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Preventing Hospital Associated Thrombosis:measuring outcomes
Roopen AryaKing’s College Hospital
VTE Prevention NHS Showcase16 September 2013
Link Nurse/Midwives
Patient information
Thrombosis team
Staff education
RCA of HAT cases
Electronic VTEp
systems
Audit programme
VTE Prevention
Supportive managers
Preventing VTE
VTE prevention: Measuring quality and outcomes
Patient admitted to hospital
Individual patient riskassessed for VTE
Professional workforce aware of VTE risk
Appropriate preventative strategy implemented
Evaluation of outcome
Process Measures• VTE risk assessment• Appropriate thromboprophylaxis• NICE VTEp Quality Standard
Outcome Measures• Coding – HES / ONS• Reporting through RCA programme
Determining outcomes:Root cause analysis of cases of HAT
DVT/ACclinic
Autopsies
DiagnosticsCoding
HAT
Thrombosis TeamData collection
NotificationLearning
Trust Quality Framework
BereavementOther hospitals
Admitting consultant
Hospital wide risk assessment rates
Apr-10
Jun-10
Aug-10
Oct-10
Dec-10
Feb-11
Apr-11
Jun-11
Aug-11
Oct-11
Dec-11
Feb-12
20
30
40
50
60
70
80
90
100 P<0.001
%
Median 85.8 93.9
IQR 72.0 - 90.4 92.3 94.5(Roberts et al, Chest 2013)
Admission characteristics
2010/11 2011/120%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
55.547.4
42.449.5
ObstetricSurgicalMedical
VTE characteristics
2010/11 2011/120
102030405060708090
100
46.7 36.7
P=0.07
2010/11 2011/12 2010/11 2011/120
5
10
15
20
25
7.3 6.2
21.1 19.3%
Fatal PE 90d mortality
% HAT presenting as PE Mortality associated with HAT
n 17 12 50 37
VTE risk assessment in HAT
Investigated HAT Hospital wide0
102030405060708090
100
43.9
81.785.493.6
RA 2010/11RA 2011/12
P<0.001P<0.001
P=0.10
Appropriate thromboprophylaxis
Anticoagulant Mechanical0
102030405060708090
100
72.1
60
91
68.5
2010/112011/12
P= 0.001
%
P= 0.24
TP prescribed (n) 62 91 51 63
TP indicated (n) 88 102 85 92
Underlying root cause
-5
5
15
25
35
45
55
37.5
16.9
30.9
8.1 6.6
22.427.3
41.2
6.1 32010/112011/12
%
P=0.005 P=0.031 P=0.063
P=0.49 P=0.14
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%
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
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
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
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 homesPlaster casts
CancerMental health
National VTE Registry
mdsasMedical data solutions and services
VTE System Guide
Username:
Password:
User
Password
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.
www.vteprevention-nhsengland.org.uk
