1. QAH HospitalPortsmouth Hospitals NHS Trust Venous Thromboembolism Patient Safety Study Day Simon Freathy

2. QAH HospitalPortsmouth Hospitals NHS Trust Session Objectives  Quiz  What is VTE  Impact of VTE  Risks and Prevention  How and what are we doing?  Case studies

3. QAH HospitalPortsmouth Hospitals NHS Trust Quiz

4. QAH HospitalPortsmouth Hospitals NHS Trust Page 45/15/2015 VTE: Collective term for:  Deep vein thrombosis (DVT)  Pulmonary Embolism (PE)  Hospital acquired VTE a patient safety priority What is VTE?

5. QAH HospitalPortsmouth Hospitals NHS Trust Page 55/15/2015 Deep vein thrombosis (DVT) is a thrombus (blood clot) in a deep vein that partially or totally blocks the flow of blood Pulmonary embolism (PE) is a clot that breaks off from the thrombus in the deep vein and moves to the pulmonary artery to block the blood supply in the lungs

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8. QAH HospitalPortsmouth Hospitals NHS Trust Page 85/15/2015 Also known as ‘The silent killer’  Between 10 - 25% of PEs are rapidly fatal: usually within 2 hours of the onset of symptoms  <50% of PEs are detected prior to death  80% of DVTs are clinically silent

9. QAH HospitalPortsmouth Hospitals NHS Trust Page 95/15/2015 DVT & it’s complications  Pulmonary embolism (PE)  Death (due to PE)  Post-thrombotic syndrome  Recurrent DVT - 30% chance at 10 years  Pulmonary hypertension

10. QAH HospitalPortsmouth Hospitals NHS Trust Page 105/15/2015 Post thrombotic syndrome

11. QAH HospitalPortsmouth Hospitals NHS Trust Page 115/15/2015 Formation of a DVT Starts in the valve pockets of the veins and extends up and down blocking blood flow

12. QAH HospitalPortsmouth Hospitals NHS Trust Page 125/15/2015 Formation of PE Some of the clot can come loose and break off, travel through the venous system, through the heart and block a blood vessel in the lung

13. QAH HospitalPortsmouth Hospitals NHS Trust Page 135/15/2015 Virchow’s Triad Being treated as a hospital patient can do all of these things

14. QAH HospitalPortsmouth Hospitals NHS Trust Signs and Symptoms of DVT  Calf swelling  Pain in the calf, thigh or groin  Engorged veins  Redness and warmth to the skin  Pitting oedema  But remember: up to 80% of DVTs are clinically silent

15. QAH HospitalPortsmouth Hospitals NHS Trust Signs and Symptoms of PE  Shortness of breath  Pleuritic chest pain  Haemoptysis  Tachycardia  Hypoxia  Fainting  Collapse

16. QAH HospitalPortsmouth Hospitals NHS Trust Page 165/15/2015 Community acquired thrombosis: CAT Hospital acquired thrombosis: HAT

17. QAH HospitalPortsmouth Hospitals NHS Trust Page 175/15/2015 Hospital-acquired Thrombosis  There are an estimated 60,000 deaths due to VTE in the UK every year, 65% are estimated to be hospital–acquired  Up to 25,000 preventable deaths a year in the UK due to HAT  10% of all hospital deaths are due to VTE  > 20 times greater than the number of deaths due to MRSA  More deaths than breast cancer, HIV/AIDS and road traffic accidents combined 1

18. QAH HospitalPortsmouth Hospitals NHS Trust Page 185/15/2015 Hospital-acquired Thrombosis  Can occur whilst the patients are inpatients, indeed they account for 10% of hospital deaths BUT  Majority occur AFTER discharge  Average post-surgical DVT presents on day 7  Average post-surgical PE presents on day 21  Critical ‘at risk’ period – 3 months

