Preventing Hospital Acquired Thrombosis Simon Noble Peggy Edwards

Preventing HAT The problem The solution The political agenda What's new….

PE responsible for 10% of deaths in hospital.

The problem

Prolonged immobilisation post-partum thrombosis known since the middle ages (‘milk leg’) car-travel related venous thrombosis in the 1930s

(Simpson, Lancet 1940) During bombing of London in WWII, 6-fold increase of pulmonay embolism in people seeking shelter Reduced by replacing deck chairs by beds

October year old woman dies from pulmonary embolism shortly after arrival at Heathrow airport, after a 20-hour journey from Australia Emma Christofferson

(The Mail on Sunday, 17/12/2000)

(Daily Mail, 18/11/2000)

(The Sunday Telegraph, 28/1/2001)

Daily Mail 3/2/01

The Guardian Thursday June 9 th 2005

Thromboprophylaxis in hospitalised patients House of Commons Health Committee 2005

25,000 Deaths from Hospital Acquired DVT

Thromboprophylaxis in hospitalised patients House of Commons Health Committee 2005

Thromboprophylaxis in hospitalised patients House of Commons Health Committee 2005 CMO 2007 –National Leadership Venous Thromboembolism Strategy –Expert working group –Risk Assessment Tool NICE Guidelines (due Jan 27 th 2010) SIGN (Draft out to consultation) CQC: VTE rate to be a KPI

Within Wales 1000 lives campaign CMO risk assessment tool All Wales Guidelines

Virchow’s triad Circulatory stasis Endothelial Hypercoagulable injury state

Simple steps can make a huge change for care Risk assessment Thromboprophylaxis to those at risk

Thrombosis risk Orthopaedic surgery Cancer surgery Neurosurgery Strokes Acute medical illness

ENDORSE 70,000 patients 358 hospitals 32 Countries 51% at risk of VTE Of those patients at risk of VTE prophylaxis given to 60% surgical 40% medical patients (Cohen et al 2008)

Surgery Circulatory stasis - Anaesthetic - Bed rest Endothelial injury Hypercoagulable state - Surgery-inflammatory processes

Surgical prophylaxis In absence of contraindications use a combination of Pharmacological –LMWH –Fondaparinux Mechanical –TEDs –Footpumps –IPCs

Barriers to implementation DVTs! Never see them! Dangerous stuff that LMWH. Aspirin is much safer.

General Medical patients Accounts for 30% all HAT Highest in –Acute infections –Heart failure –Stroke

Acute medical patients In absence of contraindications, offer pharmacological prophylaxis to acute medical admissions who are anticipated to be immobile for 3 or more days. LMWH UFH Fondaparinux

Hold on what about TEDs?

No evidence in medical patients. All supporting studies in surgical patients. MEDENOX –No additional benefit from adding TEDs

No evidence in medical patients. All supporting studies in surgical patients. MEDENOX –No additional benefit from adding TEDs But absence of evidence does not necessarily mean absence of efficacy?

CLOTS study Acute stroke patients n=2518 Full length TEDs vs usual care DVTE 10% vs 10.6% No benefit from TEDs (NEJM 2009)

CLOTS study Acute stroke patients Full length TEDs vs usual care No benefit from TEDs Increased incidence of ulceration, necrosis in intervention group (5% vs 1%)

Any surprises in the new guidelines? Aspirin is out! NICE has been developed with BOA so their response will be measured.

Challenges Detecting rates of HAT Implementing guidelines Demonstrating benefit

So how are we going to do it? 15 th December City Hall Lifeblood & 1000 Lives joint study day

VTE collaborative Over 2010 Three learning sessions Starting 12 th Jan, Llandridnod Wells Using the model for improvement We need you to… –Go back tell your Thrombosis Committee –Find your local champions / teams –Engage with your executives to get support

Many thanks See you soon….