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

2. 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

3. 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

4. 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

5. 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)

6. 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

7. 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

8. 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

9. 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%)

10. 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
£ of Tax payers money spent on unnecessary coagulation screens over a 2 week period (£70, per annum)
Significant financial implications and potential patient harm from unnecessary coagulation screens sent

11. Future Plans
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 distribution
Design an information sheet for the Drs Mess with the NICE and Trust guidelines on coagulation screening

12. 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

13. Re - Audit July 2016
4weeks after the presentation of audit results and following 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

14. 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

15. 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

16. 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%)

17. 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

18. 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

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