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This e-learning resource is designed to help nurses, pharmacists and junior doctors understand quickly the concept of hospital-associated venous thromboembolism, how to prevent it and to identify which steps of the prevention pathway are necessary to audit. SESSION OVERVIEW.
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This e-learning resource is designed to help nurses, pharmacists and junior doctors
understand quickly the concept of hospital-associated venous thromboembolism, how to prevent it and to identify which steps of the prevention pathway are necessary to audit.
The prevention of venous thromboembolism (VTE) in hospitalised patients is a top clinical priority in
VTE risk assessment
Prophylaxis decision making
NICE quality standards
By the end of this training you will be able to:
VTE is a common complication among hospital inpatients and contributes to longer hospital stays, morbidity, and mortality.
VTE is characterised by one or more blood clots (thrombus) that commonly occur in the deep veins in the leg (deep vein thrombosis, DVT) or in a pulmonary vessel (pulmonary embolism, PE) .
This image shows a DVT of the right leg; note the swelling and redness although some patients have no symptoms or signs.
The Government has highlighted that there are too many preventable deaths from VTE in hospitalised patients, with thousands of deaths a year attributed to VTE and with a financial cost estimated to be in excess of £600 million per annum.
This image shows a fatal PE apparent at autopsy.
Thrombus formation and propagation depend on the presence of abnormalities of blood flow, vessel injury and changes in blood clotting components (known historically as Virchow’s triad). These abnormalities occur frequently when patients are hospitalised, for example for surgery.
Examples of patients at risk of VTE are those admitted to hospital for elective orthopaedic surgery.
Venous stasis occurs after surgery, vessel wall injury and endothelial damage are apparent, and the surgical insult alters the blood clotting components, forming a microenvironment physically and biochemically favouring thrombus formation.
Further examples of patients at risk of VTE include surgical patients with a VTE risk factor, for example cancer and medical admissions if mobility is significantly reduced for 3 or more days.
The prevention of hospital associated VTE is now a clinical priority in the NHS and The National VTE Prevention Programme provides a comprehensive, integrated and financially incentivised approach to prevent VTE.
The Department of Health has defined hospital associated VTE as any VTE event occurring within 90 days of hospital admission/surgery.
The programme consists of a national tool for VTE risk assessment (published by the Department of Health) and a number of other related measures.
Provision of census data for VTE risk assessment is compulsory within the NHS to meet a nationally agreed goal of reducing death and disability from VTE. The goal will be deemed to have been achieved if 90% of all hospital admissions have been assessed for VTE risk.
NICE clinical guideline 92 gives comprehensive guidance on reducing the risk of VTE in hospitalised patients and on appropriate thromboprophylaxis.
Acute NHS Trusts are required to report audits of thromboprophylaxis and undertake root cause analysis of any hospital-associated VTE cases that occur.
The primary aim of root cause analysis is to identify the root cause of the VTE in order to create effective corrective actions that will prevent the problem from re-occurring.
VTE risk assessment should be undertaken using the National risk assessment tool. In some Trusts, risk assessment is performed using an electronic tool, but in others the risk assessment is paper-based.
You may find that your Trust has implemented a
local approach to VTE risk assessment that incorporates the elements of the National
risk assessment tool. You should ensure you are familiar with your local VTE prevention policy.
Step 1. Assess a patient’s mobility.
All surgical patients, and all medical patients with significantly reduced mobility, should be considered for further risk assessment.
If a patient is a medical admission and not expected to be immobile, a simple tick completes the risk assessment process.
Step 2. Assess the risk of VTE.
Any tick in these boxes indicates that the patient is at risk of VTE. For example, a patient with hip fracture is at risk of VTE.
Step 3. Assess the patient’s bleeding risk
The risk of bleeding must always be considered before prevention steps are taken.
Any tick should prompt clinical staff to consider if bleeding risk is sufficient to preclude pharmacological intervention. For example, a patient who is thrombocytopenic is at risk of bleeding.
There are two type of thromboprophylaxis : mechanical and pharmacological.
The theory behind mechanicalapproaches is that they increase mean blood flow velocity in leg veins, reducing venous stasis. They are broadlyclassified as either static (anti-embolism stockings) or dynamic (intermittent pneumatic compression).
Pharmacological agents prevent the formation of a venous thrombus and/or restrict its extension by directly altering the process of blood coagulation.
The most common agents used are unfractionated heparin (UFH) and low molecular weight heparin (LMWH). For elective total hip/knee replacement, the oral anticoagulants rivaroxaban or dabigatran can be used.
This example shows a nurse fitting anti-embolism stockings, which are an example of static mechanical prophylaxis.
This example shows a nurse a nurse starting an intermittent pneumatic compression device, which is an example of dynamic mechanical prophylaxis.
This patient is suffering from peripheral vascular disease and mechanical methods of thromboprophylaxis are contraindicated.
Use caution/clinical judgement when applying anti-embolism stockings over venous ulcers or wounds.
This patient is suffering from an ulcer and pharmacological thromboprophylaxis is contraindicated.
Pharmacological thromboprophylaxis must be carefully timed to reduce the
risk of bleeding at the catheter site in patients undergoing epidural anaesthesia.
NICE clinical guideline 92 offers simple care pathways to direct risk assessment and prophylaxis decision making.
Assessing the risk of VTE is the first and most important step in the pathway, fulfilling the compulsory audit requirements within the NHS and acting as the trigger to consider the need for prevention measures.
Increased risk of VTE (low bleeding risk)
Dependent on the reason for admission, NICE recommends pharmacological prophylaxis and or mechanical methods. The Royal College of Obstetricians and Gynaecologists make separate recommendations for obstetric patients.
NICE has introduced seven quality standards for VTE prevention. The quality standards are a key part of making quality the organising principle of the NHS. They act as markers of high quality, cost effective patient care.
A key aspect of the NICE quality standards is the need to offer patients and carers verbal and written information on VTE prevention, both at admission and as part of the discharge process.
Ensure you are familiar of your Trust’s VTE information leaflet and any other patient-related communication tools.
If a DVT or PE occurs while the patient is in hospital or up to 90 days from admission, then the clinical team should conduct a root cause analysis to attempt to understand why that patient suffered a thromboembolic event.
In this patient, ultrasound confirmed the
diagnosis of DVT. The superficial femoral
vein is occluded with the tongue of
Thrombus extending into the
common femoral vein.
Such a diagnosis within 90 days of
hospitalisation is classed as a hospital-associated VTE and should be reported to your local team for review and analysis.
A 55 year old female with a 3-year history of rheumatoid arthritis, currently treated with NSAIDs, is admitted for elective hip replacement. Her haemoglobin is 12.9 g/dL and white cell count 13.5x109/L with a neutrophil leucocytosis. Platelets and electrolytes are in the normal range, as is liver function.
A 62 year old male is admitted with cellulitis of the upper limb, requiring intravenous antibiotics; there is no reduction in his mobility. His FBC is normal, and his BMI is 25.
A 70 year old female is admitted with left sided weakness; a stroke is suspected, and an ischaemic stroke is confirmed on CT.