1. ‘Preventing and treating blood clots’ The South Tees Anticoagulation Team 1

2. Tony Roberts, Clinical Effectiveness Advisor David Webb, Anticoagulation Practitioner Dr Jamie Maddox, Consultant Haematologist Tara Ashley, Anticoagulation Practitioner Dr Angela Wood, Consultant Haematologist Judith Connor, Lead Nurse for Patient Safety Catherine Sunter, Anticoagulation Practitioner 2

3. Preventing and treating blood clots Venous thromboembolism (VTE) is common, costly and can cause death or long term morbidity. VTE is potentially preventable and high-risk patients can be easily identified. However prophylaxis has historically been suboptimal as the problem is often overlooked or underestimated. 3

4. VTE prevention is a key priority for the NHS, supported by: –Improved undergraduate and postgraduate training –National risk assessment template –NICE guidance –CQUIN program –Exemplar centres –NHS Safety Thermometer 4

5. Preventing and treating blood clots Anticoagulant drugs (warfarin and heparins) are effective treatments of venous or arterial thrombus. There is a significant risk of bleeding which increases if these medicines are mismanaged. The NPSA has issued safety alerts for both warfarin and heparin. 5

6. “Anticoagulants are one of the classes of medicines most frequently identified as causing preventable harm and admission to hospital…” 6

7. Improve VTE risk assessment / prophylaxis and by doing this to demonstrate a reduction in hospital acquired VTE. Review and, where necessary, improve anticoagulation services, to comply with NPSA alerts, and ultimately to reduce the risk of patient harm. Team goals 7

8. Admission to hospital Safe anticoagulant management Patient already taking anticoagulants Patient suffers VTE VTE risk assessment and appropriate prophylaxis Appropriate investigation and initial management Safe transfer of care to community Medical / surgical treatment 8

9. Admission to hospital VTE risk assessment and appropriate prophylaxis - Develop RAT based on national template - Staff awareness, education & training - Ongoing audit of compliance (local, CQUIN and Safety Thermometer) Safe transfer of care to community - Extended prophylaxis if appropriate - Work to develop continuity with community hospitals Medical / surgical treatment - Protocols for use of prophylaxis - Review Trustwide use of compression stockings - Patient information leaflet Teaching: VTE training Ward VTE champions Anticoagulant training Junior doctors Warfarin training pack Support problem areas 9

10. Safe transfer of care to community - Audit of discharge information - Modify discharge template to ensure adequate information Patient suffers VTE - Raise awareness to help early diagnosis - Improved patient education -Root cause analysis - Data monitoring Appropriate investigation and initial management - Protocols for investigation and initial management - Audit of VTE investigation and treatment - Improve warfarin loading protocol and chart 10 Admission to hospital VTE risk assessment and appropriate prophylaxis

11. Safe anticoagulant management -NPSA 18 fully implemented - Review INR values >5.0 -Protocols for care, e.g. perioperative, high INRs Patient already taking anticoagulants - Protocols for management of immediate problems, e.g. bleeding - Audit of warfarin reversal Safe transfer of care back to community - Audit of discharge information - Modify discharge template to ensure adequate information 11 Admission to hospital VTE risk assessment and appropriate prophylaxis

12. Standardising stocking use –Easier procurement –Easier staff training –Less chance of error (e.g. incorrect size, pressure ulcers ) –Falls reduction –Cost saving Simple changes can have a big impact... 12

13. Results Over an 8 month period VTE risk assessment improved from 20% to >90%. Achieved CQUIN goals for 2010-11 and 2011- 12. Possible reduction in hospital acquired VTE. Many root cause analysis with direct feedback to clinical teams. NHS Safety thermometer data – good performance compared to peers and national data. 13

14. Written Risk Assessment 2010 2011 14

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16. South Tees National VTE Risk Assessment (Apr ‘12)94%64% New VTE (Feb - Apr '12)0.5%1.26% NHS Safety Thermometer (May 2012) 16

17. Future Most work so far on VTE risk assessment and more recently RCA. Future focus on GP discharge information and integration with community services. Business plan to establish a warfarin stabilisation clinic. 17