Summary

A reconfiguration of the Trust’s services in 2012 meant the introduction of ambulatory care pathways, including DVT and PE pathways. Staff developed a nurse-led multidisciplinary team approach to out-patient care for the assessment, diagnosis, treatment and follow-up care of DVT and PE.

Following the publication of NICE guidelines for venous thromboembolism the team identified areas of improvement, leading to the introduction of strategies for anticoagulant therapy choices, a virtual follow-up clinic and the development of information and educational resources. The team has successfully developed a one stop integrated DVT service that has reduced patient waiting times and ensured consistency and continuity of patient care.

Challenge

In 2012 a number of ambulatory care pathways were introduced to help reduce in-patient beds.  Rivaroxaban was introduced in 2013, to address the the need for frequent blood sampling and hospital visits.

The development of a review clinic (virtual ward) has allowed exploration of the connection between unprovoked VTE and underlying malignancy, offering patients timely investigations, an earlier diagnosis and treatment.

The absence of national training standards prompted the team to develop a robust training plan.

The establishment of the Trust thrombosis network and Kent Thrombosis Network  (pending) will improve communication, and encompass the focus of VTE prevention through to diagnosis and long-term management.

Objectives

Key objectives included the transferral of DVT services from A & E to ambulatory care, providing a clear management pathway focused on quality standards and patient choice, and implementing Rivaroxaban in accordance with NICE recommendations.

The project also aimed to provide a follow-up virtual clinic for practitioners to discuss patients and their treatment, to maintain and strengthen a patient-focused multidisciplinary collaborative approach, and to work with stakeholders, including partients, to produce patient-friendly materials.

Further objectives included the development of a central DVT training facility, engaging with patients to gather feedback, and helping community services develop a community-based DVT clinic. The final objective was to work with the National Nursing and Midwifery Network to facilitate a Kent Thrombosis Network.

Solution

The clinical lead for ambulatory care attended GP forums to discuss the new pathways and GP  referral model. In collaboration with GPs and pharmacists, Lucy Harling wrote the Patient Group Direction for Rivaroxaban. This was approved and implemented in 2013. The same year, the  unprovoked VTE pathway was introduced, supported by Emergency Care consultants who participated in twice-weekly virtual ward meetings with DVT clinic staff.

Trust-approved patient materials were developed, and an educational notice board for patients was place within ambulatory care itself. The DVT clinic provided VTE training for doctors.

The team is liaising with Whitstable community services to arrange educational sessions and develop service plans.  It is also working with Bayer to share ideas and best practice, and collaborating with Kings College Hospital to establish a network via the National Nursing and Midwifery Network.

Results

The project has resulted in the safe implementation of a DVT pathway as an ambulatory care pathway. Patient group directions have been safely and effectively ustilised to expedite patient care and reduce waiting times and appointments required.

Unprovoked VTE patients are followed up in virtual ward clinics meeting the 14 day cancer pathway. Patients are undergoing investigations for possible malignancies as outpatients.

Rivaroxaban is now an informed anticoagulation drug choice, supported by Trust-agreed drug record booklets.

Ambulatory care staff are actively involved in the DVT clinic, and the service has expanded to include Bakers cyst, thrombo-phlebitis, post thrombotic syndrome and cellulitis. Patients presenting with potential DVT are seen and scanned within 24 hours, and assessed and diagnosed within two hours.

Learnings

The team found that the approach to anticoagulation is continually evolving. The project left them feeling empowered to reshape healthcare, and to challenge and change practice to keep patients at the heart of decision making.

Being ‘patient facing’, they have had the opportunity to engage with patients and their thoughts, their real life concerns and practical issues surrounding anticoagulation.  Effective anticoaguation outcomes are not possible unless every patient is treated as an individual and their voice is heard.

Traditional role boudaries are becoming blurred and the role of the nurse is rapidly evolving, so it is vital to have local and national support networks to guide and support health careworkers.

Evaluation

The impact of the team’s approach to VTE has been measured by patient response to service, by means of feedback forms and suggestion boxes.  Statistics on patient diagnosis and treatment are compiled on a monthly basis and an annual VTE compliancy and monitoring report is produced.

Further information is provided by CQC feedback and input from drug representatives. The ROSE study ( Rivaroxaban observational, safety , evaluation), once complete, will provide additional input.