QAH HospitalPortsmouth Hospitals NHS Trust
Venous Thromboembolism
Patient Safety Study Day
Simon Freathy
QAH HospitalPortsmouth Hospitals NHS Trust
Session Objectives
Quiz What is VTE Impact of VTE Risks and Prevention How and what are we doing? Case studies
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VTE: Collective term for:
Deep vein thrombosis (DVT) Pulmonary Embolism (PE) Hospital acquired VTE a patient safety priority
What is VTE?
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Deep vein thrombosis (DVT) is a thrombus (blood clot) in a deep vein that partially or totally blocks the flow of blood
Pulmonary embolism (PE) is a clot that breaks off from the thrombus in the deep vein and moves to the pulmonary artery to block the blood supply in the lungs
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Also known as ‘The silent killer’
Between 10 - 25% of PEs are rapidly fatal: usually within 2 hours of the onset of symptoms
<50% of PEs are detected prior to death
80% of DVTs are clinically silent
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DVT & it’s complications
Pulmonary embolism (PE)
Death (due to PE)
Post-thrombotic syndrome
Recurrent DVT - 30% chance at 10 years
Pulmonary hypertension
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Formation of a DVT
Starts in the valve pockets of the veins and extends up and down blocking blood flow
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Formation of PE
Some of the clot can come loose and break off, travel through the venous system, through the heart and block a blood vessel in the lung
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Virchow’s Triad
Being treated as a hospital patient can do all of these things
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Signs and Symptoms of DVT
Calf swelling Pain in the calf, thigh or groin Engorged veins Redness and warmth to the skin Pitting oedema
But remember: up to 80% of DVTs are clinically silent
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Signs and Symptoms of PE
Shortness of breath Pleuritic chest pain Haemoptysis Tachycardia Hypoxia Fainting Collapse
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Community acquired thrombosis: CAT
Hospital acquired thrombosis: HAT
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Hospital-acquired Thrombosis
There are an estimated 60,000 deaths due to VTE in the UK every year, 65% are estimated to be hospital–acquired
Up to 25,000 preventable deaths a year in the UK due to HAT
10% of all hospital deaths are due to VTE
> 20 times greater than the number of deaths due to MRSA
More deaths than breast cancer, HIV/AIDS and road traffic accidents combined1
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Hospital-acquired Thrombosis
Can occur whilst the patients are inpatients, indeed they account for 10% of hospital deaths
BUT Majority occur AFTER discharge Average post-surgical DVT presents on day 7 Average post-surgical PE presents on day 21 Critical ‘at risk’ period – 3 months
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PREVENTION
Keep your patients as mobile as possible
Stop them from getting dehydrated
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Prevention
Anticoagulants for at risk patients Extended beyond discharge where appropriate
– THR, TKR, Hip #, abdominal or pelvic surgery for cancer, at risk day surgical patients
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Prevention
Consider anti-embolism stockings (AES) and compression devices where indicated
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Remember: no intervention is risk free – risk assessment is essential
Stockings can cause harm if used inappropriately, not fitted correctly and not monitored adequately
Trust policy and competency for use of AES
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Risk factors for VTE
Surgery Trauma Immobility
Malignancy Cancer therapy (hormonal, chemotherapy etc) Previous VTE Family history of VTE Increasing age Pregnancy and the postpartum period COCP or HRT
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Acute medical illness
Heart or respiratory failure
Inflammatory bowel disease
Nephrotic syndrome
Obesity
Varicose veins with phlebitis
Central venous catheter
Inherited or acquired thrombophilia
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VTE: National picture
NICE Guidance: Jan 2010: Venous thromboembolism: reducing the risk NICE VTE Quality Standard (CQC) New NHS White Paper / CQC NHS Operating Framework NHSLA - CNST CQUIN
– > 90% patients to have a VTE risk assessment on admission to hospital using the National Tool
– >92% compliant with appropriate prophylaxis Report on and carry out RCA on all HAT events
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NICE VTE Quality Standard June 2010
No Quality Statement
1 All Patients, on admission, receive an assessment of VTE and bleeding risk using the clinical risk assessment criteria described in the National tool
2 Patients / carers are offered verbal and written information on VTE prevention as part of the admission process
3 Patients provided with anti-embolism stockings have them fitted and monitored in accordance with NICE guidance
4 Patients are re-assessed within 24 hours of admission for risk of VTE and bleeding
5 Patients assessed to be at risk of VTE are offered prophylaxis in accordance with NICE guidance
6 Patients/carers are offered verbal and written information on VTE as part of their discharge process
7 Patients receive extended postoperative VTE prophylaxis in accordance with NICE guidance
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Entering patient related thrombosis risk (cont.)