19. QAH HospitalPortsmouth Hospitals NHS Trust Page 195/15/2015 PREVENTION Keep your patients as mobile as possible Stop them from getting dehydrated

20. QAH HospitalPortsmouth Hospitals NHS Trust Page 205/15/2015 Prevention  Anticoagulants for at risk patients  Extended beyond discharge where appropriate –THR, TKR, Hip #, abdominal or pelvic surgery for cancer, at risk day surgical patients

21. QAH HospitalPortsmouth Hospitals NHS Trust Page 215/15/2015 Prevention  Consider anti-embolism stockings (AES) and compression devices where indicated

22. QAH HospitalPortsmouth Hospitals NHS Trust Page 225/15/2015 Remember: no intervention is risk free – risk assessment is essential Stockings can cause harm if used inappropriately, not fitted correctly and not monitored adequately Trust policy and competency for use of AES

23. QAH HospitalPortsmouth Hospitals NHS Trust Page 235/15/2015 Risk factors for VTE  Surgery  Trauma  Immobility  Malignancy  Cancer therapy (hormonal, chemotherapy etc)  Previous VTE  Family history of VTE  Increasing age  Pregnancy and the postpartum period  COCP or HRT

24. QAH HospitalPortsmouth Hospitals NHS Trust Page 245/15/2015  Acute medical illness  Heart or respiratory failure  Inflammatory bowel disease  Nephrotic syndrome  Obesity  Varicose veins with phlebitis  Central venous catheter  Inherited or acquired thrombophilia

25. QAH HospitalPortsmouth Hospitals NHS Trust Page 255/15/2015 Page 25 VTE: National picture  NICE Guidance: Jan 2010: Venous thromboembolism: reducing the risk  NICE VTE Quality Standard (CQC)  New NHS White Paper / CQC  NHS Operating Framework  NHSLA - CNST  CQUIN –> 90% patients to have a VTE risk assessment on admission to hospital using the National Tool –>92% compliant with appropriate prophylaxis  Report on and carry out RCA on all HAT events

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27. QAH HospitalPortsmouth Hospitals NHS Trust Page 275/15/2015 NICE VTE Quality Standard June 2010 No Quality Statement 1All Patients, on admission, receive an assessment of VTE and bleeding risk using the clinical risk assessment criteria described in the National tool 2Patients / carers are offered verbal and written information on VTE prevention as part of the admission process 3Patients provided with anti-embolism stockings have them fitted and monitored in accordance with NICE guidance 4Patients are re-assessed within 24 hours of admission for risk of VTE and bleeding 5Patients assessed to be at risk of VTE are offered prophylaxis in accordance with NICE guidance 6Patients/carers are offered verbal and written information on VTE as part of their discharge process 7Patients receive extended postoperative VTE prophylaxis in accordance with NICE guidance

28. QAH HospitalPortsmouth Hospitals NHS Trust CQUIN: 2012 What is required?

29. QAH HospitalPortsmouth Hospitals NHS Trust Risk Assessment

30. QAH HospitalPortsmouth Hospitals NHS Trust Electronic risk assessment -VitalPAC

31. QAH HospitalPortsmouth Hospitals NHS Trust Page 315/15/2015 Entering patient related thrombosis risk (cont.) Selecting Age > 60 (this can be auto-assessed from PAS)

32. QAH HospitalPortsmouth Hospitals NHS Trust Page 325/15/2015 Entering admission related thrombosis risk Selecting reduced mobility and a significant surgical procedure

33. QAH HospitalPortsmouth Hospitals NHS Trust Page 335/15/2015 Entering patient related bleeding risk

34. QAH HospitalPortsmouth Hospitals NHS Trust Page 345/15/2015 Entering admission related bleeding risk

35. QAH HospitalPortsmouth Hospitals NHS Trust Page 355/15/2015 Risk summary and recommended treatment plan Summary of patient assessment and recommended treatment plan

36. QAH HospitalPortsmouth Hospitals NHS Trust Page 365/15/2015 Entering the intended treatment plan (cont.) Entering LMWH and TED stockings

37. QAH HospitalPortsmouth Hospitals NHS Trust Page 375/15/2015 Confirming VTE treatment prescribed (cont.) Indicating ‘Patient refused’ mechanical prophylaxis

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41. QAH HospitalPortsmouth Hospitals NHS Trust How are we doing?

