1. Thromboembolism risk assessment in a Specialist Palliative Care Inpatient Unit
Anthony Williams, FY2
Jo McCarthy, FY2
Charlotte Davies, FY2
Siwan Seaman, Palliative Medicine SpR
Pola Grzybowska, Palliative Medicine Cons.
Sue Morgan, Palliative Medicine Cons.

2. Background
Venous thromboembolism (VTE) is known to detrimentally affect quality of life and survival in patients with cancer1. However management of patients with advanced cancer and VTE can often be complicated2.
Risk assessment for thromboprophylaxis contained in general medical and surgical clerking proformas used in Princess of Wales Hospital, Bridgend.
However there was no designated section for VTE risk assessment within clerking proforma used in Y Bwthyn Newydd.
Also no ABM guidelines for the use of thromboprophylaxis in patients admitted to SPCU.
1. Noble S. A step in the right direction, but one size might not fit all. Lancet Oncol. (2009) 10:
2. Johnson MJ, et al. Antithrombotic therapy in palliative care. Advances in Palliative Medicine (2009) 8: 95–100.

3. NICE Standards (2010)3
Do not routinely offer pharmacological or mechanical VTE prophylaxis to patients admitted for terminal care or those commenced on an end-of-life care pathway.
2. Consider offering pharmacological VTE prophylaxis to patients in palliative care who have reversible acute pathology. Take into account potential risks and benefits and the views of the patient and their family and/or carers.
3. Review decisions about VTE prophylaxis for patients in palliative care daily, taking into account the views of the patient, their family and/or carers and the multidisciplinary team
3. Venous thromboembolism: reducing the risk of venous thromboembolism in patients admitted to hospital. NICE Guidance. January 2010.

4. VTE audit: Ty Olwen, Swansea (2010)
Initial audit performed in early 2010 found documentation of risk assessment for VTE within Ty Olwen to be 35%.
Recommended the introduction of ‘sticker’ prompt to be inserted onto clerking proforma.
Sticker adopted for use in YBN after presentation of audit findings at trust-wide audit meeting.

5. Audit Standards
100% of patients of patients admitted to SPCU should have their VTE risk assessed and documented
Treatment review date should be set in 100% of patients admitted to SPCU

6. Methods Retrospective audit Three audit periods:
May - June (pre-sticker)
May - June (post-sticker)
Dec – March 2010/11 (following further modifications)
Patients identified using CaNISC database
Manual review of case notes using data collection proforma

7. Results
Period 1:
24 patients for 27 admissions (3 patients admitted twice)
18 patient records available for audit
Period 2:
26 patients for 27 admissions (1 patient admitted twice)
19 notes available for audit

8. Documentation of VTE risk assessment
Period 1
(total:18 patients)
Risk Assessment Documented 1
Risk Assessment
not documented 17

9. Documentation of VTE risk assessment
Period 1
(total:18 patients)
Period 2
(total:19 patients)
Risk Assessment Documented 1 9
Risk Assessment
not documented 17 10

10. Documentation of VTE risk assessment
Period 1
(total:18 patients)
Period 2
(total:19 patients)
Risk Assessment Documented 1 9
Risk Assessment
not documented 17 10
Documentation 6%
47%

11. Documentation of treatment review date
Period 1
(total:18 patients)
Review date documented
Review date not documented 18

12. Documentation of treatment review date
Period 1
(total:18 patients)
Period 2
(total:19 patients)
Review date documented 5
Review date not documented 18 14

13. Documentation of treatment review date
Period 1
(total:18 patients)
Period 2
(total:19 patients)
Review date documented 5
Review date not documented 18 14
Review Date 0%
26%

14. Conclusions
Introduction of sticker helped improve standards of practice
However current practice continues to fall short of our audit standards
Possible reasons:
Practical issues of using proforma sticker
Unclear of specific prescribing practice in palliative care setting
Frequent turnover of junior staff

15. Recommendations
1. Modify the clerking proforma

16. CLINICAL PROBLEM LIST 1. 2. 3.
PLAN
For VTE thromboprophylaxis YES / NO
Reason for decision
Review date: 1 week / ……….. / indefinite
Statement of patient’s wishes

17. Recommendations 1. Modify the clerking proforma
2. Use of an VTE risk assessment tool

18. Wales Joint Cancer Networks Palliative Care Guidelines Lead author: Byrne A. Thromboprohylaxis guidance for hospice inpatients Available from:

19. Recommendations 1. Modify the clerking proforma
2. Use of an VTE risk assessment tool
3. Strengthen Junior Doctor education on arriving at YBN
4. Repeat audit cycle

20. Re-audit - Documentation of VTE risk assessment
Period 1
(total:18 patients)
Period 2
(total:19 patients)
Period 3 (total:17 patients)
Risk Assessment Documented 1 9 14
Risk Assessment
not documented 17 10 3

21. Re-audit - Documentation of VTE risk assessment
Period 1
(total:18 patients)
Period 2
(total:19 patients)
Period 3 (total:17 patients)
Risk Assessment Documented 1 9 14
Risk Assessment
not documented 17 10 3
Documentation 6%
47%
82%

22. Re-audit - Documentation of treatment review date
Period 1
(total:18 patients)
Period 2
(total:19 patients)
Period 3 (total:17 patients)
Review date documented 5 7
Review date not documented 18 14 10

23. Re-audit - Documentation of treatment review date
Period 1
(total:18 patients)
Period 2
(total:19 patients)
Period 3 (total:17 patients)
Review date documented 5 7
Review date not documented 18 14 10
Review Date 0%
26%
41%

24. Conclusions
Re-audit has shown a further improvement of practice within YBN especially with regards to documentation of VTE risk assessment.
Still clear room for improvement of documentation of review date.

25. Further Recommendations
‘Tick Box’ Section for VTE prophylaxis on Patient board within department office – provides a visual reminder to:
a) document on admission
b) review on weekly ward round
New sticker to document review of VTE prophylaxis status on the weekly ward round:
Name:
Date:
Reviewed VTE prophylaxis status:
Treatment dose [ ]
Prophylactic dose [ ]
No prophylaxis [ ]

26. Further thoughts
Modifications assist in VTE assessment within specialist palliative care setting, which is often performed initially by junior medical staff.
Clear documentation provides useful information for non-specialists who become involved with patients in a different setting eg. Junior doctors on general medical/surgical wards.
Documentation also important for potential future studies regarding VTE4.
4. Gillon S, et al. Primary thromboprophylaxis for hospice inpatients: Who needs it? Palliat Med (201)1 25:

27. Further thoughts
Studies have investigated the use of validated guidelines (eg. Pan Birmingham Cancer Network (PBCN) VTE prevention guidelines)4 - may need to revisit our prescribing guidelines in the light of new research.
Demonstrates the importance of dynamic audit - attainment of best practice is a continual process of checking and modification.
4. Gillon S, et al. Primary thromboprophylaxis for hospice inpatients: Who needs it? Palliat Med (201)1 25:

28. Thank you