Dr Thomas Lloyd F1 Dr Aman Hargehandewal Wrexham Maelor Hospital VTE Audit Dr Thomas Lloyd F1 Dr Aman Hargehandewal Wrexham Maelor Hospital

What is VTE? Collective term for deep vein thrombosis and pulmonary embolism. DVT is common but causes symptoms in 1/1000 a year in general population. PE often results from asymptomatic DVT- can be fatal, or if not can delay discharge and increase morbidity. Resolved DVT can cause post thrombotic complications (ulcers, swelling etc)

Guidelines NICE guidelines recommend every patient admitted to be hospital should be assessed for VTE prophylaxis. Patients should be reassessed at 24hrs, if their condition changes and before discharge. NICE guidelines state that all patients on admission should be assessed for risk of VTE. The guidelines go on to state to start mechanical VTE prophylaxis at admission and add pharmacological prophylaxis for those who it is not contraindicated (e.g. low risk of major bleeding).

There is an existing VTE assessment protocol on the BCU intranet as part of the 1000lives programme (one for acute surgery shown)

Aims and standards Aims All patients should be assessed on admission to hospital to identify those who are at increased risk of venous thromboembolism (VTE) All patients should be assessed for risk of bleeding before offering pharmacological VTE prophylaxis The risks of bleeding and VTE should be reassessed within 24 hours of admission. Data Will assess drug charts for completion of requirement and prescription of VTE prophylaxis on all patients on Fleming, Lister and SAU wards Will include medical and surgical patients Will compare on call surgical patients to surgical and medical inpatients Will not include reviewing of patient notes

Data Data collected from Lister, SAU and Fleming wards Empty or unoccupied beds were those where the bed had been vacated or the patient had been taken to theatre at time of data collection. 11 On call 6 Medical 53 Inpatient

Results

Results Therefore standards currently not being met

Prophylaxis prescribed as a percentage?

TEDs prescription

Further Results 1 patient was written up for teds and enoxaparin, but it had not been signed. 1 patient had TEDS and enoxaparin written on the front of their chart, but only enoxaparin prescribed None of the warfarinised patients (3) had mechanical VTE prophylaxis prescribed.

Conclusions Currently standards not being met. Not all patients are having VTE assessments completed on the front of their charts. Not all pts are being prescribed VTE. Patients may not be adequately being re-assessed for VTE prophylaxis Many patients who could have mechanical prophylaxis are not having it. Some patients are being given TEDS without prescription which could potentially be hazardous.

Limitations Audit only performed on one day- there may be variation in on-call team prescriptions Not all NICE recommended VTE audit points were covered during this audit This audit did not differentiate between elective and emergency surgical admissions amongst the surgical inpatients. Medical notes were not consulted as to reasoning for no prophylaxis- therefore it is difficult to assess whether absence of prophylaxis appropriate in some cases.

Recommendations Continuing staff education as to importance of VTE prophylaxis VTE assessment tool as part of drugs charts or as part of a surgical admission booklet As of April 2016, there is going to be a revision of the All Wales Drug Chart which will have a VTE prophylaxis assessment as part of the chart It is therefore recommended that this topic be re-audited following the adoption of this chart.

References National Institute for Health and Clinical Excellence. Venous thromboembolism: reducing the risk. Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. NICE clinical guideline 92.London: NICE publications, 2010. https://www.nice.org.uk/guidance/cg92 http://howis.wales.nhs.uk/sitesplus/documents/861/acute_surgical_intera ctive1.pdf (Acute surgical admission form 1000 lives) http://webarchive.nationalarchives.gov.uk/20130107105354/http://www. dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/doc uments/digitalasset/dh_113355.pdf (DoH VTE assessment guideline)