I was asked a while back to be involved with our Boards attempt at reducing the rate of venous thromboembolism ,VTE. This is the development of a clot in a vein which might lead to a significant health problem such as deep venous thrombosis ( DVT) and Pulmonary Embolism, (PE )
Both can lead to chronic morbidity and death
I have been fortunate to work with a great VTE team. This multi-disciplinary advisory group includes nurses, doctors pharmacists, and local patient safety advisors. We receive valuable assistance from IT and coding staff. Regular Data collection from wards has been an important aspect of the teams work
I hope to give a brief overview of what we in the VTE group have been doing and suggest areas where we could continue to improve.
Why is VTE an issue?
The Scottish Patient Safety Initiative views VTE reduction as one of its priority points of care. A 2005 study showed that in the UK 25, 000 avoidable deaths occurred every year from hospital acquired VTE. A more recent study from 2011 puts the figure now at 1000 deaths a week.
But it’s not just deaths that are a concern. It’s all the other problems that may develop from a clot such as long term limb swelling, chronic ulceration and of course the potential dangers of requiring long term treatment with blood thinning drugs such as warfarin.
What figures do we have locally?
Deaths recorded for these patients
DVT PE
2010/11 2 24
2011/12 4 12
2012/13 6 24
2013/14 6 20
Emergency department figures
92 patients discharged home from ED with diagnosis of DVT 2013/14
Demands on Radiology July 2013-14
1115 examinations undertaken for Lower limb Ultrasound and CT pulmonary angiograms
A recent statement from The Medical Royal colleges, College of Midwives, College of Nursing and Royal Pharmaceutical Society included
“There is significant evidence to support the view that hospital-acquired VTE can be prevented through a combination of two simple, safe and effective steps “
These are
Risk assessment AND administration of preventative treatment
Guidelines to assist us have been produced including SIGN 122 (Scottish Intercollegiate guidelines network) and NICE CG92 (Google them for their quick reference guides)
So ask yourself :if you are coming in to our hospital to have surgery or you are being admitted to an inpatient ward for medical treatment what are we all doing as a team to reduce the risk of you developing a preventable complication which may lead to long term morbidity or even death?
Risk Assessment
Measures to consider putting in place for your admission
You should be risk assessed preferably using a formalised risk assessment chart. These include taking into account issues such as anticipated prolonged immobility, type of surgery, obesity, and medical comorbidity such as heart failure which all increase the risk of a clot developing .Part of the risk assessment also looks at relative contraindications to interventions so that an appropriate risk/benefit decision can be made. Depending on that assessment appropriate advice should be given to you and specific measures put into place.
Preventative Treatment
This might include:
Advising early mobilisation and good hydration,
Considering means to improve blood flow in lower limbs such as TED stockings or pneumatic pumps “mechanical prophylaxis”
Considering prescribing of drugs such as enoxaparin (clexane) to help thin the blood “chemical or pharmacological prophylaxis”
Whether you are medical or surgical the same principles should apply. Assessment followed by REGULAR further reassessment
What happens in our Trust and what have the VTE team been doing to improve things?
If you are coming in for elective surgery you will be preassessed by a member of the preassessment team in DGRI or Galloway Community Hospital. This includes a VTE risk assessment using a standardised form designed by our group.
You will also be given information verbally and in leaflet form to take home to read to allow you to be better informed on VTE risk
Day of admission surgery
There may be a gap of several weeks from your initial preassessment to the actual day of surgery and so you should be reassessed on admission to check there have been no significant changes since the preassessment. An example to think of with the summer coming up is that following preassessment you went on a holiday which involved a long haul flight. This will increase your risk of VTE and thus modify the initial assessment. Or perhaps you have since started an oestrogen containing oral contraceptive which again may modify your risk
Ward Assessment
Theatre
Once you arrive in theatre a further check is done
Following input from the VTE team, Theatre staff have now incorporated specific questions concerning VTE prophylaxis into the WHO safety checklist .This now acts as another prompt to attempt to ensure that TEDs, if indicated have been applied and clexane if indicated, has actually been prescribed .
Recovery
When you arrive in recovery after your operation the formalised SBAR handover allows another opportunity to ensure VTE prevention measures have been implemented.
Medical admissions Ward
An assessment is undertaken on all patients as part of the acute admission clerking and recommendations made
Obstetrics
A formalised chart based risk assessment is done
Paper systems
How is the VTE team trying to improve our Trust’s current paper based assessment and prescription system?
One initial modification introduced by the VTE working group was a change in how the current kardex is presented
The first “box” in our kardex has “thromboprophylaxis?” written as a prompt. This idea came from our ICU drug kardex where it had been shown to be a useful reminder for staff
A second significant issue concerns our current paper based approach
In surgical patients the risk assessment is a separate piece of documentation, either filled in at preassessment or as part of the acute admission paperwork. In medicine there is an area for assessment included in the medical clerking document. Crucially in both current systems the assessment is divorced from the actual prescription in the kardex, creating a latent risk. To try to reduce this risk The VTE team are piloting having the assessment being incorporated into the kardex This has been undertaken in the surgical assessment unit.