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43. QAH HospitalPortsmouth Hospitals NHS Trust Page 435/15/2015 Report as adverse incident and carry out RCA on all cases of hospital-associated thrombosis (HAT)  Any DVT or PE diagnosed as an inpatient  Any DVT or PE diagnosed within 90 days of an admission  Weekly meeting with Senior Clinicians  Monthly meeting with Chief Nurse & Medical Director –‘avoidable’ incidents  Data to be reported to DoH

44. QAH HospitalPortsmouth Hospitals NHS Trust Jan – Dec 2011 : 194 events, 83 PEs and 111 DVTs

45. QAH HospitalPortsmouth Hospitals NHS Trust HAT Events 2011 by CSC

46. QAH HospitalPortsmouth Hospitals NHS Trust Readmissions with HAT = potential loss of revenue

47. QAH HospitalPortsmouth Hospitals NHS Trust Page 475/15/2015 Common Themes 1. Poor documentation of risk assessment (Vitalpac and paper) 2. Delayed or missed doses of chemical prophlyaxis (57% pharmacy audit) 3. Delayed recognition of DVT or PE 4. Lack of patient information provided

48. QAH HospitalPortsmouth Hospitals NHS Trust Page 485/15/2015  5. Confusion over the concept of mobility and therefore insufficient provision of chemical prophylaxis Significantly Reduced Mobility ‘patients who are bed bound, unable to walk unaided or likely to spend a substantial proportion of their day in bed or in a chair’. NICE definition of mobility:

49. QAH HospitalPortsmouth Hospitals NHS Trust 6. Failure to consider mechanical prophylaxis when chemical prophylaxis is contraindicated (particularly in medicine) 7. Delayed reporting of VTE event 8. Renal doses 9. Failure to consider obesity doses of LMWH Page 495/15/2015 Treatment doses: 200mg and 75 mg Prophylaxis: Both 40mg?????

50. QAH HospitalPortsmouth Hospitals NHS Trust Page 505/15/2015 Summary  VTE – major patient safety issue  Majority of events can be prevented with appropriate risk assessment and provision of prophylaxis –Risk assess every patient on admission –Ensure that appropriate prophylaxis is prescribed and administered correctly –Report all cases of HAT in a timely manner –Provide patient information

51. QAH HospitalPortsmouth Hospitals NHS Trust Case study 1  57 year old man  Admitted for a total hip replacement  FBC, liver and renal function within normal limits  No relevant medical history apart from osteoarthritis

52. QAH HospitalPortsmouth Hospitals NHS Trust Which risk category does this patient fall under?  1. High risk of VTE and high risk of bleeding  2. High risk of VTE and low risk of bleeding  3. Low risk of VTE and high risk of bleeding  4. Low risk of VTE and low risk of bleeding

53. QAH HospitalPortsmouth Hospitals NHS Trust Which risk category does this patient fall under?  1. High risk of VTE and high risk of bleeding  2. High risk of VTE and low risk of bleeding  3. Low risk of VTE and high risk of bleeding  4. Low risk of VTE and low risk of bleeding

54. QAH HospitalPortsmouth Hospitals NHS Trust Treatment plan  1. Pharmacological and mechanical prophylaxis for duration of admission  2. Anti-embolism stockings only  3. Mechanical and pharmacological prophylaxis continued for 28-35 days post-op  4. Mechanical and pharmacological prophylaxis for 7 days post op

