Knowledge Natter: Hypertension: Enhancing the identification and treatment of at-risk patients

RCVS Knowledge:
Welcome to this Knowledge Natter, by RCVS Knowledge. Here, we have friendly and informal discussions with our Knowledge Award champions, and those who are empowered by Quality
Improvement in their work. Whether you are a veterinary surgeon, veterinary nurse, receptionist or member of management, Quality Improvement will and can positively impact your everyday life. Listen and be inspired.

Lou Northway:
Hello everyone and welcome to this RCVS Knowledge Natter. My name is Lou Northway, Quality Improvement Clinical Lead here at RCVS Knowledge and today I’m talking to Lizzie
McLennan-Green from CVS about their award-winning quality improvement project. Welcome Lizzie.

Lizzie McLennan-Green:
Hello, thanks for having me.

Lou Northway:
You’re welcome and welcome back. This is not the first time you have been on our Knowledge Natters, is it?

Lizzie McLennan-Green:
It’s not, no. I think it was a couple of years ago now we were talking about ear cytology, which was, it was so much fun that I’m back, I’m back again.

Lou Northway:
You’re back. So, what are we going to be talking about today, Lizzie? Tell us all about your project.

Lizzie McLennan-Green:
So, this project was a project looking at how we could drive or improve the care of and identification of cats with hypertension within our practices. And obviously we have quite a number of practices. So, it was an opportunity for lots of sites to get involved all at the same time and support each other in finding ways that worked well for them.

Lou Northway:
And how as a group did you decide that this would be a good sort of topic area to have a look at?

Lizzie McLennan-Green:
As a group, we actually run quite a lot of projects each year and we sort of operate it on a, I don’t know if the best analogy, maybe sort of a library system.

So, I think the year that this project ran, I think we actually had nine separate projects running and each practice then is
able to pick and choose as to what they think might work for them. The topics that were put into the library on the sort of projects that were developed, came off the back of really a
widespread discussion amongst the clinical lead team as to what were common themes that were coming up.

So, alongside hypertension, we also have projects around other types of imaging, dental radiography, ophthalmology. We’ve got projects related to diabetes; projects related to brachycephalic patients. So, there’s a really wide variety, but the year this project came into being, it was by far and away the most popular project.

So, I think that says a lot about people’s enthusiasm for hypertension in general, but specifically hypertension in cats.

Lou Northway:
Amazing. I really like that, that you have so many different sort of projects on the go and teams can focus on an area that’s important to them or their practice more specifically. So, in the
end, Lizzie, there was quite a lot of practices that chose this as a topic. Could we find out a little bit more about that?

Lizzie McLennan-Green:
Yeah, so I think in total, I think we had 105 practices that took it up as a primary project. And then I think we probably had somewhere in the middle of about another 40 to 50 practices
that decided to engage with it as a secondary project.

Now, each of those practices went about it in a slightly different way. So, the way the project works is that we started at the beginning and there was a framework for them to work around
which was really sort of what you know. Asking the practice to think about what it is that they hope to get out of taking part. Where they asked them to look at where they were starting from, and then also asked them to work through what it was that they were planning on implementing, so that they could just settle that out at the beginning. We asked them to come up with a project hero and a project sidekick.

Now the project hero was nominally the person who was going to lead the charge within the practice and actually, the way the frameworks have been designed in theory that could be
anybody within the practice. Whoever felt the most up for the challenge.

And then to make sure that they weren’t sort of doing this all on their own, they were asked to find themselves a sidekick. And I think it came from ideas, we sort of quite like the sort of Batman and Robin analogy.

And you don’t have to have one sidekick and there doesn’t have to be one hero, but you know, normally at least one of each is good.

Lou Northway:
Love that. Brilliant. Yeah, love it.

Lizzie McLennan-Green:
Sort of yeah, the Batman and Robin of the project, I guess.

Lou Northway:
The Batman and Robins in the practices then shared their pearls of wisdom with the team. Guys, this is what we’re doing, this is how we’re going to do it, these are the resources we have available.

What happened then? Was it smooth sailing or were there any sort of stumbling blocks or villains in the way?

Lizzie McLennan-Green:
These things are never, nothing’s ever quite as simple as it sounds, is it? You set everything out in a sort of, this is the road map, and this is how we’re going to do things. And then of
course, along the way, I think definitely different practices found their own sort of barriers that they had to overcome.

And I guess we adapted and changed the sort of resources that were, you know, available to practices to support with that. So, I think that the key things that spring to mind.

I have to thank Kate Allgood here for her amazing, absolute dogged determination to make sure that everything was absolutely, there, being adapted, changing and being agile to our needs. The key barriers that we came across with equipment, as you might imagine, availability of equipment, but then also working condition of equipment, technical skill in using that equipment and just familiarity with it. The age-old barrier that’s always time, time is something we’re all super short of and how do we fit that into everything else that’s going on in practice? And this project was running in sort of 2022 when it was a crazy busy time in practice.

