Venous Thromboembolism

1. Venous Thromboembolism Patient Safety Study Day Simon Freathy

2. Session Objectives • Quiz • What is VTE • Impact of VTE • Risks and Prevention • How and what are we doing? • Case studies

3. Quiz

4. VTE: Collective term for: Deep vein thrombosis (DVT) Pulmonary Embolism (PE) Hospital acquired VTE a patient safety priority What is VTE?

5. 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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8. 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

9. DVT & it’s complications Pulmonary embolism (PE) Death (due to PE) Post-thrombotic syndrome Recurrent DVT - 30% chance at 10 years Pulmonary hypertension

10. Post thrombotic syndrome

11. Formation of a DVT Starts in the valve pockets of the veins and extends up and down blocking blood flow

12. 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

13. Virchow’s Triad Being treated as a hospital patient can do all of these things

14. 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

15. Signs and Symptoms of PE • Shortness of breath • Pleuritic chest pain • Haemoptysis • Tachycardia • Hypoxia • Fainting • Collapse

16. Community acquired thrombosis: CAT Hospital acquired thrombosis: HAT

17. 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

18. 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

19. PREVENTION Keep your patients as mobile as possible Stop them from getting dehydrated

20. Prevention • Anticoagulants for at risk patients • Extended beyond discharge where appropriate • THR, TKR, Hip #, abdominal or pelvic surgery for cancer, atrisk day surgical patients

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

22. 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

23. 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

24. Acute medical illness Heart or respiratory failure Inflammatory bowel disease Nephrotic syndrome Obesity Varicose veins with phlebitis Central venous catheter Inherited or acquiredthrombophilia

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 Page 25

27. NICE VTE Quality Standard June 2010

28. CQUIN: 2012 What is required?

29. Risk Assessment

30. Electronic risk assessment -VitalPAC

31. Entering patient related thrombosis risk (cont.) Selecting Age > 60 (this can be auto-assessed from PAS)

32. Entering admission related thrombosis risk Selecting reduced mobility and a significant surgical procedure

33. Entering patient related bleeding risk

34. Entering admission related bleeding risk

35. Risk summary and recommended treatment plan Summary of patient assessment and recommended treatment plan

36. Entering the intended treatment plan (cont.) Entering LMWH and TED stockings

37. Confirming VTE treatment prescribed (cont.) Indicating ‘Patient refused’ mechanical prophylaxis

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41. How are we doing?

43. 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

44. Jan – Dec 2011 : 194 events, 83 PEs and 111 DVTs

45. HAT Events 2011 by CSC

46. Readmissions with HAT = potential loss of revenue

47. 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

48. 5. Confusion over the concept of mobility and therefore insufficient provision of chemical prophylaxis NICE definition of mobility:

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

50. 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