55. QAH HospitalPortsmouth Hospitals NHS Trust Treatment plan  1. Pharmacological and mechanical prophylaxis for duration of admission  2. Anti-embolism stockings only  3. Mechanical and pharmacological prophylaxis continued for 28-35 days post-op  4. Mechanical and pharmacological prophylaxis for 7 days post op

56. QAH HospitalPortsmouth Hospitals NHS Trust Case Study 2  70 year old female  Admitted to MAU Ambulatory Service with cellulitis to upper limb  No reduction in mobility  Inflammatory markers raised  Platelet count, liver and renal function within normal limits

57. QAH HospitalPortsmouth Hospitals NHS Trust Which risk category does this patient fall under  1. High risk of VTE and high risk of bleeding  2. High risk of VTE and low risk of bleeding  3. Low risk of VTE and high risk of bleeding  4. Low risk of VTE and low risk of bleeding

58. QAH HospitalPortsmouth Hospitals NHS Trust Which risk category does this patient fall under?  1. High risk of VTE and high risk of bleeding  2. High risk of VTE and low risk of bleeding  3. Low risk of VTE and high risk of bleeding  4. Low risk of VTE and low risk of bleeding

59. QAH HospitalPortsmouth Hospitals NHS Trust Treatment Plan  1. Anti-embolism stockings throughout admission  2. Enoxaparin (clexane) 40 mg daily throughout admission  3. No thromboprophylaxis required, encourage mobilisation and review VTE risk if clinical situation changes  Enoxaparin (clexane) 40mg daily and anti-embolism stockings throughout admission

60. QAH HospitalPortsmouth Hospitals NHS Trust Treatment Plan  1. Anti-embolism stockings throughout admission  2. Enoxaparin (clexane) 40 mg daily throughout admission  3. No thromboprophylaxis required, encourage mobilisation and review VTE risk if clinical situation changes  Enoxaparin 40mg daily and anti-embolism stockings throughout admission

61. QAH HospitalPortsmouth Hospitals NHS Trust Case Study 3  62 year old lady  Elective admission for total abdominal hysterectomy for cancer  Usually independent and active  Platelet count and renal function normal

62. QAH HospitalPortsmouth Hospitals NHS Trust Which risk category does this patient fall under once surgery completed?  1. High risk of VTE and high risk of bleeding  2. High risk of VTE and low risk of bleeding  3. Low risk of VTE and high risk of bleeding  4. Low risk of VTE and low risk of bleeding

63. QAH HospitalPortsmouth Hospitals NHS Trust Which risk category does this patient fall under?  1. High risk of VTE and high risk of bleeding  2. High risk of VTE and low risk of bleeding  3. Low risk of VTE and high risk of bleeding  4. Low risk of VTE and low risk of bleeding

64. QAH HospitalPortsmouth Hospitals NHS Trust Treatment plan  1. Pharmacological and mechanical prophylaxis for duration of admission  2. Anti-embolism stockings only  3. Mechanical and pharmacological prophylaxis continued for 28 days post-op  4. Mechanical and pharmacological prophylaxis for 7 days post op

65. QAH HospitalPortsmouth Hospitals NHS Trust Case Study 4  45 year old female  BMI 35, on COCP, history of inflammatory bowel disease  Admitted to ED with a non displaced ankle fracture  Placed in a lower limb cast – non weight bearing  Bloods within normal limits  Discharged with planned Fracture Clinic Follow up

66. QAH HospitalPortsmouth Hospitals NHS Trust POP Risk Assessment tool  What is this patients risk score?  What prophylaxis is indicated? –None –Mechanical –Enoxaparin 40mg daily until plaster cast removed

67. QAH HospitalPortsmouth Hospitals NHS Trust POP Risk Assessment tool  What is this patients risk score?  What prophylaxis is indicated? –None –Mechanical –Enoxaparin 40mg daily until plaster cast removed

68. QAH HospitalPortsmouth Hospitals NHS Trust Thank you Any Questions?