Humphries Angela, Peden Carol, Jordan Lesley, Crowe Josephine, Peden Carol
Royal United Hospitals Bath, NHS Foundation Trust, United Kingdom.
BMJ Qual Improv Rep. 2016 Dec 20;5(1). doi: 10.1136/bmjquality.u210590.w4267. eCollection 2016.
A significant incidence of post-procedural deep vein thrombosis (DVT) and pulmonary embolus (PE) was identified in patients undergoing surgery at our hospital. Investigation showed an unreliable peri-operative process leading to patients receiving incorrect or missed venous thromboembolism (VTE) prophylaxis. The Trust had previously participated in a project funded by the Health Foundation using the "Safer Clinical Systems" methodology to assess, diagnose, appraise options, and implement interventions to improve a high risk medication pathway. We applied the methodology from that study to this cohort of patients demonstrating that the same approach could be applied in a different context. Interventions were linked to the greatest hazards and risks identified during the diagnostic phase. This showed that many surgical elective patients had no VTE risk assessment completed pre-operatively, leading to missed or delayed doses of VTE prophylaxis post-operatively. Collaborative work with stakeholders led to the development of a new process to ensure completion of the VTE risk assessment prior to surgery, which was implemented using the Model for Improvement methodology. The process was supported by the inclusion of a VTE check in the Sign Out element of the WHO Surgical Safety Checklist at the end of surgery, which also ensured that appropriate prophylaxis was prescribed. A standardised operation note including the post-operative VTE plan will be implemented in the near future. At the end of the project VTE risk assessments were completed for 100% of elective surgical patients on admission, compared with 40% in the baseline data. Baseline data also revealed that processes for chemical and mechanical prophylaxis were not reliable. Hospital wide interventions included standardisation of mechanical prophylaxis devices and anti-thromboembolic stockings (resulting in a cost saving of £52,000), and a Trust wide awareness and education programme. The education included increased emphasis on use of mechanical prophylaxis when chemical prophylaxis was contraindicated. VTE guidelines were also included in the existing junior Doctor guideline App. and a "CLOTS" anticoagulation webpage was developed and published on the hospital intranet. The improvement in VTE processes resulted in an 80% reduction in hospital associated thrombosis following surgery from 0.2% in January 2014 to 0.04% in December 2015 and a reduction in the number of all hospital associated VTE from a baseline median of 9 per month as of January 2014 to a median of 1 per month by December 2015.
在我院接受手术的患者中，术后深静脉血栓形成（DVT）和肺栓塞（PE）的发生率较高。调查显示，围手术期流程不可靠，导致患者接受不正确或遗漏的静脉血栓栓塞（VTE）预防措施。该信托基金此前参与了一项由健康基金会资助的项目，采用“更安全临床系统”方法来评估、诊断、评估选项并实施干预措施，以改善高风险用药途径。我们将该研究中的方法应用于这组患者，表明相同的方法可应用于不同的背景。干预措施与诊断阶段确定的最大危害和风险相关联。这表明许多择期手术患者术前未完成VTE风险评估，导致术后VTE预防用药遗漏或延迟。与利益相关者的合作促成了一个新流程的开发，以确保术前完成VTE风险评估，并使用改进模型方法实施该流程。该流程通过在手术结束时将VTE检查纳入世界卫生组织手术安全检查表的“交接”环节得到支持，这也确保了开具适当的预防措施。一份包括术后VTE计划的标准化手术记录将在不久的将来实施。项目结束时，100%的择期手术患者在入院时完成了VTE风险评估，而基线数据中的这一比例为40%。基线数据还显示，化学和机械预防措施的流程不可靠。全院范围的干预措施包括机械预防设备和抗血栓栓塞袜的标准化（节省成本52000英镑），以及全信托范围的提高认识和教育计划。教育内容包括在化学预防措施禁忌时，更加重视使用机械预防措施。VTE指南也纳入了现有的初级医生指南应用程序中，并在医院内部网上开发并发布了一个“CLOTS”抗凝网页。VTE流程的改进使术后医院相关血栓形成从2014年1月的0.2%降至2015年12月的0.04%，降幅达80%，所有医院相关VTE的数量从2014年1月的每月中位数9例降至2015年12月的每月中位数1例。
