This document provides guidance on conducting audits to assess appropriate use of venous thromboembolism (VTE) prophylaxis in hospitals. It describes snap-shot and detailed audits, resources needed, steps to conduct audits, and how to report and disseminate results to drive quality improvement. The goal is to help close any gaps between evidence-based guidelines and actual clinical practice of VTE prophylaxis prescription and use.

1. Snap-Shot & Detailed Audits:
Introduction and Procedure

2. ACCREDITATION CANADA
2010 VTE Prophylaxis ROP
1. The hospital has an organization-wide, written
thromboprophylaxis policy or guideline.
2. Identifies patients at risk for VTE and provides
appropriate, evidence-based VTE prophylaxis.
3. Establishes measures for appropriate
thromboprophylaxis use, audit its
implementation, and uses this for quality
improvement.
4. Identifies major orthopedic surgery patients who
require post-discharge prophylaxis and provides
it.
5. Educates health professionals and patients about
VTE and its prevention.
www.accreditation.ca

3. Why do Audits?
Audits and feedback are an effective
strategy to identify gaps between
evidence and practice, and should
drive change in healthcare settings.

4. • It will help identify gaps between the evidence
(embedded into the local thromboprophylaxis
policy) and what is actually done in practice.
• Will be used to guide where to implement quality
improvement (QI) interventions.
• Should assess the proportion of patients at risk
for VTE who are prescribed appropriate
(evidence-based) VTE prophylaxis
− capturing correct option, dose, onset, compliance and,
where possible, duration.
What will a VTE prophylaxis
audit tell us?

5. • Data collection/generation
• Computerized pharmacy system (ability to generate
Drug 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 Personnel
Resources and Considerations
for an Audit

6. Choosing an Audit Type
Snap-Shot Audit Detailed Audit
Purpose:
To identify prevalence of
thromboprophylaxis use in one or
more patient groups.
Purpose:
To identify prevalence and
appropriateness of
thromboprophylaxis
Key Points:
•Provides point estimates of the
use of local TP options
•Indicates if evidence-based TP is
prescribed/ordered on that given
day
•Easy and most efficient audit
•Provides estimate of how well the
various services are doing
•Helps identify possible care gaps
•Provides a measure that could be
utilized for dashboards/balanced
scorecards if used as a measure of
quality of care
Key Points:
•Captures appropriate selection of
TP option, initiation, and dose
•Requires direct auditing of a
greater number of charts (DUE
reports are not sufficient), making
it more labour intensive
•Provides more useful information
and more appropriate estimates

7. Audit Advantages & Limitations
Snap-Shot Audit Detailed Audit
Advantages:
•Estimate of TP
•Quick
•Identifies major gaps in the
provision of local TP options
•Less labour intensive
•Can be completed by personnel
with less clinical experience
Advantages:
•Can provide information on
initiation, dose, adherence (if and
when given), and duration of TP
•Estimates and provides greater
insight into suboptimal TP use,
leading to the creation of remedial
Quality Improvement (QI)
strategies
Limitations:
•Does not measure appropriateness,
initiation, dose, adherence, or
duration of TP
Limitation
•Requires the direct review of
actual patient charts (DUE not
enough
•Labour intensive
•Requires personnel with clinical
experience

8. • Where a pharmacy informatics system is in place
generate a report indicating patients currently
receiving any anticoagulant
Audit Steps

9. Accounting for all the Patients

10. IMPORTANT:
Audit tools should be aligned
with
policy/ guidelines
of your institution
or
consistent with clinical order
set

11. • For real-time detailed audits, options are:
• all beds on a given day
or
• audit different services/wards/nursing care
units on consecutive days
or
• audit a single or limited number of nursing care
units
Frequency and Audit Sample
As rates of appropriate prophylaxis
increase less time will be needed,
with fewer chart audits required.

12. • Only patients who are determined NOT to be on
an anticoagulant will require a chart review
• All patients captured by the DUE 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 prophylaxis or no prophylaxis and
whether those decisions are appropriate
Snap-Shot Audit

13. Data Collection Form

14. Data Collection Table

15. Putting it all Together
The Audit Report

16. Sample Audit Report

17. Sample Audit Report

18. • To drive change the results must be
shared/disseminated with stakeholders, including
healthcare providers and administration.
• Data should be broken down at various levels
including:
• Hospital Service
• Ward Individual Physician
• Wards/ service areas should be provided with
outcomes from the audit to assist them with
improving patient safety and care.
Driving Change Toward Best
Practices

19. Dissemination and Feedback
Drive Change

20. Various methods of dissemination include:
− Newsletters
− Educational/in-service sessions
− Department Head meetings
− P&T
− Organizational public newsletters
Dissemination of Audit Results

21. The Goal of every
Hospital/Institute:
100% appropriate
prophylaxis for all patients
at risk,
when clinically indicated