Why? Because in our current paper based system the assessment is yet another piece of paper that can get “lost” in the notes. The assessment may not be acted on e.g. advice to prescribe prophylaxis might not be seen. This similar risk can occur in the current medical admissions format; the admitting consultant may document that you need clexane but this is not carried through to actually prescribing. Having assessment and kardex as one document is surely better for patient safety. This concept has been successfully introduced in other hospital in Lothian and Borders.
Electronic Prescribing
Ultimately our Trust will be moving away from paper onto the electronic casenote. Therefore our group were keen to influence the proposed electronic prescription system; HEPMA .This is being piloted in ward 18 with subsequent rollout to all wards .We advised that it should include a mandatory electronic VTE assessment tool.
(A major study from John Hopkins Hospital, Baltimore demonstrated significantly higher compliance when a computerised clinical decision support tool was implemented.)Lessons from the John Hopkins Multi-Disciplinary VTE Prevention Collaborative BMJ 2012
Incorporating the risk assessment and subsequent reassessment into an electronic mandatory system will also promote the concept of a standardised approach to VTE assessment and management. Currently our medical and surgical wards have different approaches to the same problem .Surely a uniform system practised across the hospital would be better? The team would welcome your views
Subsequent reassessment
A vital part of assessment is further reassessment during the hospital stay; ideally every 48-72hours. Why? Because circumstances change and clinical conditions alter.
Let me give you some examples
You may have come in for what was meant to be day surgery but then due to unanticipated surgical difficulties you end up having a prolonged admission.
But the clexane is never written up so you end up with a DVT…..
Or perhaps you have been admitted with pneumonia and correctly prescribed clexane on admission but subsequently your kidney function worsens. The dose should be reduced but isn’t
You then have a significant bleed due to the enhanced effect of the drug……
Or maybe you came in with what was thought to be (incorrectly) a lower g/i bleed but in fact turns out to be a colonic cancer.
You were initially assessed as an increased bleeding risk so were not prescribed clexane. Despite a significant change in diagnosis you are not reassessed. You don’t get prescribed prophylaxis and subsequently develop a PE…….
Or perhaps you come in having vomited blood and so are not prescribed clexane. Mechanical prophylaxis such as TEDs is not considered and some days later you develop a DVT……
Unlikely scenarios? Perhaps you have come across similar examples yourself?
Nationally we have evidence that no hospitals are particularly good at documenting the reassessment of VTE risk during a patient’s stay. Our patient safety team‘s local data confirms this.
In an attempt to improve reassessment rates the VTE group are grateful to Ward 6 for currently piloting a more formalised, nurse led approach to reassessment. How about your ward area? The more we all become involved the safer the patient environment will become. Again the team would value your thoughts.
Discharge
Increasing evidence is available to suggest that prolonged injectable prophylaxis post discharge is beneficial in reducing VTE rates in certain specific situations.
For some time now elective knee and hip replacement patients being discharged from ward 16 have been going home having been taught by the nurses to give themselves their own clexane. If unable, then plans are put in place so that a family member or district nurse can assist. Post Hip patients continue clexane for 28 days and post knee patients continue for 14 days.
Post Caesarean section patients (depending on risk factors )may also go home from Cresswell Maternity Unit self administering injections in some cases up to six weeks post discharge .
Other groups that may benefit from prolonged administration may include other types of major surgery such as colorectal surgery patients. Any new developments must include discussion with our Primary Care colleagues.
Feedback: Closing the loop
Post hospital discharge a team may not necessarily know or be made aware that their patient has developed a VTE. This could lead to an assumption that “it never happens to one of our patients”.)
In an initial effort to improve feedback the VTE group has suggested that if a patient develops a VTE following a recent surgical procedure then that surgeon should receive a copy of the medical discharge letter. This type of feedback would also be very useful for patients seen and treated for DVT in the Emergency Department and indeed for any team with recent involvement in that patient’s care.
Conclusion
VTE prevention involves all of us
If you come in as a patient you would want a proper thorough assessment
You would want appropriate safeguards put into place to minimise the risk of a clot developing.
You would also want a regular reassessment to make sure that interventions are modified appropriately.
You would want to go home safe in the knowledge that you have been given appropriate discharge advice. Above all you want to feel that all the team are doing their utmost to minimise harm.
VTE? Vital Team Effort!
If you would like to contribute and join our group then contact me on vincent.perkins@nhs.net
Special thanks to Emma McGauchie, Staff nurse day surgery/Improvement Advisor and Becky Henderson, Project Officer, Patient Safety
Thanks to staff for posing as patients in the photos!
Vince Perkins is a Consultant Anaesthetist for NHS Dumfries and Galloway
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