Finalists & Winners2017
In 2017, the inaugural award ceremony for the prestigious Anticoagulation Achievement Awards was hosted by Andrew Gwynne MP in the Terrace Pavilion, House of Commons on Wednesday 11 October 2017.
The awards were presented by:
- Andrew Gwynne MP
- Sir David Amess MP
- Kavita Oberoi OBE
- Helen Williams
- Baroness Walmsley
- Lynn Faulds Wood
Best Comprehensive Thrombosis Management Centre
Staffordshire Thrombosis and Anticoagulation Centre (STAC) University Hospitals of North Midlands, Stoke on Trent
Staffordshire Thrombosis and Anticoagulation Centre (STAC) provides a full range of DVT prevention, diagnosis, treatment and follow-up service through a multi-disciplinary team based at Royal Stoke University Hospital.
Serving a population of over 700,000 people in Stoke-on-Trent, Stafford and surrounding areas our services include, same-day walk-in DVT diagnosis, Counselling and anticoagulation induction of nearly 400 new patients every year, inpatient anticoagulation, outpatient follow-up and monitoring of over 8000 patients via STAC centre, 37 community clinics, 14 affiliate GP centres.
Specialised anticoagulation nurses completed comprehen-sive annual follow-up of over 6,500 patients via telephone clinics last year, ensuring all patients were reviewed at least once, in line with national recommendations.
A weekly thrombosis MDT for complex patients and provid-ing leadership and support to highly successful hospital VTE prevention team are other successes. STAC provides a dedicated telephone help-line for patients and a web-based advice line for GP’s and hospital doctors managed by thrombosis consultants.
DOAC clinics, Peri-operative clinic and a dedicated clinical governance team for adverse event monitoring, reporting and investigation are also provided within the set-up. An active audit programme with several presentations in national and international meetings have been other highlights.
Patient feedback (April 2017) confirmed a very high level of satisfaction (98%) from over 300 respondents. External benchmarking confirmed an above average overall TTIR (>70%) and STAC achieved all Key performance indicators in the last 12 months.
GP Care NHS Community DVT Service Bristol
GP Care Ltd has been providing a comprehensive Community DVT Service for NHS patients living in the Bristol and South Gloucestershire area for the last 9 years. By moving the service out of secondary care and into primary care, our aim has always been to improve the patient’s overall experience as well as to deliver significant savings to local NHS commissioners.
There are three distinct phases to the service:
Phase 1: In line with NICE guidance, referring GP uses the Wells score and near patient D-dimer testing to assess the clinical probability of DVT.
Phase 2: Where probability of DVT is high, patient receives a guaranteed same or next day Ultrasound scan at one of four anticoagulation clinics.
Phase 3: Where DVT is confirmed, patient attends for anticoagulation therapy at a local primary care Treatment Centre. The patient’s GP receives a full record of treatment and a management plan on the day of discharge.
Since July 2012, following NICE approval of DOACs as an anticoagulant for patients with DVT, GP Care have developed safe alternative pathways to warfarin pathway.
The service delivers Innovation with:
- Community locations close to patient’s homes, choice of treatment
- Primary and secondary care partnership, integrated protocols and patient administration systems. Concentrated expertise at our community based treatment centres providing a specialist, local service
- Information, guidance and training programs, delivered to primary care and other professionals
- Patient support group offering peer support and information on management and prevention
- Training of nurses to undertake diagnosis through ultrasound scanning
Best written advice on anticoagulation therapy for patients and carers
Great Eccleston Heath Centre - Preston
Great Eccleston Health Centre is a rural GP Surgery in the North West of England. It has provided anticoagulant monitoring for its patients for the last 10 years. As many patients, living remotely, find it difficult to attend hospital clinics, they welcome their monitoring being closer to home. Our annual patient satisfaction audit shows high levels of satisfaction.
The service enables a close support network from our nurses and doctors in providing the care and advice patients need. With more patients on long term warfarin, we have increased our clinics from once to twice a week, allowing increased flexibility for the patients but also tighter monitoring of newly initiated patients or those outside of the therapeutic range. Clinics are run by experienced nurses using INR Star which is amongst the leading software for anticoagulation management, with GP support available during clinic times, enabling us to remain safe and effective.
