developing a systems-based approach to vte a uk perspective dr anita thomas obe, uk
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Developing a systems-based approach to VTE
a UK perspective
Dr Anita Thomas OBE, UK
Developing a systems-based approach to VTE
a UK perspective
Modern understanding of VTE
• Natural history • Methods of prevention and treatment
• Professor Vijay Kakkar NHS research in 1970-80s Medical Research Council
• Low dose low mol wt heparins global ‘gold standard’ treatment
Developing a systems-based approach to VTE
a UK perspective
Health CommitteeHealth Committee
Developing a systems-based approach to VTE
a UK perspective
2005 UK House of Commons Health Committee VTE Report
• Each year over 25,000 people in England die from venous thromboembolism (VTE) contracted in hospital
• More than combined total of deaths from breast cancer, AIDS and traffic
accidents, more than twenty-five times the number deaths from MRSA
• Figures alarmingly high. Many of these deaths are preventable
• Safe, efficacious and cost effective method of preventing venous
thrombosis – not as widely administered as should be
Developing a systems-based approach to VTE
a UK perspective
Developing a systems-based approach to VTE
a UK perspective
UK Government’s formal response to Health Committee
• Government agrees with Health Committee that much more needs to be done - too many preventable deaths from venous thromboembolism in hospitalised patients
• Health Committee’s estimate of 25,000 deaths a year due to VTE is a serious issue which requires rapid and comprehensive action
• Welcome advice and information Health Committee provided
Developing a systems-based approach to VTE
a UK perspective
• Recognise there is no systematic approach to identifying and treating those patients at risk from VTE in hospitals - significant room for improvement
• Not just people at risk from developing VTE in hospitals – need to ensure robust risk assessment but also consider people with existing VTE conditions
Bergan et al NEJM 355 488-498
Developing a systems-based approach to VTE
a UK perspective
Chief Medical Officer (CMO) England, Professor Sir Liam Donaldson established an independent expert working group
• consider how current best practice and guidance can be promoted and implemented
• what resources might be needed to support delivery of strategy through existing structures
• include consideration of need to promote or clarify existing guidance on use of
• mechanical devices (foot-pumps) • aspirin • other pharmacological preparations (heparin or other anti–Xa agent)
Developing a systems-based approach to VTE
a UK perspective
• The National Institute for Health and Clinical Excellence (NICE) working closely with CMO’s VTE Implementation Working Group
• NICE recently published guidelines on VTE for surgical inpatients in England and Wales - in 2009 are due to publish guidance for all hospitalised patients
• Suite of guidance will provide an important contribution to national VTE Strategy in England
Developing a systems-based approach to VTE
a UK perspective
VTE expert group considered best existing guidelines
for thromboprophylaxis
• All medical patients
• Intermediate-risk surgical patients
• Low risk surgical patients
Developing a systems-based approach to VTE
a UK perspective
Report of the VTE expert group published by the Chief
Medical Officer/Department of Health on 19 April 2007
Developing a systems-based approach to VTE
a UK perspective
CMO announcement
Every hospital patient must be assessed to prevent potentially fatal blood clots
Widespread media coverage across England
National newspapers The Times Guardian Daily Telegraph The SunNational online BBC.co.ukNational & regional broadcast BBC News 24 Sky News Radio Sky News BBC Radio 2 Heart 106 Specialist magazines BMJ, Hospital Doctor, The House, Health Services JournalRegional newspapers
National & Specialist Media Coverage
BBC News Online
19 April 07
The Times
20 April 07
The House Magazine 7 May 2007
The Daily
Telegraph
20 April 07
The Guardian 20 April 07
Developing a systems-based approach to VTE
a UK perspective
Key recommendations of the report
• A VTE risk assessment of every patient on admission to hospital in England
• Raising awareness and improving understanding of VTE by patients public and professionals
• Establishing exemplar centres to share best practice throughout the NHS and wider healthcare settings
Developing a systems-based approach to VTE
a UK perspective
Recommended effective preventative measures
• For medical patients, particularly those at increased risk, low dose heparins
• For intermediate surgical risk patients (or any surgical patients with concomitant medical conditions) low dose heparins and graduated stockings