And then I suppose in terms of other things, like confidence, sometimes always comes back to, you know, a little bit what do we charge for this and how do we make that work? You know,
and how do we balance that against our sort of will and want to do more of these things.  Then balance that against, you know, how do we fairly charge for the time involved.

Lou Northway:
Yeah, and in the consultations in practice, who was performing the hypertension sort of monitoring? Was it the nurses or was it the vets or was it a bit of both?

Lizzie McLennan-Green:
I think, if I’m being honest, it’s probably a bit of both. This project absolutely lends itself to being nurse-led, nurse-driven, and then long-term sustainable through our nursing teams
within practice. But I think it comes down to everybody’s got to have the confidence, the clinician confidence, whether you’re a vet or a nurse, is kind of key in terms of whether you’re
recommending blood pressure monitoring.

I think, whilst it’s definitely a nurse-led project, it required everybody within the practice to be 100% and on board, gain that experience and gain that technical knowledge so that they
could feel confident making their recommendations and doing that in a consistent way across the practice.

Lou Northway:
And you did a marketing campaign for pet owners as well, didn’t you? Looking at sort of encouraging them to monitor the signs of hypertension in their pets and that it may be something that’s looked at in the consult room. Did you find that owners were quite receptive to their pets having their blood pressure taken?

Lizzie McLennan-Green:
I think most owners, once you have the conversation about the benefits of blood pressure monitoring, and particularly, I think because it’s something that lends itself to being done in front of the owner, again, that comes down to clinician confidence.

But once you’ve got that confidence, it lends itself to something that’s done in front of the owner, the owner feels really involved in the process, and I actually think that can be really good from a vet-client bond trust.

Lou Northway:
Yeah.

Lizzie McLennan-Green:
Point of view as well, I think also a lot of clients are really interested in the number of clients. I mean, I don’t know how many clients you have said, but, that’s how you do that. I’ve no idea how you do that, that’s a bit tricky, isn’t it? Or, wow, cool.

So, you know, I’ve had clients who’ve wanted to, you know, put the headphones on and have a listen, have a, a little go themselves, and they think, do you know what?

Lou Northway:
Yeah, it is really nice, isn’t it? And I always find they’re really like, look at the little blood pressure cuff. It’s just like what we have. When we go to the doctors and you’re like, yeah, it literally is the same. Apart from the doctors don’t pat us and stroke us whilst we’re having our blood pressure taken, but hey-hey.

Lizzie McLennan-Green:
If the doctor’s got out the lucky licks for us, you know.

Lou Northway:
Yeah, maybe a bar of chocolate, who knows, maybe we could put that forward.

Lizzie McLennan-Green:
We’d be queuing up, wouldn’t we?

Lou Northway:
Absolutely. So, you rolled this out across the whole group, and you had teams that were sort of like, yes, this is our number one project. And you had teams that were like, this is not our
primary focus, but we’re still engaged. Even those teams had really good results as well, didn’t they?

Lizzie McLennan-Green:
They did and I think in a way sometimes, the fact that a practice chose to take on a secondary project, sometimes actually their engagement is on par or even above those that with one project because they’re really keen and they’re really pushing themselves. It’s a lot to fit in a clinical project and to really get your teeth into it and get under the bonnet and really, really drive that change in the practice.

To commit to doing two takes a really focused team. I think the nice thing as well is that they can be different champions and sidekicks as well. So different people are focusing on different
things. Actually, some of the projects complemented each other really, really well, which was good.

I think part of what we tried to achieve with the projects is trying not only to affect clinical change in those specific areas, but we’re trying to support teams to understand how you would
change other aspects of things that are within your practice.

So, you know, we talked a little bit about using the Contributive Factors checklist, our sort of work through which is, you sort of almost start with what is it you’re trying to achieve, and then considering as an individual person or as a practice, what are the contributory factors that are creating a challenge for you?

So, I don’t know in terms of hypertension, it might be caseload, might be the confidence we’ve already spoken about, it might be the equipment that we spoke about. And then breaking that
down into the next layers. And the thing is it’s going to be different for each practice, but breaking that down into, you know, caseload or how do we identify our cases, or how do we
make that consistent recommendation, and do we have enough technical knowledge, and do we have enough experience within the team. Then equipment wise, you know, what do we
need to adapt? Do we need new equipment, or is it just that we need to upgrade, or we just need to make it more available and easier to get at? Because sometimes that can be enough of a barrier in itself, and then that leads you on to the next step which is what resources do we actually need to engage with? And I think each practice having the opportunity to work through it on their own, but also to come together as a community.

Because that’s something we haven’t sort of touched on yet, is that all of these resources sit on a platform that we have, which everybody has access to. And there are discussion boards and
forums, meaning that people could share best sort of tips and tricks and, you know, support each other. This is not going so well, or that’s not going so well, or I’ve got this question, what’s
everybody doing about this? And it’s really nice to see the whole community sort of jump in and help each other.

