Transcript Document

IMPLEMENTING GUIDELINES AND REDUCING PATIENT RISK OF
VENOUS THROMBOEMBOLISM IN A LARGE UK TEACHING HOSPITAL
Sharron Millen, Head of Clinical Pharmacy and Juliane Kause, Consultant in Acute Medicine and Critical Care,
Southampton University Hospital NHS Trust, Southampton, Hampshire (UK)
Background
Venous thromboembolism (VTE) causes an estimated 25,000 preventable
deaths1. As a result prevention and management of VTE is promoted within
the NHS2. The National Institute of Clinical Excellence (NICE) has issued
guidance3 on the use of thromboprophylaxis in surgical patients but not yet in
medical patients.
Medical
NICE Surgical
NICE
Medical
guidelines
guidelines
Guidelines
ACCP
SUHT thrombosis
committee
TP Nurse Specialist
March 2008
CMO request for
thromboprophylaxis
Anticoagulants are the cornerstone of successful prophylaxis and are one of
the classes of medicines most frequently identified as causing preventable
harm to patients as recognised by the National Patient Safety Agency
(NPSA)4.
Trial of risk assessment stickers
Nov 2007
In recognising this area as a national priority, Southampton University
Hospitals Trust (SUHT) established a Thrombosis Committee, developed local
guidelines and formalised a structure to implement them. To ensure that the
guidelines were being used effectively an audit was conducted with the aim to
determine whether patients are risk assessed and prescribed appropriate
thromboprophylaxis.
April 2008
SUHT Trust Induction
Core Medical Education
Oct 2006
Oct 2007
Oct 2008
Method
Southampton is one of the largest teaching hospitals in the south of England, serving a population of 500 000 from diverse backgrounds. Every year the 7500
staff employed by the trust, treat 115000 in-patients and day patients including 40 000 emergency admissions. Specialist services at the trust include:
neurosciences, cardiac services and children’s intensive care. Data was collected during October 2006 and October 2008 from representative clinical areas:
emergency department, acute medicine, general medicine, cancer care, gynaecology, surgery and orthopaedics. For each of these areas 30 patients were
reviewed using an electronic audit tool, gathering the following information: patient demographics, risk assessment documentation, thromboprophylaxis
modality and if pharmacological thromboprophylaxis: indication, dose, frequency and duration of heparins. Compounding factors influencing
thromboprophylaxis were also recorded: admission diagnosis, length of stay, renal failure, contraindications to enoxaparin, systemic anticoagulation and
antiplatelet medications.
Results
Our audit included 163 patients in the first cycle (1) and 186 patients in the
second cycle (2). There were comparable patient demographics in both data
sets.
Risk assessment documentation, including risk factors for VTE, was poor. Risk
assessment document completion improved from 8% (n1=13) to 24% (n2=45)
between audit cycles, largely due initiation of prescribing being supported by
aide memoire stickers.
Thromboprophylaxis given improved from 12% (n1=19) to 83% (n2=155)
between October 2006 and October 2008. However, the percentage of
appropriate thromboprophylaxis given was smaller: The discrepancies
occurred due to the dosages of low molecular weight heparins and the false
assumption that patient on antiplatelet medication do not require the usual
protocolised thromboprophylaxis. At the same time, hypersensitivity and
contraindications to Low Molecular Weight Heparins (LMWH) were poorly
documented
Enoxaparin 40mg usage within SUHT
1000
800
600
400
200
0
Jan
Feb
Mar
Apr
May
June
July
Concurrently, enoxaparin usage increased by 28% in our hospital.
Confusion about co-prescribing of LMWH with oral antiplatelet drugs, such as
aspirin and clopidogrel was widespread.
However when LMWH were
prescribed this followed our
guidelines.
Expected duration of
thromboprophylaxis prescribing was only well documented in elective
orthopaedic and elective surgical patients.
Quotes
Nurses:
"I thought the Dr's did it"
"I don't complete admission notes"
“Leave it to the medical team-but flag it up to them"
"Didn't know there was one" (risk assessment)
"not on ward at time of assessment"
Pharmacist:
“Takes time, often have too
many jobs to do”
“ Don't feel it is my clinical
decision-I may be unaware
of pts risk factors”
Doctors:
“Normally documented in notes,
although maybe I should document
reassessment”
“Not doctors role”
“Patient already on Aspirin and
Clopidogerel.”
Conclusion
Within our organisation prescribing of LMWH is improving but not yet achieving the national standard. Expected duration of thromboprophylaxis was well
documented in elective orthopaedic and elective surgical patients. Actual prescribing followed guidelines. Particular attention must now focus on risk
assessment and it’s documentation. It appears that in those patients, whose risk assessment was documented, accurate prescribing occurred frequently,
whereas the errors associated with choice, dose and duration of LMWH occurred in those patients without any risk assessment documentation.
Confusion about co-prescribing of LMWH with oral antiplatelet drugs, such as aspirin and clopidrogel was widespread, and was captured in written comments
from staff during the audit process. Additional training and education are required, focusing on risk assessment and correct dosage in particular. We have
implemented further education since this audit and have already seen improvements in our thromboprophylaxis compliance. Implementation of electronic
prescribing systems and patient involvement by own risk assessment would aid this process.
References
1.
2.
3.
4.
Report of the independent expert working group on the prevention of venous thromboembolism in hospitalised patients. DOH; Gateway Ref 7666, March 2007
Letter from Sir Liam Donaldson. DOH; Gateway Ref 6855, April 2007
Venous Thromboembolism. Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients undergoing surgery. ISBN 0-9549760-3-7,
April 2007 (NICE)
NPSA alert. Ref NPSA/2007/18, March 2007