Ensayo aleatorio (bloque 8)

Following efficacy testing and clinical validation o f T1 (see Section 4), online user training

packages w e re developed fo r doctors. On com pletion o f th e training, users w e re assessed

online before th e y could carry out VTE risk assessments on patients. VTE awareness

campaigns detailing th e CQUIN requirem ents and correct usage o f T1 w e re published on

th e study Trust's In tra n e t and added to th e agenda o f m ultidisciplinary te a m m eetings. T1

was im p lem en ted a t th e beginning o f April 20 1 0 , fo u r m onths earlier than th e reporting

deadline in o rd er to give th e project te a m tim e to m o n ito r its usage and com pliance

against th e set CQUIN targets and w ith a view to resolving any problem s arising.

T IL ead C o n su ltan t revealed th a t th e re was significant resistance im m ediately, particularly

fro m senior clinicians in th e surgical specialties. They believed th a t th e VTE incidence

published in th e Health Select C o m m ittee rep o rt in 2 0 0 5 w e re exaggerated and th a t T1

w ould deliver little b en efit to th e ir patients.

There are significant groups of people who don't regard hospital associated VTE as something that happens to their patients and think of this process as bureaucratic and of little clinical benefit. Part of the problem is that VTEs usually happen weeks after the admission episodes... we didn't have a mechanism to feedback to some of those consultants [before the Root cause Analysis process], as often they will not be reviewing these patients until weeks later...

TILeadConsultant

Despite th e opposition, initial Trust-w ide com pliance follow ing T l's im p le m e n ta tio n was

70% , com pared w ith th e 50% forecast by th e T1 project te a m and 35% previously achieved

using th e paper-based VTE risk assessment tool. The T1 project te a m a ttrib u te d th e

training th a t accom panied its introduction. H ow ever, th e w ord in g o f th e VTE CQUIN

fra m e w o rk inferred th a t all patients, including those ad m itted fo r m inor procedures and

routine tests in ou tp atien ts' clinics, w ould be risk assessed. This included patients w ho

w ould norm ally be considered as being at low risk o f developing VTE. This inevitably led

to disruptions in routine processes such as th e day surgery unit and o th e r p a tie n t groups

w h o w e re considered to be at low risk o f developing VTE. T1 Im p lem en tatio n N u rse noted

th e e x te n t o f operational disruptions follow ing T1 im p lem en tatio n .

There wasn't time for a pilot. It [Tl] had to go [live]. It did work but there were departments where it absolutely caused mayhem. The way it was worded meant that every admission had to be risk assessed, even minor procedures... For example, in the Surgical Day Unit, day surgery lists for minor procedures were held back. On the day the tool went live, most of the VTE project team were away and I had to deal with the various issues.

TllmplementationNurse

In response to these challenges (around July 2 0 10), th e study Trust and others in the

region approached th e ir Strategic Health A uth o rity to seek permission to re w rite local

policies to exclude low risk p atien t groups w ith o u t incurring penalties and losing VTE

CQUIN paym ents. A subsequent m eeting betw een th e Strategic Health A u th o rity and all

regional M edical Directors led to an ag reem en t fo r cohort exclusion fo r day surgery

patients on th e basis th a t th e y w e re a t low risk o f developing VTE. To im prove com pliance

fu rth e r, th e T l project te a m introduced a restriction th a t denied access to th e p atien t's

clinical profile on th e clinical results reporting system in cases w h e re th e VTE risk

assessment had not been com pleted w ithin 12 hours o f admission. In cases of

em ergencies or w h ere p atien t safety was param ount, permission to d e fe r a VTE risk

assessment fo r a fu rth e r tw o hours could be obtained and te m p o ra ry access g ran ted to 1 5 5

th e user to view th e clinical results reporting system in th e m ean tim e. This sanction was

rem arkably successful. W ith in tw o m onths o f im p lem en tatio n , th e clinical results

reporting system access blocking and exem ption o f day surgery admissions had im proved

CQUIN com pliance to th e required m inim um o f 90% .

In some areas, particularly surgicai specialties and obstetrics and gynaecology, provisions

w e re m ade fo r senior nurses began to p erform VTE risk assessments follow ing online

training and assessment. H ow ever, throm boprophylaxis prescription rem ained th e

responsibility o f doctors. T1ANP questioned th e effectiveness o f th e online training fo r

senior nurses w h o w e re carrying o u t VTE risk assessments.

