qah hospitalportsmouth hospitals nhs trust venous thromboembolism patient safety study day simon...

QAH HospitalPortsmouth Hospitals NHS Trust

Venous Thromboembolism

Patient Safety Study Day

Simon Freathy


Session Objectives

Quiz What is VTE Impact of VTE Risks and Prevention How and what are we doing? Case studies


Quiz

QAH HospitalPortsmouth Hospitals NHS Trust 04/18/23

VTE: Collective term for:

Deep vein thrombosis (DVT) Pulmonary Embolism (PE) Hospital acquired VTE a patient safety priority

What is VTE?


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


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


DVT & it’s complications

Pulmonary embolism (PE)

Death (due to PE)

Post-thrombotic syndrome

Recurrent DVT - 30% chance at 10 years

Pulmonary hypertension


Post thrombotic syndrome


Formation of a DVT

Starts in the valve pockets of the veins and extends up and down blocking blood flow


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


Virchow’s Triad

Being treated as a hospital patient can do all of these things


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


Signs and Symptoms of PE

Shortness of breath Pleuritic chest pain Haemoptysis Tachycardia Hypoxia Fainting Collapse


Community acquired thrombosis: CAT

Hospital acquired thrombosis: HAT


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


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


PREVENTION

Keep your patients as mobile as possible

Stop them from getting dehydrated


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


Prevention

Consider anti-embolism stockings (AES) and compression devices where indicated


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


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


Acute medical illness

Heart or respiratory failure

Inflammatory bowel disease

Nephrotic syndrome

Obesity

Varicose veins with phlebitis

Central venous catheter

Inherited or acquired thrombophilia

QAH HospitalPortsmouth Hospitals NHS Trust 04/18/23 Page 25

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


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


CQUIN: 2012 What is required?


Risk Assessment


Electronic risk assessment -VitalPAC


Entering patient related thrombosis risk (cont.)

Selecting Age > 60 (this can be auto-assessed from PAS)


Entering admission related thrombosis risk

Selecting reduced mobility and a significant surgical procedure


Entering patient related bleeding risk


Entering admission related bleeding risk


Risk summary and recommended treatment plan

Summary of patient assessment and recommended treatment plan


Entering the intended treatment plan (cont.)

Entering LMWH and TED stockings


Confirming VTE treatment prescribed (cont.)

Indicating ‘Patient refused’ mechanical prophylaxis


3


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?


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


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


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


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


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


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:


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

04/18/23

Treatment doses: 200mg and 75 mgProphylaxis: Both 40mg?????


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


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


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


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


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


Which risk category does this patient fall under






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


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


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


Which risk category does this patient fall under once surgery completed?






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


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


POP Risk Assessment tool

What is this patients risk score?

What prophylaxis is indicated?

– None– Mechanical– Enoxaparin 40mg daily until plaster cast removed


Thank you

Any Questions?

qah hospitalportsmouth hospitals nhs trust venous thromboembolism patient safety study day simon...

Documents

hrt slide

dehydrated slide

use of aes slide

vte impact of vte risks

hospital deaths

risk patients

risk day surgical patients

risk period