Coagulation Screening In Elective & Emergency General Surgery D j porter, j Kilkenny, a geddes & m checketts

Background Coagulation screening involves sampling venous blood to detect congenital and acquired coagulation disorders and to examine the effects of anti - coagulant drugs In the pre - operative setting, the test is used to establish a baseline for the patient It may be used to plan the use of blood products and blood salvage techniques in the peri - operative period The test may be painful for the patient

Background There is a low risk of complications including haematoma formation, vasovagal reactions and infection Detection of abnormalities is uncommon in asymptomatic, fit and healthy individuals There is uncertainty about the clinical effectiveness of performing routine pre - operative haemostasis tests in all individuals The total cost of a coagulation screen is £29.421

NICE Guidelines - April 2016 Do not routinely offer haemostasis tests before surgery Consider haemostasis tests in people with chronic liver disease having intermediate or major or complex surgery If people taking anti - coagulants need modification of their treatment regimen, make an individualised plan in line with local guidance

NHS Tayside Trust Guidelines Coagulation screening is indicated in patients with: Severe liver disease Known or suspected major coagulopathy Those on anti - coagulation drugs such as warfarin (not anti - platelet medications)  

Audit of Practice Despite these recent NICE guidelines and the NHS Tayside trust guidelines, coagulation screens are routinely performed in elective and emergency general surgical admissions with no history of CLD, no indications of severe coagulopathy and in patients who are not taking anti - coagulant medications This may cause patient harm and clearly has economic implications for the Trust

Audit of Practice To determine whether coagulation screens were appropriately requested on elective and emergency general surgical patients Retrospective audit All Emergency (ward 7) and elective (wards 10 and 11) general surgical patients were reviewed over a 2 week period from 13th - 27th May 2016 Clinical Portal, ECS and ‘ICE’ were reviewed to determine if there was any clinical evidence of coagulopathy, chronic liver disease or whether the patient was on anti - coagulant medication, the type of proposed surgery and whether a coagulation screen was sent

Results A total of 192 patients were included in the initial audit 124 emergency patients (ward 7) and 68 elective patients (wards 10 and 11) 8 patients had chronic liver disease, 21 patients were on anti - coagulant medications, no patients were coagulopathic

Results 29 patients appropriately had a coagulation screen taken (15%) 121 patients actually had a coagulation screen taken (63%) 92 unnecessary coagulation screens were taken and sent for analysis (48%)

Conclusion Despite clear NHS Tayside Trust guidelines and recent updated NICE guidelines a significant number of unnecessary coagulation screens are being taken and sent for analysis £2706.64 of Tax payers money spent on unnecessary coagulation screens over a 2 week period (£70,372.64 per annum) Significant financial implications and potential patient harm from unnecessary coagulation screens sent

Future Plans Email a summary of the NICE and Trust guidelines on coagulation screening in elective and emergency general surgical patients to staff members on NHSmail Include hospital at night practitioners and ANPs in ASRU in email distribution Design an information sheet for the Drs Mess with the NICE and Trust guidelines on coagulation screening

Future Plans Allow a 4 week period of time to allow changes to be initiated Re - audit after this time to determine whether a change in clinical practice has occurred Represent final results at the Sept CEM to close the audit loop

Re - Audit July 2016 4weeks after the presentation of audit results and following email distribution of a suggested proforma to all staff involved in admissions a re - audit was conducted Retrospective audit All patients admitted to wards 7, 10 and 11 over a 2week period (1st - 15th July) were included in the audit

Re - Audit July 2016 Clinical Portal, ECS and ‘ICE’ were reviewed to determine if there was any clinical evidence of coagulopathy, chronic liver disease or whether the patient was on anti - coagulant medication, the type of proposed surgery and whether a coagulation screen was sent Results were compared to determine whether there were less inappropriate coagulation screens sent in July 2016 following presentation of initial audit results in June 2016 The estimated saving to the trust from the reduction in unnecessary coagulation screens coagulation was calculated

Results of Re - Audit A total of 247 patients were included in the audit 206 emergency patients (ward 7) and 41 elective patients (wards 10 and 11) 9 patients had chronic liver disease, 15 patients were on anti - coagulant medications, and 1 patient had a coagulopathy

Results of Re - Audit 25 patients appropriately had a coagulation screen taken (10%) 93 patients actually had a coagulation screen taken (37.5%) 68 patients inappropriately had a coagulation screen taken (27.5%)

Conclusion Following initial audit presentation and circulation of results and suggestions less inappropriate coagulation screens were sent 27.5% Vs 48% 22 fewer patients had inappropriate coagulation screens sent as a result of the audit £638 was saved as a result of fewer inappropriate coagulation screens being sent over the two week period of the audit This audit has led to a change in clinical practice with reduction in potential patient harm and significant financial savings

Caveats This audit did not include those patients undergoing vascular or endovascular surgery or interventional radiology procedures Junior Drs should be guided by individual consultant practice especially in HPB patients If in doubt as to whether to request a coagulation screen juniors should discuss with SpRs or consultant surgeons

References National Institute for Health and Care Excellence, Preoperative tests (update), Clinical guideline NG45, Methods, Evidence and Recommendations, April 2016