• Low risk surgical patients do not require specific prophylaxis
• Aspirin is not recommended for medical patients or for intermediate and low-risk surgical patients
Developing a systems-based approach to VTE
a UK perspective
Government announces a national strategy for VTE
• June 2005 Government published response to Health Committee on the prevention of venous thromboembolism in hospitals
• Established an independent expert working group to make recommendations on developing a national strategy on the prevention and treatment of venous thromboembolism (VTE)
• Report and recommendations of the expert group presented to the CMO in July 2006
Developing a systems-based approach to VTE
a UK perspective
• It is clear from the expert group's report that introducing a VTE risk assessment for all patients on admission has the potential to save thousands of lives every year
• We have therefore established an implementation working group which will develop a national risk assessment tool, and will provide leadership both within the NHS and the wider healthcare sector to assess what needs to be done to ensure that a VTE risk assessment of every patient on admission to hospital becomes a reality
Developing a systems-based approach to VTE
a UK perspective
• Common• Silent• Difficult to predict • Preventable• High risk is identifiable• High cost of inaction
UK Government and CMO consider VTE a major patient issue
Developing a systems-based approach to VTE
a UK perspective
COMMON • 25,000 VTE hospital deaths; 50,000 hospital & community
in England • 1 in 5 medical patients develop VTE if no prophylaxis
• Around 1 in 4 of all VTE (hospital and community) occur in medical patients in hospital
Developing a systems-based approach to VTE
a UK perspective
SILENT
DIFFICULT TO PREDICT
• Less than 1 in 10 fatal pulmonary emboli diagnosed before death
Developing a systems-based approach to VTE
a UK perspective
AT RISK
Medical patients
¾ of all fatal PEs occur in patients admitted for non surgical reasons
Admission with acute medical illness increases risk x 8
Risk often unrecognised by clinicians
Immobility Older patients Chronic Disease
Risk profile similar to heart disease and stroke
Surgical patients
Immobility Individual risk Procedures
Developing a systems-based approach to VTE
a UK perspective
COSTLY
• Lives and long term illness of people of all ages
• Total cost of managing VTE around £640m (appx 936m Euros) in UK each year
• At least £68m (appx 100m Euros) paid or outstanding for litigation re VTE related conditions over last 10 years
Developing a systems-based approach to VTE
a UK perspective
National VTE Strategy in England
• September 2007 to end of 2009
• CMO’s VTE Implementation Working Group developing a national VTE risk assessment tool to be made available by Government to all hospitals (NHS and others)
Developing a systems-based approach to VTE
a UK perspective
• Hospitals in England risk assess all patients on admission by end of 2009
• Exemplar VTE sites (hospitals, Primary Care Trusts) promote best practice
• Current exemplar VTE hospitals Kings College Hospital London (NHS) and the London Clinic (Independent Sector)
• Information on national risk assessment tool and exemplar sites to be made available on Department of Health VTE web pages - www.dh.gov.uk/vte
Developing a systems-based approach to VTE
a UK perspective
• Encouraging high quality research and innovation within the NHS
• Providing leadership by working closely with key stakeholders including professional bodies and societies
Developing a systems-based approach to VTE
a UK perspective
• Catalyst for patients and patient representative organisations to influence VTE prevention at hospital level.
• VTE Implementation Working Group in England partnered with Plymouth Hospitals NHS Trust and the Thrombosis Research Institute, London
Developing a systems-based approach to VTE
a UK perspective
Patient admitted to hospital
Individual patient risk of VTE assessed
Professional workforce aware of VTE risks
Able to institute timely prophylaxis
Appropriate preventative strategy implemented
Evaluation of outcome
What will success look like?
Developing a systems-based approach to VTE
a UK perspective
Prevention of VTE is emerging as a major patient safety issue across Europe
• CMO for England’s VTE Implementation Working Group welcomes the opportunity to share our experience and learn from those of other European countries
• Developing and implementing a national strategy to reduce the many thousands of avoidable deaths from VTE in hospitalised patients
Developing a systems-based approach to VTE
a UK perspective
Dr Anita Thomas OBE, UK