However, in 2016, a patient received severe facial bruising after dental treatment, and was found to have a raised INR in a subsequent routine clinic visit. We raised this as a significant event with the dental surgery, and reviewed our own information-giving policy. It was felt that, while patients are given verbal safety information at initiation and at other points in their treatment, they don’t always recall this later on, and many patients are on warfarin for many years. An information leaflet was produced, and all patients now keep this in their yellow monitoring books for easy reference.
Wessex Academic Scientific Health Network Starting Anticoagulation with Jack
Anticoagulants are prescribed to prevent harmful blood clots that can lead to stroke. They are designed to prevent or treat clots, but can increase the risk of bleeding. Recognising the need for better information for patients and carers, based on patients’ experiences, the idea for Jack came to light.
Our new video, 'Starting Anticoagulation with Jack' has been developed to meet this need for patients, their family and carers after anticoagulants have been prescribed. It explains about clotting and why abnormal clots can form as people age. The different types of medicines are shown, and Jack and his son talk about Jack’s concerns, side effects and sources of support. It is supported by a Patient Information Leaflet and also available in a format with subtitles.
The production of this film has been a collaborative piece of work bridging primary and secondary care, industry and has included patient charities throughout production so that the patient remains the focus of the work. The AHSN network and has been pivotal in supporting implementation in local practice.
How can Jack help you to support patients with counselling on anticoagulants?
The centre best able to demonstrate adherence to NICE Quality Standards for atrial fibrillation
Cardiff and Vale University Hospital Board – Stop a Stroke
The Stop a Stroke project led by a clinical team supported by service improvement practitioner within Cardiff and Vale UHB set out to develop a model for providing Primary Care clinicians with the knowledge, skills and confidence to deliver anticoagulation reviews for patients with atrial fibrillation. The challenge was to provide a service in Primary Care usually associated with expertise found in Secondary Care.
The team used the pilot AF Audit Plus tool to identify patients who need a treatment review. During phase 1 of the project Plan, Do, Study, Act (PDSA) cycles were used in 4 GP clusters to test which interventions achieved the greatest impact on. In the model that has been developed, clinical members of the project team attend a GP cluster meeting to provide education on anticoagulation.
The Stop a Stroke webpage contains all guidance documents, FAQs, links to e-advice and patient information resources. These tools have been built based on the feedback from GPs, pharmacists and nurses in primary care.
The data suggest that 40% of AF patients within C&V who are not on the appropriate treatment can be anticoagulated. So far the number of AF patients on anticoagulation has increased by 209. The project has taken place in 4 out of 9 GP clusters in Cardiff and Vale and will expand to the remaining 5 in 2017. The learning from the Stop a Stroke project is being shared across Wales.
West of England Academic Health Science Network. Don’t Wait to Anticoagulate, preventing strokes amongst patients with atrial fibrillation
In collaboration with pharmaceutical giant Bayer and Gloucestershire Clinical Commissioning Group (CCG), the West of England AHSN planned, developed and delivered the Don’t Wait to Anticoagulate project (DWAC) to help prevent strokes amongst patients with atrial fibrillation (AF) by optimising medicines management in primary care.
Co-designed with a wide range of stakeholders, including NICE, patient representatives and clinical partners, DWAC offers a range of user-friendly resources for clinicians, pharmacists and patients to aid shared decision-making and to optimise anticoagulation for AF patients, supported by quality improvement (QI) and clinical skills training. This includes the website www.dontwaittoanticoagulate.com.
The project was rolled out to over 100 GP practices in the West country during three 12-week phases. Modelling of the changes in prescribed treatments during this period indicates that DWAC has potentially prevented 27 strokes amongst people with AF, representing an estimated saving of over £629,000.
Additionally, feedback from users confirms that the DWAC approach has led to improved patient care, increased confidence in shared decision-making, and improved working practices in AF care pathways through a multidisciplinary approach. There has been a strong shift in focus from “Why anticoagulate?” to “Why not anticoagulate?”
DWAC is enjoying widespread interest and national recognition, with the initiative currently being adopted and spread across the North West of England, Yorkshire and Humberside, Buckinghamshire and East Berkshire with a further 85 GP practices involved and many more engaged to start, plus further spread across the West.
