Preventing Hospital Associated Thrombosis: measuring outcomes

1. VTE Prevention NHS Showcase 16 September 2013 Preventing Hospital Associated Thrombosis:measuring outcomes Roopen Arya King’s College Hospital

2. Preventing VTE Link Nurse/ Midwives Thrombosis team Patient information Staff education Electronic VTEp systems VTE Prevention Supportive managers RCA of HAT cases Audit programme

3. VTE prevention: Measuring quality and outcomes Patient admitted to hospital • Process Measures • VTE risk assessment • Appropriate thromboprophylaxis • NICE VTEp Quality Standard Professional workforce aware of VTE risk Individual patient risk assessed for VTE Appropriate preventative strategy implemented • Outcome Measures • Coding – HES / ONS • Reporting through RCA programme Evaluation of outcome

4. Determining outcomes:Root cause analysis of cases of HAT Coding Diagnostics Autopsies DVT/AC clinic HAT Bereavement Other hospitals Thrombosis Team Data collection Notification Learning Admitting consultant Trust Quality Framework

5. Hospital wide risk assessment rates P<0.001 % (Roberts et al, Chest 2013)

7. Admission characteristics

8. VTE characteristics % HAT presenting as PE Mortality associated with HAT P=0.07 % 90d mortality Fatal PE

9. VTE risk assessment in HAT P=0.10 P<0.001 P<0.001

10. Appropriate thromboprophylaxis P= 0.001 P= 0.24 %

11. Underlying root cause P=0.063 P=0.005 P=0.031 % P=0.49 P=0.14

12. Mortality associated with HAT • Most fatal PE in medical patients • Post-op VTE: 6 deaths in 2010, 3 in 2011 • 9% medical HAT fatal, 4.7% surgical HAT • Procedures: #NOF, abdominal hysterectomy, Achilles tendon repair, glioma for biopsy, Meningioma resection, prostatectomy, right hernia repair, sleeve gastrectomy • 90-day mortality: medical 26% vs surgical 15%

13. HAT due to failure of thromboprophylaxis • 43% HAT cases at King’s due to TP failure • PE in 46% patients • 79.4% episodes symptomatic • Medical admission 44% • Surgical admission 53% • Median time to TP failure events 17d • TP failure events were more common after hospital discharge

14. Thromboprophylaxis failure • Mean number of risk factors higher in HAT due to TP failure • HAT post-hip fracture surgery more likely due to inadequate prophylaxis than TP failure • Increased risk in subgroups of surgical patients e.g those with dehydration or prolonged abdominal surgery • In medical patients, increased age, dehydration and cardiorespiratory disease associated with TP failure

15. King’s HAT project: conclusions • Electronic solutions with dedicated VTE training led to sustained improvement in risk assessment • 20% reduction in overall HAT events • Comprehensive VTE prevention significantly reduces preventable patient harm

16. Where we can improve • Identifying those at risk for HAT • Delivery of appropriate prophylaxis • Better prophylaxis to reduce TP failure rates • Address uncertainty regarding: Nursing homes Plaster casts Cancer Mental health

17. National VTE Registry

18. VTE System Guide mdsas Medical data solutions and services Username: User Password Password:

19. If the patient is already on the system, their details will appear automatically. If not you can enter the patient details here. Enter the VTE Event details.

23. www.vteprevention-nhsengland.org.ukroopen.arya@nhs.net