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Award-winning service transforms care for people with suspected DVT

By using ultrasound in the community to confirm or exclude DVT, Jo Boyd and her team reduce patient risk and waiting times

A team of nurses has transformed the care of patients with possible deep vein thrombosis (DVT) by keeping them out of hospital and dramatically reducing the use of anticoagulants.

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Jo Boyd uses ultrasound to rule in or out deep vein thromboses. Picture: Chris Balcombe

The service is the first in the country in which a nurse practitioner uses ultrasound  in the community to confirm or exclude DVT among patients, thereby reducing risk and waiting times while saving money and improving care.

Team leader Jo Boyd, who undertakes ultrasound, says: ‘Our DVT service was facing lots of challenges.

‘The acute hospital could offer the team only four scans per day. There was a national shortage of qualified members of staff. But referrals came in peaks and troughs: one day there would be 25 and another two. We were always playing catch-up.’

Only 4% of patients with suspected DVT were receiving ultrasound within four hours of assessment and only 20% received one within 24 hours. Patients awaiting ultrasound were not only anxious, but needed daily anticoagulant injections, yet only 14% of these patients had DVT confirmed. In 2014, 1,476 patients received an average of three unnecessary doses.

Managing pressures

Jo decided to investigate how other services were managing the pressures but found most were in the same position. She says: ‘I have learnt not to assume that something is done the right way because it has always been done that way. So I looked to see if we, as nurses, could provide the service. I worked with our local hospital, which embraced our proposal. It has been a really good partnership. The support and mentorship has been vital to its success.’

Jo approached the University of the West of England outlining her plans and devised a nine-month master’s level sonography programme to ensure the appropriate training supported the service. She says: ‘We had to make sure that the standard of diagnostic accuracy we would be offering was directly comparable to the service we replaced.’

A portfolio of 280 supervised cases with a variety of diagnoses was completed before competency was agreed by the local hospital, a hospital in Bristol and the university. ‘I thought it was better to have two hospitals signing us off,’ says Jo.

The service has been a resounding success. ‘Our initiative has improved patient experience by streamlining the patient pathway and minimising anxiety by reducing time to diagnosis,’ says Jo. ‘Specialist nurse sonographers manage the complete patient episode – from assessment to diagnosis, then treatment and review –  in one location.

‘Our autonomous nurses can interpret their own scans and decide holistic individual treatment plans. 

Episodes of care

‘The episode of care is much quicker for patients. The original pathway required 90 minutes of clinic time divided into a minimum of two visits, but this has now halved. Patients were required to wait, often up to five hours, for blood results before leaving the department.

Now blood testing is reserved for the 14% of patients with confirmed DVTs.’

About 1,800 patients a year are seen by the service. They are usually referred by healthcare professionals, such as GPs, physiotherapists, pharmacists or community nurses, but they can also self refer through the urgent care walk-in centre.

Nurses go to patients’ homes to make an initial assessment if necessary. When diagnosed, patients are referred to secondary care for ongoing management.

‘Referrals are often for patients who are elderly, have limited mobility or live alone,’ explains Jo. ‘The implications of attending for several appointments can have a huge financial and practical impact.’

The team from the SEQOL specialist treatment centre in Swindon recently won the Superdrug sponsored Community Nursing category of the prestigious RCNi Nurse Awards. The judges were ‘amazed by the impact the service has had on patients and how much it reassures them without having to resort to anticoagulants’.

‘The team’s leader Jo Boyd is inspirational,’ they added.

Robust care

Because every patient receives an ultrasound, the service has been able to diagnose a range of other problems, such as Bakers Cysts, superficial vein thrombosis and venous insufficiency.

Jo says: ‘We have more capacity to bring patients back when previously we would not rescan. We can look holistically at patients, but also look at blood flow as an indicator of other issues.

‘A greater understanding of the pathogenesis of thrombosis has led to a more robust service, such as our new pathway for superficial vein thrombosis.’

The team provides health education and now has the time to address risk factors, such as obesity and smoking cessation, which improves long term health outcomes and quality of life. 

Clinical audit of 10 per cent of the unit’s work monitors both performance and patient outcome.

‘Our audit is the best evidence of the positive changes we have made,’ says Jo. ‘Previously only 20% of our patients received a scan within 24 hours and 4% at initial consultation- these figures are now 97% and 94% respectively. However, 99.8% of patients referred between 8am - 6pm Monday to Friday were offered a scan within 4 hours.

Feedback

Patient's written feedback is consistently positive, often praising the efficiency and professionalism of the service and the friendly and caring nature of the nursing.

When patients were asked: ‘What is good about the service?’ The replies included ‘excellent attitude from staff’, ‘very professional, dedicated, caring, friendly staff’, ‘putting me at ease’, ‘I can’t thank the staff enough for saving my life by talking me into going to hospital’, ‘thanks for arranging a lift home’, ‘convenient’ and ‘much better than at the hospital’.

Jo adds that the team is keeping its patients out of hospital and using a tiny amount of anticoagulants.

The team is now turning its attention to the 85%-90% of patients who attend with red, swollen legs, but who have DVT excluded by their ultrasound scan. The team is writing a business plan to extend its service to include differential diagnoses, such as active lipodermatosclerosis, venous disease and cellulitis.

‘We also hope to use the ultrasound machine to insert PICC lines in the community,’ says Jo. ‘Expanding the nursing role to include ultrasound diagnosis has been enlightening and empowering, and a real delight. It showcases the ability of contemporary nursing to evolve.’

The team’s manager and nurse Sue Jones, SEQOL’s Business Partner Community Services, says: ‘These nurses have carried out genuinely pioneering work in diagnosing DVT that speeds up treatment for patients and gives them a better service.

‘Jo took the initiative to become the first nurse in the country to be trained as a deep vein thrombosis sonographer, and has since shared her expertise with her team so that we can offer a service that is second-to-none for patients who need to be screened for DVT. The team’s ingenuity and commitment is helping so many people.’

The impact on patient experience has been huge and has led to significant savings of about £130,000 per year.

The Community Nursing award finalists

Advancing Intravenous Antibiotics in the Community team, Wirral Community NHS Trust

Previously at Wirral Community NHS Trust, two nurses had to visit patients receiving IV antibiotics to check calculations. Team leaders Annie Baker and Mary Lyden-Rodgers examined whether the procedure could be undertaken safely by one nurse, then embedded the change into practice. They reviewed a timed bolus route, which has halved the time of an administration, releasing nurses’ time to care and improving patient experience.

Donna Rowe, East Bradford Medical Centre and Rushcliffe CCG

Donna developed a fracture liaison service to improve the care of people with osteoporosis, identify patients at risk or struggling with traditional treatments, and deliver IV biphosophates as a first-line treatment. She has written guidelines, built links with physiotherapists and the falls team, and reviewed 7,000 patients’ notes to identify people who could benefit from her service.

Erika Frohlick, CSH Surrey

Erika’s workshops have supported 400 stroke survivors and their relatives following discharge. Participants influence the agenda by sharing experiences relating to mobility, diet and nutrition, speech and continence. Sessions cover occupational therapy, depression and fatigue. She encourages peer support, and relatives and friends are invited. An evaluation shows that 93% of participants have found the sessions ‘very useful’.

Clinical Training Team, Bupa Home Healthcare

This team’s training programme has improved practice in a UK-wide team of 250 nurses. Clinical training managers Jo Camp and Amy Smith introduced trainers to promote best practice, devising more than 50 competency documents and standard operating procedures. Trainers regularly join nurses on patient visits and new starters have a four-day induction. Patients have reported better care and nurses say they feel more supported.

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