Selecting Age > 60 (this can be auto-assessed from PAS)
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Entering admission related thrombosis risk
Selecting reduced mobility and a significant surgical procedure
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Risk summary and recommended treatment plan
Summary of patient assessment and recommended treatment plan
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Entering the intended treatment plan (cont.)
Entering LMWH and TED stockings
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Confirming VTE treatment prescribed (cont.)
Indicating ‘Patient refused’ mechanical prophylaxis
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VTE assessment % by CSC - 2011-13
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr-12 May-12 Jun-12
Surgery / Cancer
incl Day Surgery -
Head&Neck
MSK
MOPRs
Emergency
Women&Children
Medicine
Renal
PHT Reported
Year-to-Date
How are we doing?
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Report as adverse incident and carry out RCA on all cases of hospital-associated thrombosis (HAT)
Any DVT or PE diagnosed as an inpatient
Any DVT or PE diagnosed within 90 days of an admission
Weekly meeting with Senior Clinicians
Monthly meeting with Chief Nurse & Medical Director– ‘avoidable’ incidents
Data to be reported to DoH
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Jan – Dec 2011 : 194 events, 83 PEs and 111 DVTs
9
2
15
910
1314
8
11
4
76
8 8
12
4
0
17
109 9
6
12
0
2
4
6
8
10
12
14
16
18
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
DVT
PE
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HAT Events 2011 by CSC
35
22
34
14
18
14
810
6
10
64
25
2 2 1 10
5
10
15
20
25
30
35
MOPRS MSK MED SUR Cancer EmMED
W&C Renal HNU
DVT
PE
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Readmissions with HAT = potential loss of revenue
39
1511
96
42
0
5
10
15
20
25
30
35
40
MSK MED SURG Em Med MOPRS W&C Cancer
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Common Themes
1. Poor documentation of risk assessment (Vitalpac and paper)
2. Delayed or missed doses of chemical prophlyaxis (57% pharmacy audit)
3. Delayed recognition of DVT or PE
4. Lack of patient information provided
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5. Confusion over the concept of mobility and therefore insufficient provision of chemical prophylaxis
Significantly Reduced Mobility
‘patients who are bed bound, unable to walk unaided or likely to spend a substantial proportion of their day in bed or in a chair’.
NICE definition of mobility:
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6. Failure to consider mechanical prophylaxis when chemical prophylaxis is contraindicated (particularly in medicine)
7. Delayed reporting of VTE event
8. Renal doses
9. Failure to consider obesity doses of LMWH
Page 4904/18/23
Treatment doses: 200mg and 75 mgProphylaxis: Both 40mg?????
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Summary
VTE – major patient safety issue Majority of events can be prevented with appropriate risk assessment
and provision of prophylaxis
– Risk assess every patient on admission– Ensure that appropriate prophylaxis is prescribed and
administered correctly– Report all cases of HAT in a timely manner – Provide patient information
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Case study 1
57 year old man Admitted for a total hip replacement FBC, liver and renal function within normal limits No relevant medical history apart from osteoarthritis
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Which risk category does this patient fall under?
1. High risk of VTE and high risk of bleeding
2. High risk of VTE and low risk of bleeding
3. Low risk of VTE and high risk of bleeding
4. Low risk of VTE and low risk of bleeding
QAH HospitalPortsmouth Hospitals NHS Trust
Which risk category does this patient fall under?
