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www.england.nhs.uk
Implementing National
Clinical Reform:
The National VTE
Prevention Programme
in England
Roopen Arya &
Helen Morrison
The Quantum Leap, 9 September 2014
www.england.nhs.uk
Implementing National
Clinical Reform:
The National VTE
Prevention Programme
in England
Roopen Arya &
Helen Morrison
The Quantum Leap, 9 September 2014
www.england.nhs.uk
Setting the scene – rationale for VTE prevention
Devising a VTE prevention protocol
The national VTE prevention programme
Improving outcomes
Summary
Our Presentation:
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Venous Thromboembolism (VTE)
Deep vein thrombosis (DVT)
Pulmonary embolism (PE)
Presentation:
Acute VTE
Complications:
Post thrombotic syndrome
Pulmonary hypertension
Recurrent VTE
~10% mortality
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Burden of VTE
Population of UK, 2011
63 MILLION
Annual national VTE rate
63,000
VTE deaths
6,300
1/1000/year
10%
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Preventing VTE in hospitalised patients
• Hospitalised patients at high risk of VTE
• VTE leads to substantial cost, mortality and morbidity
• Effective, safe and cost-effective measures to prevent hospital-acquired VTE exist
• Prevention of VTE should be standard of care in hospitals
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Health Committee: Key themesFeb 2005
• Awareness
• National guidelines
• NICE guidelines
• Education
• Implementation
Risk assessment
Thrombosis Committees
Thrombosis Teams
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Identify at-risk patient
Counsel at-risk patient
Prescribethromboprophylaxis
VTE Prevention Pathway
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Ensuring quality in VTE prevention:
NICE Quality Standard for VTE Prevention (QS3)
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 VTE prophylaxis in
accordance with NICE guidance
6 Patients/carers are offered verbal and written information on VTE
prevention as part of the discharge process.
7 Patients are offered extended (post hospital) VTE prophylaxis in
accordance with NICE guidance
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Link Nurse/
MidwivesPatient
information
Thrombosis
team
Staff
education
RCA of
HAT cases
Electronic
VTEp
systems
Audit
programme
VTE
Prevention
Supportive
managers
Preventing VTE
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Patient information
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Electronic solutions: VTE risk assessment
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Electronic solutions: prescribing thromboprophylaxis
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Electronic solutions: real-time monitoring
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VTE prevention: Patient-centred care
• Risk assessed for VTE
• Patient information
• Care plan
• Suitable prophylaxis
• Mobilisation and physio
• Extended prophylaxis
• Advice on discharge
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The national VTE prevention
programme
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2004 2005 2006 2007 2008 2009 2010 2011
Adaptive strategy and consistent pressure
ensures VTE prevention is made a clinical priority
The Journey
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Timeline
Feb 2005: Health Select Committee Inquiry leads to establishment of an independent expert working group on VTE Prevention
Apr 2007: CMO announces national approach recommending risk assessment for all patients admitted to hospital
Nov 2007: VTE Exemplar Centres launched
Sep 2008: national risk assessment tool
Jun 2009: NHS Leadership Summit
2010: Focal point for change
Beginning of implementation phase of national programme
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Introduction of system measures
21
National clinical guidelines for reducing risk in hospitalised patients
National risk assessment tool updated in line with guidance
Mandatory collection of VTE risk assessment data
Introduction of financial incentive to encourage providers to focus on VTE prevention
VTE becomes first national CQUIN goal
Strengthening of commissioning arrangements in NHS standard contract
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VTE Prevention in the NHS
Quality Framework
22
Programme transferred to NHS England in April 2013: maintained a high profile
Although it is a theme that cuts across all Domains, VTE Indicator is in Domain 5 of NHS Outcomes Framework
Priority area for improvement in Patient Safety
VTE
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Programme governance
NHS England Board
Expert Groups VTE Board Expert Groups
Patient Safety Steering Group
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Priority work streams
Commissioning Education Outcomes
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Proportion of adult hospital admissions risked assessed for VTE
(Quarter 2 2010/11 to Quarter 2 2013/14, England)
Impact of CQUIN
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Clear vision
26
Important to extend the reach of the programme beyond hospitals
Whole system issue
VTE prevention should be seen as part of the necessary foundations of the provision of safe, high quality, effective patient care
High quality VTE prevention should underpin the commissioning of services across whole range of specialities – medical & surgical
Education, education, education…….