Lou Northway:
I think that is a testament to its success really, isn’t it? That as you say, you’ve all learnt from how your teams are doing around you, but also then taking a closer look at what’s actually
going on in your own practice.

Because that was one thing that really stood out to me in the
application, was the use of the Contributee Factors Checklist to really sort of bring the team together to say, guys, this is what we’re going to do. But how is this going to work and what is
not going to work so well and how can we make it work better?
Then getting the buy-in then from everybody feeling that they’ve contributed. I think that’s just really, really valuable. It’s so impressive. And I have some statistics in front of me from
your application, which I thought I’d share because it really is, wow.

So, you guys managed to increase your blood pressure measurements 110% in your focus groups and increased by 79% in the non-focused groups. That’s how many more patients – 79% and 110% across the group – and that’s amazing. And of those, 34% of patients ended up requiring anti-hypertensive medication, which could have been missed obviously if we weren’t measuring it. So, it’s really, really impactful and lots of nephrons saved in the process.

Lizzie McLennan-Green:
Absolutely, I think it’s really interesting, isn’t it? It wasn’t something that we were particularly expecting to see, but the improvement and the group as a whole, if that makes sense, because we were talking about it.

So, even the groups that weren’t involved in the project directly, we saw an improvement there as well. And so, it just goes to show that just talking about things, just making resources available, I think is what’s also really important.

Lou Northway:
Yeah.

Lizzie McLennan-Green:
I probably need to mention is that all of the resources and all of the materials that were given to the project groups were actually open access to anybody. So, if your practice wasn’t doing a particular project, but you as an individual felt particularly strongly that you wanted to know more about something, all of that material was still available. And I think it’s really interesting to see how it spreads. And just talking about things and just giving things a little go does spread and creates change, which is amazing.

Lou Northway:
Yeah, it has a massive ripple effect, I think, doesn’t it really? You know, across your group, you started by saying just how many projects you’ve got underway at the moment, and they’re only going to increase in number. So, you know, it’s really, really impressive.

Lizzie McLennan-Green:
Wow, thanks.

Lou Northway:
So, Lizzy, what’s next? What’s next? What’s next on the agenda? Because this is the tip of the iceberg really, isn’t it?

Lizzie McLennan-Green:
It, is. I think, everything is about continual progression, isn’t it? You know, when we started back doing this, I think it was 2019, we did our first sort of, I don’t know, in inverted commas clinical project of this type. And we set about with one single standalone project that we sort of put out to everybody.

And we started to develop that over a few years and then we moved much more to this library sort of structure and giving a lot more choice.

And I think that choice is really helpful. But I think we’ve also learned that sense of community is also really important. So, this project, because there was the numbers involved in it, it felt like it gave a lot more as a project, if that makes sense, because we had so many people involved.

So, I think, you know, that’s something that going forward in the next year, we want to focus on is that sense of community that we create across groups. That’s sort of we’re all in it together, and we’re all trying to push forward together, if that makes sense. I think it is really inspiring for a lot of people. And I think sharing, sharing what we’ve learned, sharing where we’ve failed, where it’s not gone so well. If we put our hands up and saying, do you know what? Awesome. Great. But I gave it a go.

I think that really encourages people to just say, do you know what, I’m going to give it a go. Because the thing about everything is the getting started, isn’t it? And it’s OK that it’s not perfect. It’s OK if you thought, I tried that. Wasn’t quite that, wasn’t that great. But I gave it a go. And then I learned from that. And I did it again a bit differently. And it worked a bit better this time. And sharing.

Lou Northway:
Yes, it is.

Lizzie McLennan-Green:
Sharing I think is really, really key. I think it brings a lot to not only practice, but also for the colleagues working within these projects, I think it a lot as well.

Lou Northway:
Yes, yeah, especially on the communication front, doesn’t it as well? Like just including everybody and getting everybody’s insights and making them feel like they’re part of the team.
Yes, it’s so valuable.

Auditing does so much more than just giving you results. It just shapes everything. It’s the backbone of what we do. So yeah, magic.

Lizzie McLennan-Green:
And I think a lot of the projects that we’ve got are, they’re very clinical projects. And I think that’s brilliant. And they do to some extent involve every member of the team. But I think we
would like to start to branch out and bring some more projects in that genuinely, absolutely depend on every member of the team, if that makes sense. So that real sense of this is making
massive steps forward. But, you know, every massive step forward is built up of, you know, 10 little steps in the background.

Lou Northway:
Lots of little steps and shuffles and steps back and steps forward again inside.

Lovely. Well, thank you so much, Lizzie, for giving me 20 minutes of your time to tell us about the amazing project. I hope everyone’s feeling inspired. Lizzie’s and CVS’s Knowledge Award will be available to view online so you can have a closer
read of everything they have achieved and how they did everything.

All of our RCVS knowledge resources are available online, so please have a look at those and they will help you get started with your own QI projects in practice. Thank you so much, Lizzie.

Lizzie McLennan-Green:
Thank you, Lou.

RCVS Knowledge:
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