I don't think it [online VTE training for nurses] was effective. It was almost like a task. I remember it being quite hard to work through, not that it was a difficult assessment, just not very user friendly. Those online assessments are sometimes like tick box exercises. How much that actually adds to the assessment being complied with, I really don't know. I don't think it adds much knowledge as to why it's important. I don't think the training itself added much to my knowledge... I can't even remember what was in that training... it just doesn't stick really

T1ANP

T1ANP argued th a t face to face VTE risk assessment training fo r assessors could have been

m ore effective.

Maybe if it was delivered in a group environment where you were being talked through it and you could ask questions, it stimulates discussion - those things could be so open to different interpretations - in a group setting, rather than being left to just doing it yourself.

Following recom m endations by th e VTE Exem plar Centre N etw o rk, in January 2011 th e

study Trust appointed a VTE Specialist Nurse (T ILeadN urse) to cham pion VTE prevention

at w ard level in collaboration w ith th e Trust's VTE Link Nurse N e tw o rk . The role o f th e VTE

link nurses was to cham pion VTE prevention in th e ir respective w ard areas. This initiative

was expected to increase VTE awareness and also im prove overall VTE com pliance across

th e study Trust. Additionally, T IL e a d N u rs e was also responsible fo r perfo rm in g VTE root

cause analysis w ith support fro m TILeadC onsultant as w ell as coordinating th e study

Trust's m an d ato ry training and th e Link Nurse N etw ork.

Although th e study Trust's VTE risk assessment figures continued to im prove, th e T l

project te a m reported variations in how T l was used in various clinical specialties across

th e Trust. For exam ple some th e a tre d ep artm en ts requested th a t VTE risk assessments

be com pleted before patients w e re transferred to th e a tre , although th e VTE guidelines

reco m m en d ed post-operative risk assessment instead (depending on th e p o st-o p erative

risks presented). In some cases, Advanced Nurse Practitioners (ANPs) w e re asked to

in itia te th e VTE risk assessments in p re -th e a tre o u tp a tie n t clinics to ensure th a t CQUIN

com pliance was m et. This initiative was also m ean t to m inim ise th e w o rkload fo r doctors

on th e day o f surgery. H ow ever, most interview ees (including th e T l project te a m leaders)

expressed concern th a t th e nurses could not prescribe throm boprophylaxis and in some

cases this resulted in patients not having th e ir Exnoxparin© doses because doctors

assumed th a t risk assessments had been com pleted. H ow ever, T IL e a d C o n s u lta n t noted

th a t his role was to facilitate and support o th e r clinicians to m e e t CQUIN com pliance

ra th e r th an dictate how th e y ran th e ir departm ents.

There are lots of ideas, for example, to block patients from theatre until the risk assessment has been done... The actual requirement is for post-operative

thromboprophylaxis, not preoperative [so] from a NICE compliance and thromboprophylaxis point of view, it doesn't make a difference. ... I am happy to support them [departments' compliance ideas], but ultimately, they are the ones who best understand their patients. I can't tell them how to do things. I only give them the minimum requirements, in a facilitative role.

T IL ead C o n su ltan t

H ow ever, these d iffe re n t interpretations had little effect on th e study Trust's m o n th ly

CQUIN com pliance, which rem ained above 90% . VTE prevention rem ained a key fe a tu re

o f th e study Trust's annual quality accounts since 2 0 1 0 , in line w ith NICE and th e

D e p a rtm e n t o f H ealth's recom m endations. By th e end o f 2 0 1 4 , T l had not required any

technical alterations ap art from m aintenance o f its clinical aspects, particularly additional

training, ensuring correct usage and addressing ad-hoc o perational issues, w hich w e re

largely undocum ented but said to be tim e consuming by T l project te a m leaders. A t th e

end of 2 0 1 2 , TILead C o n su ltan t presented a business case to th e Trust Board seeking

additional funding fo r an adm inistrator and a n o th e r VTE Specialist Nurse to ensure

adequate oversight o f all VTE-related operational issues. H ow ever, by th e end o f 2 0 1 4 ,

th e funding had not yet been approved despite th e increasingly dem anding w o rklo ad .