Preventing Hospital Acquired Thrombosis

Simon Noble

Peggy Edwards

Preventing HAT

• The problem

• The solution

• The political agenda

• What's new….

PE responsible for 10% of deaths in hospital.

The problem

Prolonged immobilisation

• post-partum thrombosis known since the middle ages (‘milk leg’)

• car-travel related venous thrombosis in the 1930s

(Simpson, Lancet 1940)

During bombing of London in WWII, 6-fold increase of pulmonay embolism in people seeking shelter

Reduced by replacing deck chairs by beds

October 2000

28-year old woman dies from pulmonary embolism shortly after arrival at Heathrow airport, after a 20-hour journey from Australia

Emma Christofferson

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

(Daily Mail, 18/11/2000)

(The Sunday Telegraph, 28/1/2001)

Daily Mail3/2/01

The Guardian Thursday June 9th 2005

Thromboprophylaxis in hospitalised patients

• House of Commons Health Committee 2005

25,000 Deaths from Hospital Acquired DVT

Thromboprophylaxis in hospitalised patients

• House of Commons Health Committee 2005

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

Within Wales

• 1000 lives campaign• CMO risk assessment

tool• All Wales Guidelines

Virchow’s triad Circulatory

stasis

Endothelial Hypercoagulable injury state

Simple steps can make a huge change for care

• Risk assessment

• Thromboprophylaxis to those at risk

Thrombosis risk

• Orthopaedic surgery• Cancer surgery• Neurosurgery• Strokes• Acute medical illness

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)

Surgery Circulatory stasis - Anaesthetic - Bed rest

Endothelial injury Hypercoagulable state - Surgery -inflammatory

processes

Surgical prophylaxis

In absence of contraindications use a combination of

• Pharmacological– LMWH– Fondaparinux

• Mechanical– TEDs– Footpumps– IPCs

Barriers to implementation

• DVTs! Never see them!

• Dangerous stuff that LMWH.

• Aspirin is much safer.

General Medical patients

• Accounts for 30% all HAT

• Highest in – Acute infections– Heart failure– Stroke

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

Hold on what about TEDs?

No evidence in medical patients.

• All supporting studies in surgical patients.

• MEDENOX– No additional benefit from adding TEDs

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?

CLOTS study

• Acute stroke patients n=2518

• Full length TEDs vs usual care

• DVTE 10% vs 10.6%

• No benefit from TEDs(NEJM 2009)

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%)

Any surprises in the new guidelines?

• Aspirin is out!

• NICE has been developed with BOA so their response will be measured.

Challenges

• Detecting rates of HAT

• Implementing guidelines

• Demonstrating benefit

So how are we going to do it?

• 15th December

• City Hall

• Lifeblood & 1000 Lives joint study day

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

Many thanks

See you soon….