Challenges in implementing government-directed VTE guidance for medical patients: a mixed methods study

Abstract

BackgroundImplementing venous thromboembolism (VTE) risk assessment guidance on admission to hospital has proved difficult worldwide. In 2010, VTE risk assessment in English hospitals was linked to financial sanctions. This study investigated possible barriers and facilitators for VTE risk assessment in medical patients and evaluated the impact of local and national initiatives.SettingAcute Medical Unit in one English National Health Service university teaching hospital.MethodsThis was a mixed methods study; National Research Ethics Service approval was granted. Data were collected over four 1-week periods; November 2009 (1), January 2010 (2), April 2010 (3) and April 2011 (4). Case notes for all medical patients admitted during these periods were reviewed. Thirty-six staff were observed admitting 71 of these patients; 24 observed staff participated in a structured interview.Results876 case notes were reviewed. In total, 82.1% of patients had one or more VTE risk factors and 25.3% one or more bleeding risks. VTE risk assessment rose from a baseline of 6.9–19.6%, following local initiatives, and to 98.7% following financially sanctioned government targets. A similar increase in appropriate prescribing of prophylaxis was seen, but inappropriate prescribing also rose. No staff observed in period 1 conducted VTE risk assessment, risk-assessment forms were largely ignored or discarded during period 2; and electronic recording systems available during period 3 were not accessed. Few patients were asked any VTE-related questions in periods 1, 2 or 3.Interviewees’ actual knowledge of VTE risk was not related to perceived knowledge level. Eight of the 24 staff interviewed were aware of national policies or guidance: none had seen them. Principal barriers identified to risk assessment were: involvement of multiple staff in individual admissions; interruptions; lack of policy awareness; time pressure and complexity of tools.ConclusionsNational financial sanctions appear effective in implementing guidance, where other local measures have failed.

Annotation: Developing a national programme for VTE prevention

“…Whilst the audit spanned the implementation of mandatory VTE risk assessment reporting, the authors did not comment on this as a driver of improved risk assessment rates. A single centre retrospective study of 876 acute medical unit admissions from November 2009 to April 2011 reported a significant increase in risk assessment rates (from 6·9–19·6% to 98·7%) and appropriate thromboprophylaxis (49·7–92·6%) following the imposition of the financial penalty (Basey et al , ). Interestingly, local efforts to improve VTE prevention practice with the development of paper and, later, electronic risk assessments produced only modest increases in both VTE risk assessment and appropriate thromboprophylaxis prior to mandatory reporting of VTE risk assessment rates.…”