Sandwell and West Birmingham Hospitals NHS Trust and Sandwell and West Birmingham(SWB) Clinical Commissioning Group(CCG) - Streamlining primary and secondary care management pathways for stroke prevention in atrial fibrillation: the simple ‘Birmingham 3 step’ approach
NICE guidelines on AF (2014) advised against aspirin for stroke prevention, advocating oral anticoagulation (OAC) for all AF patients with ≥1 stroke risk factors. In line with NICE guidance CG 180 2014, OAC rates should be at 85%, with an exception rate of 15%.
Sandwell and West Birmingham Clinical Commissioning Group (SWBCCG) data from the Quality Management and Analysis System in 2014 reported AF prevalence lower than the national average (0.98% vs. 1.46%), suggesting under-detection of AF. Of these, only 65.9% were taking OAC, 15.6% received no therapy, with the remainder receiving antiplatelet therapy.
Brief outline of service
Dr Sarwar (SWBCCG) and Prof Lip (Sandwell and West Birmingham Hospital) have led a collaborative programme of simplifying and streamlining the patient management pathways, through upskilling AF half day workshops, to increase awareness, improve detection, simplify the OAC decision-making process and optimise OAC treatments.
Care pathway or treatment
The ‘Birmingham 3-step approach’ was cascaded to the GP practices at the training/upskilling events to increase awareness and to facilitate pragmatic-prescribing of OAC.
Results and conclusions
Implications for patient/service benefit
The intuitive approach with the ‘Birmingham 3 step’ approach has had a cumulative, dynamic effect on primary care in our region. This has facilitated collaborative working with Trusts and reinforced at grass root levels of dealing with inequalities in this important cohort of patients. Plans in place are to roll out the programme to other CCGs in the region.
Best work in the prevention of hospital acquired thrombosis (HAT)
Plymouth Hospitals NHS Trust - Using Radiology records and real time clinician feedback to reduce hospital acquired thrombosis
In 2010, following NICE guidance on reducing hospital acquired thrombosis (HAT), outcome data on this was initiated locally. Radiology records continue to be used to review targeted scans: V/Q SPECT, CTPA and Doppler ultrasound. Positive events are matched against the hospital management system to ensure HAT criteria, fulfilled. Root cause analysis on HAT events is completed ensuring: whether risk assessment took place, what prophylaxis given, if this was appropriate and whether other errors or omissions around VTE prevention were identified.
For HAT events associated with inadequate thromboprophylaxis (TP), the responsible discharging team are to review and feedback about the episode. For other cases of HAT, a standard letter is sent to the discharging Consultant, to inform them about the event in their patient.
In 2010 there were 2.09 HAT events per 1000 admissions and fifty associated with inadequate TP. By 2016 this had reduced to 1.47 HAT events per 1000 admissions with 9 cases of inadequate TP. Both statistically significant reductions. In addition, HAT events by admitting speciality as a fraction of patients admitted are identified annually. In 2010, this demonstrated neurosurgery as having the highest risk for HAT at 0.84% of all admissions. As a result, the VTE prevention team worked with the neurosurgeons to ensure post-operative reassessment of bleeding risk was undertaken and to increase the use of mechanical TP.
There appears to be little doubt that the combination of real time feedback and working closely with specialties is associated with a significantly reduced incidence of HAT.
Portsmouth Hospital NHS Trust, Department of Surgery, Surgery & Cancer Clinical Services Centre Patient Safety Up Award
An innovative idea by Mr Simon Toh, Portsmouth Hospital, led to a Patient Safety-Up Award in 2016 resulting in 2 live videos and 2 animations to improve compliance with best practice DVT prophylaxis. They can be accessed 24/7 on patients’ smartphones via a QR app or link.
Patients are sent home with a striking leaflet designed to be stuck to their fridge to remind them of their individual need for prophylaxis (with precise duration of self-injection of heparin or TEDS to wear) and QR code links to:
- Pre-operative measures to reduce risk of thrombosis
- Correct wearing of TED Stockings
- How to safely inject heparin
- What to look for to diagnose DVT or PEs
The video-animations have been carefully scripted by a clinical team under Mr.Simon Toh working in close collabora-tion with a media team from the University of Portsmouth under Toby Meredith.
We ensured they are understandable even to an 8-yr old; used nudge methodology with humour and characters that reflect the diversity of patients (Gary, Luke and Lucy). The remit was brevity & simplicity; to be effective rather than comprehensive. These videos are easy to update as advice changes unlike out-of-date paper copies (a green solution).
