BC QUALITY FORUM CONFERENCE February 28 th 2013, Melanie Basso, RN, MSN, PNC(C)

1. Venous Thromboembolus (VTE) Prophylaxis: Using ImPROVE Methodology to Implement an Accreditation Canada Standard BC QUALITY FORUM CONFERENCE February 28th 2013, Melanie Basso, RN, MSN, PNC(C) Senior Practice Leader-Perinatal Dorothy Shaw, MBChB, FRCSC Vice President, Medical Affairs BC Women’s Hospital and Health Centre

2. Objectives Primary project objective: Ensure 100% of women who deliver at BCW, receive a VTE risk assessment Presentation objectives: Describe the use of ImPROVE - RPIW methodology to strengthen the implementation of a pre-existing protocol on Venous Thromboembolism (VTE) Prophylaxis Identify the interventions used to sustain this accreditation Canada standard Describe our lessons learned along the way

3. Disclosure Images of commercial products in the patient brochure are included as examples for illustration purposes and were obtained from “Google Images”. These pictures do not represent the products used or endorsed by BC Women’s Hospital and Health Centre, or by the presenters. Neither of the presenters has any disclosures of conflict of interest D. Shaw is a member of several Advisory groups for non-profit organizations, none related to this presentation

4. Background • BC Women’s Hospital has over 7000 births/ year • A lack of VTE prophylaxis protocol was identified as a Best Practice issue for our woman at risk. • In January 2011, we received the 2012 Accreditation Standards which included having a VTE Risk Prophylaxis protocol

5. BC Statistics • Between 1987-2004 there were 35 maternal deaths in BC • 51% of obstetric deaths in BC were potentially avoidable • 28% were related to blood clot issues • Developing a blood clots is a bad outcome. Patients are on blood thinners for extended periods of time if they get one and are always at an increased risk for additional clots in the future.

6. BC Women’s Statistics

9. RPIW Project Form Previously Linked RPIW #: • RPIW 47 & Project Name: VTE StandardizationRPIW Week (Date): April 30th – May 4th 2012 Sponsors: Heather Mash/Ruth Dueckman Process Owners: Pam O’Sullivan/Roane Preston Team Leader: Melanie Basso Sub-team Leader: Dorothy Shaw imPROVE Support: Lily Farris Content Experts:Nancy Kent (MFM), Henry Woo (OB), Peter Tsang (Hematology), June Yee (Pharmacy), Simon Massey (Anesthesia) Team Members/Dept. Team Members/Dept. 1. Lisa Scigliano (PP RN) 5. Caitlyn Atkinson (Birthing RN) 8. Thea Parkin (RM) 2. Cathy West (AP RN) 6. Sarah Saunders (OB Res) 9. Grace Dublanko (Quality) 3. Kathy Greenberg (FP) 7. Hanna Ezzat (OB) Current State (Cont.) • Assessment and Treatment: 75% of VTE risk assessment incomplete • Staff process: 64% of staff surveyed mentioned lack of clarity on when to provide fragmin doses • Patients: 0% of patients refused the VTE protocol, 0% of patients received written information on VTE Chart Audit: % of patients with risk assessment complete Chart Audit: % of patients who receive appropriate treatment Background Maternal mortality and morbidity found to be associated in BC with a lack of prophylaxis protocol in place. Guidelines being implemented internationally/nationally/provincially and to meet RoP VSM Name, Date & Related Goal: Accreditation RoP VTE Problem statement: No assessment of risk or prevention of VTE post partum at BCW existed. Primary Objective 100% of women who deliver at BCW, receive a VTE risk assessment Key Measure % of women who deliver at BCW, receive a VTE risk assessment. Secondary Measure:% of women who are assessed as high or intermediate risk receive VTE protocol until discharged or reassessed. Countermeasures Developed provider information sheet including evidence and implementation details, Revised order forms to streamline process, and drafted a patient information sheet for VTE. Current State & Analysis Process Map What are the system requirements? Average of 19 women arriving to deliver at BCW (takt time) per day. Approximately 9 women will receive the VTE protocol Project Scope All women who deliver at BCW (or are transferred post delivery to BCW) Women with pre-existing history assessed as high risk Women with intermediate risk receive protocol Patient Delivers SVD Patient assessed for VTE Risk Patient receives VTE protocol until discharge Women with intermediate or high risk receive protocol TEDs applied to all women Patient Ready for Cesarean Patient Delivers Cesarean Patient assessed for VTE Risk Patient receives VTE protocol until discharge Sustainment Plan Audits: Chart audits Audit Leader: Melanie Basso imPROVE: improve@phsa.ca Revision Date: Oct 31, 2011

