Mandatory Training: VTE prevention and anticoagulation practice Mandatory Training: VTE prevention and anticoagulation practice Mr A McSorley Lead Thrombosis.

Mandatory Training: VTE Mandatory Training: VTE prevention and prevention and anticoagulation practiceanticoagulation practice

Mr A McSorley Mr A McSorley

Lead Thrombosis Nurse RCHTLead Thrombosis Nurse RCHT

--Risk assessment and VTE Risk assessment and VTE avoidanceavoidance

-RCA of hospital acquired VTE -RCA of hospital acquired VTE (HAT) (HAT)

-Thrombosis & anticoagulation -Thrombosis & anticoagulation guidanceguidance

Venous Thrombo-Embolism Venous Thrombo-Embolism (VTE)(VTE)

VTE VTE is a major public health is a major public health Issue & results in approximatelyIssue & results in approximately60,000 deaths per year in the UK60,000 deaths per year in the UK

VTE VTE causes more deaths thancauses more deaths thanbreast cancer, RTAs and AIDSbreast cancer, RTAs and AIDScombined and 5 times thecombined and 5 times thenumber of deaths from HAI’snumber of deaths from HAI’s(MRSA / C.Diff)(MRSA / C.Diff)

The total cost (direct & The total cost (direct & indirect)indirect)

of managing a of managing a VTEVTE is £640 is £640 millionmillion

1 in 3 people with a 1 in 3 people with a DVTDVT(Deep Venous Thrombosis) will(Deep Venous Thrombosis) willdevelop post-thromboticdevelop post-thromboticsymptoms within 3 years & 25%symptoms within 3 years & 25%will develop a VLU later in lifewill develop a VLU later in life

25,000 die from a hospital25,000 die from a hospitalacquired acquired VTE VTE every yearevery year11

4 out of 5 DVTs are4 out of 5 DVTs areundetected as their symptomsundetected as their symptomsmimic other conditionsmimic other conditions

Your Responsibility (c/f AC policy)Your Responsibility (c/f AC policy)

5.6. 5.6. Role of Individual Staff Members Role of Individual Staff Members All Staff are responsible for: All Staff are responsible for: • Taking positive steps to ensure the Taking positive steps to ensure the

appropriate patient VTE assessment is appropriate patient VTE assessment is completed accurately. completed accurately.

• Ensuring any actions identified through Ensuring any actions identified through monitoring and evaluations are undertaken. monitoring and evaluations are undertaken.

• Ensuring that any incidents linked with VTE Ensuring that any incidents linked with VTE assessment, prophylaxis or management assessment, prophylaxis or management are reported using the Trust’s incident are reported using the Trust’s incident reporting procedure reporting procedure

Avoiding hospital related Venous Avoiding hospital related Venous thrombo-embolism (VTE):thrombo-embolism (VTE):

target >95% recorded initial risk target >95% recorded initial risk assessmentassessmentwith monthly submission % to the DoHwith monthly submission % to the DoH

CQUIN so RCHT received 2012-13 ~£0.3MCQUIN so RCHT received 2012-13 ~£0.3M

2013-4 RCA of hospital acquired VTE 2013-4 RCA of hospital acquired VTE £0.11M£0.11M

Assessment on admission (1) Assessment on admission (1) andand at 24 hrs (2) at 24 hrs (2)Thrombosis prevention and anticoagulation policy (June 2011) (June 2011)

RCH-T SchemaRCH-T SchemaSTEP FOUR – Document appropriateness of STEP FOUR – Document appropriateness of

thrombo-prophylaxisthrombo-prophylaxis

• Assess and decide on the Assess and decide on the appropriateness of appropriateness of thromboprophylaxis thromboprophylaxis

• Tick Tick completecomplete the Risk Assessment Decision and the Risk Assessment Decision and Action box on admission to column 1 on the Action box on admission to column 1 on the bottom of the prescription sheet, bottom of the prescription sheet,

Monthly pharmacy auditMonthly pharmacy auditOverall monthly results - target 95%

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

% with initial assessment done% with appropriate RxLinear (% with initia l assessment done)Linear (% with appropriate Rx)

EPMA: the problem and the EPMA: the problem and the answeranswer

•Currently requires a 4 page Currently requires a 4 page supplementary sheet, with RA on supplementary sheet, with RA on back page back page

•Module due with Feb 2014 Module due with Feb 2014 upgradeupgrade

•Your support pleaseYour support please

Thrombosis Practitioner/facilitatorThrombosis Practitioner/facilitator

Support the Risk assessment processSupport the Risk assessment process

HAT RCAHAT RCA

-from July 2013 as part of CQUIN-from July 2013 as part of CQUIN

-reports to Divisions (via DQLG)-reports to Divisions (via DQLG)

DoH quality standards patient informationDoH quality standards patient information

Peri-operative anticoagulation Peri-operative anticoagulation

Anticoagulation related bleedingAnticoagulation related bleeding

RCA to dateRCA to date• Q2 = 90 RCA, preventable HAT = 13Q2 = 90 RCA, preventable HAT = 13

• Q3 = 112 RCA, preventable HAT = 11 Q3 = 112 RCA, preventable HAT = 11

• Emerging themes/causes of HATEmerging themes/causes of HAT– Failure to prescribe AES for Failure to prescribe AES for

patients not suitable or unwilling patients not suitable or unwilling for LMWHfor LMWH

– Failure to initiate LMWH or Failure to initiate LMWH or omission of doses – EPMA issue??omission of doses – EPMA issue??

– Failure to provide AES when LMWH Failure to provide AES when LMWH stopped for interventionstopped for intervention

Clinical Guideline For Thrombosis PreventionClinical Guideline For Thrombosis PreventionInvestigation And Management Of Investigation And Management Of AnticoagulationAnticoagulation• Venous thrombo-embolismVenous thrombo-embolism

– Risk assessmentRisk assessment

• Therapeutic anticoagulationTherapeutic anticoagulation– investigation, therapy and durationinvestigation, therapy and duration– cancercancer

• ComplicationsComplications– bleedingbleeding

• Special circumstancesSpecial circumstances– SurgerySurgery– Thrombophilia investigationThrombophilia investigation– PregnancyPregnancy