1. High risk of VTE and high risk of bleeding
2. High risk of VTE and low risk of bleeding
3. Low risk of VTE and high risk of bleeding
4. Low risk of VTE and low risk of bleeding
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Treatment plan
1. Pharmacological and mechanical prophylaxis for duration of admission
2. Anti-embolism stockings only 3. Mechanical and pharmacological prophylaxis continued for
28-35 days post-op 4. Mechanical and pharmacological prophylaxis for 7 days post
op
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Treatment plan
1. Pharmacological and mechanical prophylaxis for duration of admission
2. Anti-embolism stockings only 3. Mechanical and pharmacological prophylaxis continued for
28-35 days post-op 4. Mechanical and pharmacological prophylaxis for 7 days post
op
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Case Study 2
70 year old female Admitted to MAU Ambulatory Service with cellulitis to upper
limb No reduction in mobility Inflammatory markers raised Platelet count, liver and renal function within normal limits
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Which risk category does this patient fall under
1. High risk of VTE and high risk of bleeding
2. High risk of VTE and low risk of bleeding
3. Low risk of VTE and high risk of bleeding
4. Low risk of VTE and low risk of bleeding
QAH HospitalPortsmouth Hospitals NHS Trust
Which risk category does this patient fall under?
1. High risk of VTE and high risk of bleeding
2. High risk of VTE and low risk of bleeding
3. Low risk of VTE and high risk of bleeding
4. Low risk of VTE and low risk of bleeding
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Treatment Plan
1. Anti-embolism stockings throughout admission
2. Enoxaparin (clexane) 40 mg daily throughout admission
3. No thromboprophylaxis required, encourage mobilisation and review VTE risk if clinical situation changes
Enoxaparin (clexane) 40mg daily and anti-embolism stockings throughout admission
QAH HospitalPortsmouth Hospitals NHS Trust
Treatment Plan
1. Anti-embolism stockings throughout admission
2. Enoxaparin (clexane) 40 mg daily throughout admission
3. No thromboprophylaxis required, encourage mobilisation and review VTE risk if clinical situation changes
Enoxaparin 40mg daily and anti-embolism stockings throughout admission
QAH HospitalPortsmouth Hospitals NHS Trust
Case Study 3
62 year old lady Elective admission for total abdominal hysterectomy for cancer Usually independent and active Platelet count and renal function normal
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Which risk category does this patient fall under once surgery completed?
1. High risk of VTE and high risk of bleeding
2. High risk of VTE and low risk of bleeding
3. Low risk of VTE and high risk of bleeding
4. Low risk of VTE and low risk of bleeding
QAH HospitalPortsmouth Hospitals NHS Trust
Which risk category does this patient fall under?
1. High risk of VTE and high risk of bleeding
2. High risk of VTE and low risk of bleeding
3. Low risk of VTE and high risk of bleeding
4. Low risk of VTE and low risk of bleeding
QAH HospitalPortsmouth Hospitals NHS Trust
Treatment plan
1. Pharmacological and mechanical prophylaxis for duration of admission
2. Anti-embolism stockings only 3. Mechanical and pharmacological prophylaxis continued for
28 days post-op 4. Mechanical and pharmacological prophylaxis for 7 days post
op
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Case Study 4
45 year old female BMI 35, on COCP, history of inflammatory bowel disease Admitted to ED with a non displaced ankle fracture Placed in a lower limb cast – non weight bearing Bloods within normal limits Discharged with planned Fracture Clinic Follow up
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POP Risk Assessment tool
What is this patients risk score?
What prophylaxis is indicated?
– None– Mechanical– Enoxaparin 40mg daily until plaster cast removed
QAH HospitalPortsmouth Hospitals NHS Trust
POP Risk Assessment tool
What is this patients risk score?
What prophylaxis is indicated?
– None– Mechanical– Enoxaparin 40mg daily until plaster cast removed