RCEM national QIP finds EDs making significant improvements in assessing risk of blood clots in patients with lower leg injuries

22 July 2019

The Royal College of Emergency Medicine’s 2018/9 national quality improvement project (QIP) of Venous Thromboembolism (VTE) risk in lower limb immobilisation has found that Emergency Departments (EDs) have made significant progress against RCEM standards.

The QIP looked at the proportions of injured adult patients discharged from an ED with a leg plaster cast or boot. They were assessed for their risk of developing a blood clot as a complication of their leg immobilisation, received timely thromboprophylaxis and were given an appropriate patient information leaflet.

It was the first QIP of VTE risk since the clinical audit in 2015/16, with a total of 14,376 patients from 171 EDs having their documented care reviewed.

The key findings from the QIP include:

• The data showed significant improvement in the proportion of patients with a documented VTE risk assessment (43.7% vs 25.9% in the previous audit).
• There was also improvement in the proportion of patients provided with written information (20.9% vs 13.3% in the previous audit, with overall performance remaining low). But only around 15% of patients whose thromboprophylaxis was initiated in the ED received their first dose of medication before leaving the department.
• During the six-month data collection period (August 2018 – January 2019) improvements in performance were seen against all three standards.

The QIP also found that:

• Only 19% of EDs are using a tool of the type recommended by NICE.
• Of the remaining departments, 14% responded that no guideline or protocol was in place locally.

Dr Taj Hassan, President of the Royal College of Emergency Medicine said: “The commitment of Emergency Departments to engage in quality improvement is a source of great pride to us. We applaud the enthusiasm with which departments have embraced our new style of national clinical audit with integrated QIP methodology. RCEM recognises the pressurised environment most departments continue to work in and is keen to support their fantastic efforts by keeping this QIP open online for use locally whenever required.

“We encourage all departments to build upon the fantastic quality improvement successes shown in this report. For all three standards we have seen consistent national improvement over the six-month period, which is likely to be a testament to the engagement of local teams in quality improvement. However, there is still work to be done and departments should consider how they can make progress on the three recommendations, particularly if their data shows that this is a challenging area.

“We call on all EDs to introduce a NICE guideline compliant tool to assess VTE risk in ambulatory adult patients requiring leg immobilisation if they have not already done so.  Once a risk assessment tool is in place, patients assessed as needing thromboprophylaxis should have their initial dose of medication before leaving the ED.

Chair of the RCEM Quality Assurance and Improvement Sub-Committee, Dr Elizabeth Saunders said, “Providing patients with adequate information to allow them to truly take control of their care is highly important. Patients discharged from the ED with a leg immobilisation device should be given a patient information leaflet describing the increased risk of VTE and the importance of urgent medical attention if they experience signs that may indicate a clot.”

To improve the care of patients discharged from an ED with an immobilised leg, RCEM makes three key recommendations:

1. All EDs that have not already done so should introduce a NICE guideline NG 89-complaint tool for the assessment of VTE risk in ambulatory adult patients requiring leg immobilisation.
2. Patients discharged from the ED with a leg immobilisation device should routinely be provided with a patient information leaflet that outlines the increased risk of VTE and the need to seek urgent medical attention if they develop symptoms suggestive of a clot.
3. All patients in whom risk assessment reveals a need for thromboprophylaxis should have their initial dose of medication before leaving the ED.

-ENDS-

Notes to Editors
‘VTE Risk in Lower Limb Immobilisation 2018/19’ is one of three QIPs published by the Royal College of Emergency Medicine in July 2019.
The purpose of the QIP was to monitor documented care against the quality standards published by RCEM in July 2018, and to facilitate improved care using Quality Improvement (QI) methodology and weekly data feedback.
The College promotes QI methodology to encourage EDs to improve towards more consistent delivery of the quality standards, helping clinicians examine the work they do day-to-day, benchmark against their peers, and recognise excellence.
A total of 14,376 patients presenting to 171 Emergency Departments were included in this QIP.
This was the second time the topic had been run, and the first time the topic had been conducted using QI methodology.
If you have any queries about the report, please e-mail audit@rcem.ac.uk or phone 020 0674812.