmacy system (ability to generateDrug Use Evaluation (DUE) reports)• Data Collection Tables• Supplemental Data Collection sheets• Staffing resources• Pharmacy staff: pharmacists, pharmacy students• Quality Improvement: QI personnel• Nurses• Research Personnel• Medical Students• Health Records Analysts• Other Health PersonnelResources and Considerationsfor an Audit
Choosing an Audit TypeSnap-Shot Audit Detailed AuditPurpose:To identify prevalence ofthromboprophylaxis use in one ormore patient groups.Purpose:To identify prevalence andappropriateness ofthromboprophylaxisKey Points:•Provides point estimates of theuse of local TP options•Indicates if evidence-based TP isprescribed/ordered on that givenday•Easy and most efficient audit•Provides estimate of how well thevarious services are doing•Helps identify possible care gaps•Provides a measure that could beutilized for dashboards/balancedscorecards if used as a measure ofquality of careKey Points:•Captures appropriate selection ofTP option, initiation, and dose•Requires direct auditing of agreater number of charts (DUEreports are not sufficient), makingit more labour intensive•Provides more useful informationand more appropriate estimates
Audit Advantages & LimitationsSnap-Shot Audit Detailed AuditAdvantages:•Estimate of TP•Quick•Identifies major gaps in theprovision of local TP options•Less labour intensive•Can be completed by personnelwith less clinical experienceAdvantages:•Can provide information oninitiation, dose, adherence (if andwhen given), and duration of TP•Estimates and provides greaterinsight into suboptimal TP use,leading to the creation of remedialQuality Improvement (QI)strategiesLimitations:•Does not measure appropriateness,initiation, dose, adherence, orduration of TPLimitation•Requires the direct review ofactual patient charts (DUE notenough•Labour intensive•Requires personnel with clinicalexperience
• Where a pharmacy informatics system is in placegenerate a report indicating patients currentlyreceiving any anticoagulantAudit Steps
IMPORTANT:Audit tools should be alignedwithpolicy/ guidelinesof your institutionorconsistent with clinical orderset
• For real-time detailed audits, options are:• all beds on a given dayor• audit different services/wards/nursing careunits on consecutive daysor• audit a single or limited number of nursing careunitsFrequency and Audit SampleAs rates of appropriate prophylaxisincrease less time will be needed,with fewer chart audits required.
• Only patients who are determined NOT to be onan anticoagulant will require a chart review• All patients captured by the DUE as being on ananticoagulant can be classified as receivingtherapeutic or prophylactic anticoagulation• Patients not appearing on the DUE report require achart audit to determine if they are receivingmechanical prophylaxis or no prophylaxis andwhether those decisions are appropriateSnap-Shot Audit
• To drive change the results must beshared/disseminated with stakeholders, includinghealthcare providers and administration.• Data should be broken down at various levelsincluding:• Hospital Service• Ward Individual Physician• Wards/ service areas should be provided withoutcomes from the audit to assist them withimproving patient safety and care.Driving Change Toward BestPractices