Using Innovation to Standardise and Optimise Acute Deep Vein Thrombosis Management

This project implemented a number of solutions, including a web-based, mobile-friendly clinical decision support tool, to help Emergency Department (ED) staff provide best practice care to patients with acute deep vein thrombosis (DVT).

Aim

To ensure that 95 per cent of people presenting to Westmead Hospital ED with acute upper or lower limb DVT undergo standardised assessment, investigation, treatment initiation and follow up consistent with evidence-based best practice and international guidelines¹, by June 2017.

Benefits

• Improves the ability of doctors to assess, diagnose, investigate and manage DVT.
• Maintains best practice guidelines in the assessment and treatment of acute DVT.
• Reduces clinical variation by ED and haematology staff.
• Standardises the policies and processes for haematology investigations and anticoagulant treatments.
• Allows ED staff to prescribe internationally recommended treatments.
• Reduces delays in follow-up care and streamlines the outpatient booking process.
• Improves patient care and satisfaction with their healthcare journey.

Background

DVT occurs when a blood clot forms in one or more veins in the body, often in the legs. It can cause pain and swelling, but may also have no symptoms. DVT can be dangerous if the blood clot travels through the body and lodges in the heart or lungs, blocking blood flow. Acute DVT occurs when symptoms have been present for 14 days or less.

An audit conducted between 1 February and 31 May 2016 found that people who presented to Westmead Hospital ED with acute DVT were receiving care with marked variation in clinical practice. It was determined that this was due to a number of factors, including:

• the experience and knowledge of ED staff
• the advice they received from the consulting haematologist
• a lack of standardised process for investigation
• a lack of standardised process for selecting an anticoagulant treatment
• an inability for ED doctors to access internationally recommended treatments such as Non-Vitamin K Antagonist Oral Anticoagulants (NOACs)
• an inconsistent patient referral and follow-up process once they were discharged from the ED.

The audit also showed that:

• baseline blood tests and weight were not always measured, with 43 per cent of patients having incomplete tests and bHCG blood tests often forgotten
• five per cent of acute DVT patients did not receive a follow-up consultation, either because faxed referrals were never received or the patient could not be contacted by phone or letter
• 46 per cent of patients had their anticoagulant changed at their first haematology appointment after leaving the ED
• there was an average of 30 days between the ED presentation and haematology follow up and during this time, 22 per cent of patients reported adverse effects from their anticoagulant therapy or acute DVT, including heavy menstrual bleeding or gastrointestinal bleeding.

The variations in clinical care meant that many patients were not on the right coagulant therapy, or were on multiple coagulants. The delay between presenting to the ED and seeing a haematology specialist increased the risk of bleeding and recurring thrombosis, making it more likely for a patient to experience an adverse event.

Implementation

• A baseline audit was conducted and primary and secondary drivers identified, before solutions were developed.
• The process for receiving phone calls from the ED requesting haematology consultations was mapped and modified, to provide ED staff with a single point of contact moving forward.
• A standardised pathology order set for acute DVT patients was established in the PowerChart clinical database, to reduce variation in tests given to patients on arrival in the ED.
• A NOAC starter pack was developed for ED staff, with a standardised process for 24-hour medication dispensing from the ED.
• Patient information brochures were developed and added to the starter pack, to help ED staff inform clients of the tests and treatments associated with acute DVT.
• Multidisciplinary education sessions were provided to ED and haematology staff on the new model of care and best practice management and treatment of acute DVT.
• Rapid acute clot clinic outpatient appointments were established and an electronic referral system developed, to reduce delays to follow-up appointments and gaps in the patient journey.
• A clinical decision support tool was developed to help doctors assess, diagnose, investigate and manage DVT. It is a web-based, mobile-friendly tool that was tested in sprints with agile user methodology. User data was analysed to ensure appropriate use of the tool, with modifications made to support the needs of users, such as shortcuts to frequently used content.

Status

Sustained – The project has been implemented and is sustained in standard business.

Dates

Project start: October 2016
Project implementation: February 2017
Project Evaluation: June 2017

Implementation Sites

Emergency and Haematology Departments, Westmead Hospital, WSLHD

Partnerships

Clinical Leadership Program

Results

An evaluation was conducted between 1 February and 31 May 2017, comparing results with the original audit undertaken during the same time frame the previous year. The following results were achieved.

• Patient surveys were conducted following implementation of all solutions. Of 26 patients surveyed, 92 per cent received information on their DVT diagnosis in the ED and 100 per cent received information about their treatment. Patients reported a reduced burden from their treatment, and the median number of treatments received was reduced from two to one. Patients reported a reduction in stress due to their treatment and high rates of satisfaction with the care provided in the ED and acute clot clinic.
• Surveys were conducted with ED and haematology staff. They showed that 81 per cent of ED staff and 93 per cent of haematology staff knew the most appropriate first-line coagulant choice for acute DVT patients without cancer. All haematology staff and 48 per cent of ED staff reported ease of access to approved DVT management guidelines. Staff also reported increased confidence in using NOACs.
• There was improved clinician understanding of appropriate diagnostic measures for investigation, demonstrated by an increase in patients who had a complete set of baseline tests in the ED, from 58 per cent to 83 per cent.
• Clear processes for identifying the appropriate therapy choice for patients resulted in a reduced number of changes to therapy at their first haematology clinic, from 46 per cent to 18 per cent.
• Providing ED staff with the ability to prescribe the most appropriate therapy in the ED increased the prescription of NOACs from 5 per cent to 74 per cent. Hospital in the Home use was also reduced by 48 per cent.
• Improved referral processes resulted in 92 per cent of patients seen for follow-up within three days of discharge from the ED, and 100 per cent within seven days. Only one patient was lost to follow-up and this patient did not have an electronic referral.
• There was an increase in the proportion of ED patients referred to the acute clot clinic, from 54 per cent to 79 per cent.
• There was an increase in the proportion of patients seen by thrombolysis subspecialists for follow-up, from 68 per cent to 94 per cent.
• Fewer patients experienced complications as a result of their treatment, with self-reported adverse events occurring before clinic follow-up reducing from 22 per cent to 12 per cent.
• There was a minor increase in laboratory costs, but this was outweighed by significant cost savings as a result of the project. There was an overall cost saving of $34,058 in the first four months of the project, with the cost per patient reducing from $1985 to $1042.
• Overall, 84 per cent of people presenting to Westmead Hospital ED with acute DVT received a standardised assessment, investigation, treatment and follow up consistent with best practice guidelines, an improvement of 71 per cent.
• The impact of this project is likely to include less ED presentations of people with complications from their therapy and reduced admission rates.
• The project is currently being rolled out to all WSLHD sites.

Awards

• 2017 NSW Health Awards Recipient, Patient Safety First - Not another DVT in ED
• 2017 WSLHD Innovation Awards Winner - Innovation

Lessons Learnt

• Engagement of key stakeholders in emergency, haematology and pharmacy departments was crucial to the success of the project.
• Ongoing education of junior staff and demonstration of key solutions, including the clinical decision support tool, is necessary for optimal management and sustainability of the project.

References

1. Kearon C, Akl EA, Ornelas J et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest 2016;149(2):315-52.

Contact

Dr Jennifer Curnow
Director Clinical Haematology
Westmead Hospital, WSLHD
Phone: 0404 451 327
Email: jennifer.curnow@health.nsw.gov.au