Aim: to reduce avoidable death, disability and chronic ill-health
from hospital-associated VTE
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VTE Risk Assessment –
A National Quality Requirement
27
National Quality
Requirement
Threshold
(2014/15)
Method of Measurement
(2014/15)
Consequence of breach Monthly or annual
application of
consequence
Applicable
Service
Category
VTE risk assessment:
all inpatient Service
Users undergoing risk
assessment for VTE, as
defined in Contract
Technical Guidance
95% Review of monthly Service
Quality Performance
Report
Where the number of
breaches in the month
exceeds the tolerance
permitted by
the threshold, £200 in
respect of each excess
breach above that
threshold
Monthly Acute
2014/15 NHS Standard Contract Particulars, Schedule 4B (p48)
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Contract Service Conditions for VTE
28
2014/15 NHS Standard Contract Service Conditions: Records & Reporting, SC20 (p16)
SC20 Venous Thromboembolism 20.1 The Provider must: 20.1.1 comply with Guidance (including NICE Guidance) in relation to venous thromboembolism; 20.1.2 perform Root Cause Analysis of all confirmed cases of pulmonary embolism and deep vein thrombosis acquired by Service Users while in hospital (both arising during a current hospital stay and where there is a history of hospital admission within the last 3 months, but not in respect of Service Users admitted to hospital with a confirmed venous thromboembolism but no history of an admission to hospital within the previous 3 months); and 20.1.3 if required by the Co-ordinating Commissioner, perform local audits of Service Users’ risk of venous thromboembolism and of the percentage of Service Users assessed for venous thromboembolism who receive the appropriate prophylaxis, and the Provider must report the results of those Root Cause Analyses and audits to the Co -ordinating Commissioner on request. There is a specific requirement in the Reporting Requirements (Schedule 6B of the Particulars) for the provider to report “the outcome of all Root Cause Analyses and audits performed pursuant to Service Condition 20 (Venous Thromboembolism)”.
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Best Practice
29
NICE Quality Standard for VTE Prevention (QS3)
Use measures in contract service specs to set KPIs to drive up quality & improvement
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The National VTE Exemplar Centres network
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The National VTE Exemplar Centres network
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Our website: a central resource of
information
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Patient empowerment
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Education
Currently working with HEE on 3 more e-learning modules:
Primary care
Commissioning
Undergraduate Education
Implementing change
Changing practiceChanging
systems
Changing culture
Making VTE a priority
Working to a national model
Changing the cultural landscape
Strategic leadership of change
Operational leadership of change
Changing culture for healthcare professionals
Changing culture through training
System for recording information
Managing change
Establishing an implementation
Team
Education & training to support
systems change
System feedback
New processes
Comprehensive practice guidance
Named lead
Support for changing practice
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The results of our programme…
Improving
Outcomes
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Identify at-risk patient
Counsel at-risk patient
Prescribethromboprophylaxis
VTE PREVENTION PATHWAY
Hospital-associated Thrombosis
Bleeding
Process
Measures
Outcome
Measures
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Process measures: AUDIT
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VTE Prevention Audit
Sept’11 Feb’12 Sept’12 Feb’13 Sept ‘13
Sample
Size
530 patients 476 patients 553 patients 452 patients 515 patients
Clinicians 27 23 35 25 25
Wards/
Units
21 20 29 25 29
CCTD 32 patients 25 patients 15 patients 15 patients 25 patients
LRS 176 patients 25 patients 211 patients 171 patients 145 patients
NS 91 patients 83 patients 130 patients 112 patients 161 patients
TEAM 201 patients 145 patients 147 patients 120 patients 138 patients
W&C 30 patients 40 patients 50 patients 34 patients 46 patients
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Findings: Standard 1
