VTE Risk Assessment Dr Roopen Arya King’s College Hospital London firstname.lastname@example.org
Thrombosis prevention in the NHS • House of Common Health Committee Report March 2005 • Government response July 2005 • CMO publishes Independent Expert Working Group report April 2007 • NICE guidance re: surgical patients April 2007
Health Committee: Key themes • Awareness • National guidelines • NICE guidelines (2007) • Education • Implementation Risk assessment Thrombosis Committees Thrombosis Teams
Health Committee recommendations 2005 • We recommend that procedures for counselling both medical and surgical patients be supported by hospital specialist thrombosis teams and included in the VTE guidelines developed by NICE. • We recommend that all patients, both medical and surgical, who are admitted to hospital undergo a risk assessment for venous thrombosis.
CMO Recommendations April 2007 • Published VTE expert working group’s guidance in full • Documented mandatory risk assessment for all hospitalised patients • VTE risk assessment embedded in local risk management structure • Improved public/professional understanding of VTE • VTE exemplar centres • Guidance on thromboprophylaxis
NICE clinical guideline 46: VTEKey priorities for implementation • Risk assessment • Thigh-length graduated compression / anti-embolism stockings • In addition to mechanical prophylaxis, patient at increased risk of VTE because they have individual risk factors and patients having orthopaedic surgery should be offered LMWH. • LMWH or fondaparinux continued for 4 weeks after hip fracture surgery.
The way forward • Implementation of existing national guidance • National: Implementation working group Develop a national risk assessment tool Provide leadership Exemplar Centres • Local: thrombosis committees & teams local guidelines 100% risk assessment
VTE Implementation Working Group • Develop a national VTE risk assessment tool • Develop Exemplar Centres • Raising awareness • Education
Risk Assessment & Clinical Governance • The highest ranking safety practice was the appropriate use of prophylaxis to prevent VTE in patients at risk. AHRQ “Making Health Safer: A Critical Analysis of Patient Safety Practices” 2001 • We recommend that every hospital develop a formal strategy that addresses the prevention of thromboembolic complications. This should generally be in the form of a written thromboprophylaxis policy especially for high risk groups. ACCP guidelines “ Prevention of VTE” 2004
Risk Assessment for VTE Identifying at-risk patient Counselling at-risk patient Prescribing thromboprophylaxis
VTE risk assessment tool • Risk assessment is trigger for prophylaxis • Evolve from existing guidelines • Specialty-specific, procedure-specific • Template that may be adjusted for local use • Standards for implementation and audit • Risk assessment – key performance measure
Risk assessment: practical aspects • Specialty-specific policy agreed by hospital thrombosis committee, owned by specialties • Individualised vs Group-targeted risk assessment • Appropriate evidence-based local guidelines • Mechanical Pharmacological prophylaxis • Explicit guidance regarding aspirin
Risk assessment: key elements • Procedure-related risk of thrombosis • Patient-related risk of thrombosis • Bleeding risk & contraindications to prophylaxis • Linked to ACTION of thromboprophylaxis
Risk assessment: practical aspects • Who will perform VTE risk assessments? Junior drs / nurses / pharmacists / patients • Stand-alone VTE RAM vs integration with other risk assessments e.g. MRSA, falls, nutrition • Documentation: Risk assessment forms / stickers / prescription charts / wristbands • Computer alerts and prescriptions
An Ideal RAM: DVT Prophylaxis in Medical Patients • Accurately identify patients at risk of DVT • Predict correct risk level • disease-specific and predisposing risk factors • Reliably exclude patients without a beneficial risk:benefit ratio • Evidence based and validated • Methodologically transparent • Simple to use in clinical practice
Post surgical risk of DVT Type of operation Incidence of DVT Knee surgery 75% Hip fracture surgery 60% Elective hip surgery 50-55% Retropubic prostatectomy 40% General abdominal surgery 30-35% Gynaecological surgery 25-30% Neurosurgery 20-30% Transurethral resection of prostate 10% Inguinal hernia repair 10%
Incidence of DVT according to length of surgery and age Borow M, Goldson H. Am J Surg. 1981;141:245-51.
50% 36% 24% n = 197 n = 152 n = 48 2 0–1 3 The greater the number of risk factors, the higher the risk of DVT Total risk factor score(based on number of risk factors*) *Risk factors included age > 40 years, obesity, malignancy, recent surgery, and history of VTE. Wheeler HB. Am J Surg. 1985;150:7-13.
Levels of VTE risk in surgical patients without prophylaxis ACCP = American College of Chest Physicians; HFS = hip fracture surgery; ICS = International Consensus Statement; THA = total hip arthroplasty; TKA = total knee arthroplasty; VTE = venous thromboembolism. 1Nicolaides AN, et al. Int Angiol. 2006;25:101-61. 2Geerts WH, et al. Chest. 2004;126(3 Suppl):338S-400S.
Frequency of VTE/PE accordingto risk Low risk Events Moderate High Very high (%) risk (%) risk (%) risk (%) Calf vein 2.0 10-20 20-40 40-80 thrombosis Proximal vein 0.4 2.4 4.8 10-20 thrombosis Clinical PE 0.2 1-2 2-4 4-10 Fatal PE 0.002 0.1-0.4 0.4-1.0 1-5 Chest 1998;114:531S-60S
Electronic Alerts to Prevent VTE in Medical Patients Intervention group Freedom from DVT or PE (%) Control group P<0.001 Time (days) No. at risk Intervention group 1,255 977 900 853 Control group 1,251 876 893 839 Kucher N, et al. N Engl J Med. 2005;352:969-77.
Conclusion • Thromboprophylaxis Risk assessment guidelines tools • Varied approaches: one size DOES NOT fit all • Local leadership + agreement by users & thrombosis committees essential • National guidance on risk assessment will be available