Preventing Hospital Acquired Thrombosis

1. Preventing Hospital Acquired Thrombosis Simon Noble Peggy Edwards

2. Preventing HAT • The problem • The solution • The political agenda • What's new….

5. PE responsible for 10% of deaths in hospital.

6. The problem

7. Prolonged immobilisation • post-partum thrombosis known since the middle ages (‘milk leg’) • car-travel related venous thrombosis in the 1930s

8. During bombing of London in WWII, 6-fold increase of pulmonay embolism in people seeking shelter Reduced by replacing deck chairs by beds (Simpson, Lancet 1940)

9. Emma Christofferson October 2000 28-year old woman dies from pulmonary embolism shortly after arrival at Heathrow airport, after a 20-hour journey from Australia

11. (The Mail on Sunday, 17/12/2000)

13. (Daily Mail, 18/11/2000)

14. (The Sunday Telegraph, 28/1/2001)

17. Daily Mail 3/2/01

18. The Guardian Thursday June 9th 2005

21. Thromboprophylaxis in hospitalised patients • House of Commons Health Committee 2005

22. 25,000 Deaths from Hospital Acquired DVT

23. Thromboprophylaxis in hospitalised patients • House of Commons Health Committee 2005

24. Thromboprophylaxis in hospitalised patients • House of Commons Health Committee 2005 • CMO 2007 • National Leadership Venous Thromboembolism Strategy • Expert working group • Risk Assessment Tool • NICE Guidelines (due Jan 27th 2010) • SIGN (Draft out to consultation) • CQC: VTE rate to be a KPI

25. Within Wales • 1000 lives campaign • CMO risk assessment tool • All Wales Guidelines

27. Circulatory stasis Endothelial Hypercoagulable injury state Virchow’s triad

28. Simple steps can make a huge change for care • Risk assessment • Thromboprophylaxis to those at risk

30. Orthopaedic surgery Cancer surgery Neurosurgery Strokes Acute medical illness Thrombosis risk

31. ENDORSE • 70,000 patients • 358 hospitals • 32 Countries • 51% at risk of VTE • Of those patients at risk of VTE prophylaxis given to • 60% surgical • 40% medical patients (Cohen et al 2008)

32. Circulatory stasis - Anaesthetic - Bed rest Endothelial injury Hypercoagulable state - Surgery -inflammatory processes Surgery

33. Surgical prophylaxis In absence of contraindications use a combination of • Pharmacological • LMWH • Fondaparinux • Mechanical • TEDs • Footpumps • IPCs

34. Barriers to implementation • DVTs! Never see them! • Dangerous stuff that LMWH. • Aspirin is much safer.

35. General Medical patients • Accounts for 30% all HAT • Highest in • Acute infections • Heart failure • Stroke

36. Acute medical patients • In absence of contraindications, offer pharmacological prophylaxis to acute medical admissions who are anticipated to be immobile for 3 or more days. • LMWH • UFH • Fondaparinux

37. Hold on what about TEDs?

38. No evidence in medical patients. • All supporting studies in surgical patients. • MEDENOX • No additional benefit from adding TEDs

39. No evidence in medical patients. • All supporting studies in surgical patients. • MEDENOX • No additional benefit from adding TEDs • But absence of evidence does not necessarily mean absence of efficacy?

40. CLOTS study • Acute stroke patients n=2518 • Full length TEDs vs usual care • DVTE 10% vs 10.6% • No benefit from TEDs (NEJM 2009)

41. CLOTS study • Acute stroke patients • Full length TEDs vs usual care • No benefit from TEDs • Increased incidence of ulceration, necrosis in intervention group (5% vs 1%)

42. Any surprises in the new guidelines? • Aspirin is out! • NICE has been developed with BOA so their response will be measured.

43. Challenges • Detecting rates of HAT • Implementing guidelines • Demonstrating benefit

45. So how are we going to do it? • 15th December • City Hall • Lifeblood & 1000 Lives joint study day

46. VTE collaborative • Over 2010 • Three learning sessions • Starting 12th Jan, Llandridnod Wells • Using the model for improvement • We need you to… • Go back tell your Thrombosis Committee • Find your local champions / teams • Engage with your executives to get support

47. Many thanks See you soon….