96 93 96 96 100
84
98
73
98 98 99 10099 100 99 100 98 100
0
20
40
60
80
100
KCH Critical Care LRS NS TEAM Womens
%
Sept'12 Feb-13 Sep-13
Patients risk assessed
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Findings: Standard 4
Was pharmacological or mechanical TP correct? Sept 2013
90 88 8493 92 9694 100
8898 96
85
0
20
40
60
80
100
KCH CriticalCare
LRS NS TEAM Womens
Appropriate Chemical Appropriate Mechanical
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Determining outcomes:Hospital episode statistics VTE rates
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National VTE mortality data
England
Year VTE listed as
cause of death
2007 4,827
2008 4,862
2009 4,910
2010 4,971
2011 4,557
2012 4,663
Office for National Statistics, 2012
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Potential Lives Saved
2011 495
2012 449
Actual Mortality Rate vs
Predicted (%)
2011 90.63
2012 91.59
National VTE mortality data
England
Office for National Statistics, 2012
Catterick & Hunt 2014
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Patients >3 days hospital stay
0.5 1 2
Total Primary VTE related deaths 0.85 (0.75, 0.96; p=0.011: n=2213)
Total VTE related deaths 0.92 (0.85, 0.99; p=0.033: n=5985)
Primary VTE related inhospital deaths 0.86 (0.74, 1.01; p=0.061: n=1318)
VTE related inhospital deaths 0.92 (0.84, 1.00; p=0.057: n=4334)
Primary VTE Deaths at 90 days 0.81 (0.67, 0.97; p=0.026: n=895)
VTE related deaths at 90 days 0.91 (0.79, 1.05; p=0.196: n=1651)
VTE related Readmissions 1.04 (0.97, 1.11; p=0.301: n=8578)
Relative Risk (95% CI; p: n = events)
Reduction with Programme
Increase with Programme
*
*
*
www.england.nhs.uk Roberts et al – Chest 2013;144:1276
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Root cause analysis of cases of HAT
DVT/AC
clinic
Autopsies
DiagnosticsCoding
HAT
Thrombosis Team
Data collection
Notification
Learning
Trust Quality Framework
BereavementOther
hospitals
Admitting consultant
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• QI project at King’s College Hospital 2010-12
• Mandatory, documented VTE risk assessment,
thromboprophylaxis guidance, mandatory VTE education,
identification of hospital-acquired VTE with root cause analysis
VTE Prevention Programme Reduces
Hospital-Associated VTE
2010-11 2011-12 p
VTE risk assessment 63% (38-88) 93% (90-97)
HA-VTE 236
19.7/mo
189
15.8/mo
0.014
Inadequate prophylaxis
among HA-VTE
37% 21% 0.005
Anticoag prophylaxis in
high VTE/low bldg group
70% 89% 0.001
Roberts et al - Chest 2013;144:1276; Geerts 2014
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Admission characteristics
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VTE characteristics
P=0.07
%
Fatal PE 90d mortality
% HAT presenting as PE Mortality associated with HAT
n 17 12 50 37
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Underlying root cause
%
P=0.005 P=0.031 P=0.063
P=0.49 P=0.14
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Mortality associated with HAT
• Most fatal PE in medical patients
• Post-op VTE: 6 deaths in 2010, 3 in 2011
• 9% medical HAT fatal, 4.7% surgical HAT
• Procedures: #NOF, abdominal hysterectomy,
Achilles tendon repair, glioma for biopsy,
Meningioma resection, prostatectomy, right
hernia repair, sleeve gastrectomy
• 90-day mortality: medical 26% vs surgical 15%
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When best practice fails:HAT due to thromboprophylaxis failure
• 43% HAT cases at King’s
• Medical 44%; Surgical 53%
• Median time to events 17d, so more common after
hospital discharge
• Mean number of risk factors higher
• Increased risk in subgroups of surgical patients
e.g. those with dehydration or prolonged abdominal
surgery
• In medical patients, increased age, dehydration and
cardiorespiratory disease associated with TP failure
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Summary
VTE prevention is a top clinical priority in hospitals in England
Comprehensive VTE prevention reduces preventable patient harm
• Improving VTE prevention methods
• VTE prevention outside of acute care
• Defining outcomes
• Sustaining good practice
Challenges remain:
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Thank you!
www.vteprevention-nhsengland.org.uk
www.england.nhs.uk
Implementing National
Clinical Reform:
The National VTE
Prevention Programme
in England
Roopen Arya &
Helen Morrison
The Quantum Leap, 9 September 2014