The initial feedback from patients has been very positive and we have rolled out the videos to all our patients and via the thrombosis network to other NHS Hospitals. Try this for yourself – scan this QR code on your phone or surf to: goo.gl/GXx21U and Lucy will show you how to inject heparin safely.
Abertawe Bro Morgannwg University Health Board (ABMUHB) - Nurse Led Thromboprophylaxis Re-Assessment Tool
English Hospital Trusts attached a CQUIN payment to Venous Thromboembolism (VTE) Risk Assessment (RA) to achieve a 95% uptake. Welsh Health Boards’ have no financial incentives.
Since 2012 a Nurse led Thromboprophylaxis (TP) Re-Assessment tool has been used on all wards in the Princess of Wales Hospital Bridgend. On admission Clinicians complete and document a Thromboprophylaxis Risk Assessment. Nurses hold the key in ensuring TP Re-Assessment takes place during the patient’s admission.
The tool has a 2 fold benefit:
- Nurses prompt clinicians to complete TP risk assessment improving number of patients risk assessed and treated appropriately.
- Ensures all patients are re-assessed daily or as their condition alters.
The TP Re- Assessment tool was added to the Welsh Care Metrics in 2013 as a tool to measure quality of care at ward level. Monthly indicators include:
- Number of patients risk assessed for VTE on admission
- Number of patients re-assessed for VTE during admission
Root Cause Analysis (RCA) is undertaken in all reported VTE’s in hospitalised patients, or within 90 days of discharge, case notes must confirm one or both of the following:
- A documented risk assessment
- Appropriate Thromboprophylaxis prescribed
Confirmed Hospital Acquired Thrombosis are reported to the admitting Consultant using the DATIX incident reporting system. This completes the investigation and provides feedback to improve future performance.
- Governance arrangements are overseen by unit quality and patients safety group
- Assurance arrangements overseen through monthly performance reviews and monthly Quality and Safety committee
- Data displayed on HAT dashboard
Since the implementation of the Nurse Led Thromboprophylaxis Re-Assessment Tool, we can now clearly demonstrate a consistent 85%+ uptake of TP RA and a consistent reduction of the number of HATs in the Princess of Wales hospital.
Best work in the prevention of cancer acquired thrombosis (CAT)
Hull & East Yorkshire Hospitals Trust (HEYHT) - Nurse led pathway for management of incidental pulmonary embolism/vte in cancer patients
In 2008 the applicants formed a working group to address the findings of an 18-month retrospective audit (August 2006 to January 2008) of cancer patients diagnosed with incidental pulmonary embolism (IPE), which found poor communication, a lack of standardised care and unnecessary often lengthy admissions, along with a lack of any documentation of assessment, treatment outcome and complications.
They developed a nurse-led service in accordance with the Medical Research Council (MRC) guidance to streamline diagnosis and assessment, and standardise management of IPE.
The service became operational in March 2010 and to date has managed upwards of 390 patients. It is evidence - and protocol (SOP)-driven and is evolving all the time as new evidence and data is collected. A multidisciplinary team (MDT) meets every 2 months to assess the management of patients, pathway integrity and safety, and implement new evidence.
The core elements of the service include a training programme for CNSs and radiographers that includes a training DVD and video, and is adaptable to any NHS Acute Oncology practice, with recent adoption by York University Hospitals and work ongoing with Coventry and NLAG as part of service improvement drives. We have also developed a Patient Information Leaflet and, as of 2016, the service has expanded to include out-of-hours and weekends. To date in HEY we have trained 4 specialist nurses, 6 nurse practitioners and 22 radiographers.
Our clinical material has recently evolved to capture patient reported outcomes and a patient survey has shown how much patients value the service.
Special Patient Nominated Award
Hull & East Yorkshire Hospitals Trust (HEYHT) - Nurse led pathway for management of incidental pulmonary embolism/vte in cancer patients
This prestigious award acknowledges the importance for healthcare providers to listen, discuss and involve the greatest stakeholder - the patient, in in the decision-making process.
Evidence is clear, managing anticoagulation, even more complex when alongside illness and long-term conditions, has far better outcomes when there is shared understanding, consideration of well-being and the prescribing of appropriate therapies.
The winner of this category has been personally nominated by a patient, and will receive an engraved crystal tribute in recognition of their work.