FileNewTemplateHospital Associated Thrombosis: the current situation in England Roopen Arya
National Thrombosis Week 2016
2004 2005 2006 2007 2008 2009 2010 2011
Adaptive strategy and consistent pressure ensures VTE prevention is made a clinical priority
The Journey
Delivering high quality care Reducing avoidable harm Safer hospitals
• Leadership from NHS, parliamentarians, charities…. • Striving for excellence – VTE Exemplar Centres Network • Delivered change, enabled by levers provided by NHS
System measures 1
National risk assessment tool
System measures 2
Recommendations for audit of thromboprophylaxis and root cause analysis of hospital-associated thrombosis
Strengthening of commissioning arrangements in NHS standard contract
NICE Quality Standard defines best VTE prevention practice
Patient empowerment
Ongoing Education
Audit programme
VTE Prevention
Supportive managers
Preventing VTE:
VTE prevention: what’s changed? • Patient Safety has moved to NHS Improvement • Healthcare Safety Investigation Branch (HSIB) established • VTE prevention should be ‘business as usual’ • All system requirements are included in the NHS standard
acute care contract • Continue to refine understanding of VTE outcomes • National VTE Exemplar Centres Network will continue to
provide leadership and support the national programme
The VTE Exemplar Centres Network
NHS Champions for VTE Prevention
Guy’s and St Thomas’
St George’s
A global VTE network: Canada
A global VTE network: Australia
A global VTE network: Wales Princess of Wales & Neath Port Talbot hospital
Understanding outcomes in VTE prevention • Markers of process:
- VTE risk assessment - Appropriate prophylaxis rates
• Cases identified via local HAT-RCA programmes • Identifying cases of VTE and HAT at a national
level
Understanding VTE outcomes • Limitations of thromboprophylaxis • Limitations of coding • Limitations of death reporting • Limitations of the outcome indicator as a
marker for quality of VTE prevention process – Evaluation of surveillance bias and the validity of the VTE quality measure
Bilimoria et al, JAMA 2013; 310(14):1482-1489 – Association between inpatient surveillance and VTE rates after hospital discharge
Holcomb et al, JAMA Surg 2015 (online April 1) – Thromboembolic complications and prophylaxis patterns in colorectal surgery
SCOAP-CERTAIN collaborative, JAMA Surg 2015 (online June 10)
Impact of national VTE prevention programme in England
1. Blood Coagul Fibrinolysis 2014; 25(6):571-62. 2. Heart 2013; 0:1–6. 3. Chest. 2013 ; 144(4):1276-81.
VTE risk assessment rates
total acute providers
Nov-14
1,086,377
1,132,723
96%
1
159
Dec-14
Sheet1
1628323.09
1779219.98
2146430.62
2412686.09
2744544.94
3093172.98
3360841.83
3609075.84
CLEXANE
CLEXANE
CLEXANE
CLEXANE
CLEXANE
FRAGMIN
FRAGMIN
FRAGMIN
FRAGMIN
FRAGMIN
FRAGMIN
FRAGMIN
INNOHEP
INNOHEP
INNOHEP
INNOHEP
Volume
2006
2007
2008
2009
2010
2011
2012
2013
2014
Volume
Costs
Heparin Volume to the NHS in Secondary Care by Month
Product
2006
2007
2008
2009
2010
2011
2012
2013
2014
CLEXANE
£ 44,301,774
£ 48,349,767
£ 57,094,667
£ 61,366,117
£ 71,192,585
£ 74,075,523
£ 66,045,583
£ 59,366,946
£ 18,695,791
FRAGMIN
£ 11,021,804
£ 12,325,595
£ 13,491,852
£ 14,911,550
£ 17,846,899
£ 23,640,308
£ 35,148,857
£ 43,144,391
£ 15,890,000
INNOHEP
£ 10,548,751
£ 11,951,472
£ 16,010,844
£ 18,479,133
£ 21,502,428
£ 24,560,402
£ 22,957,714
£ 23,610,246
£ 7,553,492
Secondary Care RX
Process measures: AUDIT
Audit findings: Standard 4 Was pharmacological or mechanical TP correct?
90 88 84 93 92 9694 100 88 98 96 85
0
20
40
60
80
100
LRS NS TEAM Womens
Appropriate Chemical Appropriate Mechanical
Deaths from VTE related events within 90 days post discharge from hospital (NHS Outcomes Framework Indicator 5.1) Rate per 100,000 adult admissions, 2007/08 to 2013/14.
Chart1
2007
2008
2009
2010
2011
2012
2013
72
70.7
69
67.7
66.1
70.2
67.5
Sheet1
Column1
Column2
2007
72
2008
70.7
2009
69
2010
67.7
2011
66.1
2012
70.2
2013
67.5
DVT/AC clinic
Preventing HAT
• National VTE prevention programme has developed a comprehensive systems-based approach to VTE prevention
• There have been demonstrable improvements in process measures and VTE outcomes
• Devising a meaningful VTE outcomes indicator remains a priority
Where next? • Sustaining best practice in VTE prevention is a
continuing challenge
• Need for further research to help improve best practice
roopen.arya@nhs.net
The Journey
Global Leaders
Slide Number 11
Slide Number 12
Slide Number 13
Slide Number 14
Slide Number 15
Understanding VTE outcomes
VTE risk assessment rates
Expenditure on prophylactic LMWH
Audit findings: Standard 4
Deaths from VTE related events within 90 days post discharge from hospital (NHS Outcomes Framework Indicator 5.1) Rate per 100,000 adult admissions, 2007/08 to 2013/14.
Root cause analysis of cases of HAT
Local HAT trends
Preventing HAT
Where next?