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VTE Risk Assessment

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  1. VTE Risk Assessment Dr Roopen Arya King’s College Hospital London roopen.arya@kch.nhs.uk

  2. 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

  3. Health Committee: Key themes • Awareness • National guidelines • NICE guidelines (2007) • Education • Implementation Risk assessment Thrombosis Committees Thrombosis Teams

  4. 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.

  5. 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

  6. 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.

  7. 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

  8. VTE Implementation Working Group • Develop a national VTE risk assessment tool • Develop Exemplar Centres • Raising awareness • Education

  9. 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

  10. Risk Assessment for VTE Identifying at-risk patient Counselling at-risk patient Prescribing thromboprophylaxis

  11. 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

  12. 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

  13. Risk assessment: key elements • Procedure-related risk of thrombosis • Patient-related risk of thrombosis • Bleeding risk & contraindications to prophylaxis • Linked to ACTION of thromboprophylaxis

  14. 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

  15. VTE risk assessment for medical patients

  16. 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

  17. KCH guidelines for medical thromboprophylaxis

  18. VTE risk assessment for surgery

  19. 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%

  20. Incidence of DVT according to length of surgery and age Borow M, Goldson H. Am J Surg. 1981;141:245-51.

  21.  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.

  22. 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.

  23. 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

  24. 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.

  25. 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