11. RPIW Plan: Goals for the week Audit and observe VTE process and develop kaizen Revise VTE orders and implement Review audit of oozy wounds and develop kaizen Draft, revise, and implement patient pamphlet Revise “Anticoagulant Chart” CV0700 Appendix C Review Second Trimester Induction orders, develop new process, draft new orders, implement new process Develop evidence reference and fact sheet (SHORT) Visual cue for Fragmin patients How do we make the standard obvious, self explanatory and mistake proof? How do we energize staff to have a “standard work” culture? Same practice for everyone Explore training communication to care team (MD, Nurse, etc.) and patient How do we make BCWs standard obvious to the providers? (regular staff and others)

12. Adapted from RCOG Green Top Guidelines

19. Provider Information (EXAMPLE) Background: VTE occurs in 0.5 – 3/1000 pregnancies.[1] Pulmonary embolism (PE), along with pre-eclampsia, is the number one cause of maternal death in Canada. Of the 1,054,828 live births in Canada between 1997 and 2000, there were 44 direct maternal deaths, 9 of these were the result of PE. This makes PE the leading potentially preventable cause of maternal mortality.[2] Review of BC women’s data from the past 8 years identified at least 18 postpartum inpatient thrombotic events equally divided between vaginal and c-section births. Of these, 11 were PEs. Even in low risk women, VTE is at least 5 times more common in pregnant than in non-pregnant women. The greatest increase in risk is in the postpartum period. (~22 fold) Multiple studies have been done to identify patients at greatest risk for VTE. One of the most consistently identified and strongest risk factors is emergency c-section, with a risk for VTE of 0.5% to 2%.[3] Many other patient factors can increase the risk further, hence the basis for stratifying patients into risk categories. [1] Sultan et al, British Journal of Hematology, 2011 [2] Health Canada. Special Report on Maternal Mortality and Severe Morbidity in Canada- Enhanced surveillance: The Path to Prevention. Ottawa: Minister of Public Works and Government Services Canada, 2004 [3] Jacobsen et al, Thrombosis Research, 2004

20. VTE Patient SurveyComments Patient 1- The nurse said the stockings are to keep the blood flowing; nurse said ‘you need stockings’; nurse said ‘If you walk more you can take off stockings’ Patient 2 – The nurse in delivery suite measured my legs and put on the stockings. She said that the stockings and medication would help me avoid blood clots so I said definitely Patient 3- When the nurse told me that the stockings and meds would prevent clots that made sense to me. I would like a short pamphlet -1 page of bullets on benefits, risks (if there are any). Don’t put it in the prenatal package because I won’t remember it, already too much information.

23. Workshop Summary So, what did we accomplish? We revised all the Prescriber Order Forms related to VTE Prophylaxis Protocol and embedded them in existing practices Developed Provider Information Sheets (evidence- based) Developed the Patient Information Sheet Drafted the education roll-out plan

25. Lessons Learned • Project implementation success is not guaranteed just because it is a “must do” • Need staff buy in –don’t just tell them what to do, they want to have evidence • Patients want answers too, and need resources created for them at the appropriate literacy level • Embedding practice change into existing processes, try not to create additional paper work • Audits keep you honest about how your project is going and identify areas for further development/strategy.

26. Questions Thank you Questions? Email: Melanie Basso mbasso@cw.bc.ca Dorothy Shaw dshaw@cw.bc.ca