Background

As we are all aware, there was huge media interest in Deep Vein Thrombosis (DVT); mainly surrounding the so called ‘economy class syndrome’ and airlines were being sued.  Victims of DVT demanded that there should be European Union (EU) action to prevent them and consequently DVT became a much talked about issue

John Smith MP raised the issue in Parliament and the Department of Health (DoH) asked the Health Select Committee to investigate the problem.  A report was produced in 2005 by the committee and it was the first time in history that all the recommendations of the Health Select Committee have been taken up by the DoH.  The UK National Institute of Clinical Excellence (NICE) were commissioned to produce guidelines by for patients admitted to hospital by April 2007 and a VTE working party was asked to produce some guidance for the Chief Medical Officer (CMO) by July 2006 for the population NOT covered by NICE – these guidelines were published in April 2007

‘Highs’

The NICE guidance was welcomed as it was hoped that it would remove the controversy that existed between the different senior physicians (consultants) and specialities and thus reduce the continual dialogue that surrounded the use of aspirin, footpumps and LMWH

The NICE guidance raised awareness of the issue of thromboprophylaxis and it was easily assessable to all healthcare professionals (HCPs.) 

NICE guidance helps HCPs to deliver high quality care and conforms to Clinical Governance.

Following the publication of the NICE guidance there was an increase in the uptake of thromboprophylaxis in our Hospital Trust

‘Lows’ – the reality

Although most of the senior physicians (consultants) were happy with the guidance some doctors felt that they had had their clinical decision  and individual approach to their patient care removed from them In the main, it is orthopaedic consultants that appear to disagree with the guidance and indeed the British Orthopaedic Association has written to NICE with their concerns - which rightly need to be aired.

The advice from NICE to offer and fit all patients with thigh length antiembolic stockings has met some resistance:

a)  There is no clear evidence that thigh length are any better than below knee (see Health Technology Assessment 2005)) so why recommend them?

b)  The VTE working party suggest below knee

c)  As HCPs we are aware that well fitting thigh length stockings are few and far between and poor fitting stockings can cause more harm than good.

In our Trust we have agreed through the thrombosis committee and with the backing of the vascular surgeons that we will fit below knee socks as standard.

The list of predisposing factors is too long (difficult to remember) and cites some very obscure conditions not often seen; which simply adds to the confusion as to whom should receive thromboprophylaxis.

There is a recommendation for extended prophylaxis for e.g. Total Hip Replacement (THR) and Fracture of the neck of femur (#NOF) but who is going to pay for it?  The PCT and the Acute Trust are still discussing the problem

Orthopaedic Surgery

Recently we have had an increased in the number of GI bleeds in those patients with #NOF who have had extended prophylaxis – 5 admissions in 2 weeks - Is this a coincidence?

Consultants are aware of the admissions for a GI bleed but they are less aware of the incidence of VTE. Wound haematoma is a major concern in joint replacement surgery and quite rightly a potential increase in the incidence of this does give cause for concern.

Should patients be risk assessed prior to implementing the NICE guidance for extended prophylaxis or should we take a blanket approach and give the LMWH to all? 

Despite guidelines:-

Case history

• Patient admitted for day case arthroscopy
• Previous PE 4 years ago
• LMWH prior to surgery – as per guidelines
• Antiembolic socks measured – as per guidelines

Post op

• Developed asthmatic complications and stayed in hospital for 4 days – no reassessment and no thromboprophylaxis given

• Seen in DVT clinic 2 weeks later  - calf vein DVT

Questions: - Why was she not reassessed?

Possible answer -  medical condition treated on orthopaedic ward  - no NICE guidance for medical patients at the moment but we  have a prophylaxis policy on the medical wards – LMWH for all unless contraindications

HOW CAN WE;-

Implement the guidance?
Improve the patient education?
Obtain more patient information leaflets?
Increase awareness amongst all HCPs and thus improve the uptake of thromboprophylaxis?
Prevent similar cases in the future?

Scarborough

• There is a Clinical Nurse Specialist in DVT whose role is not just facilitating the care for the patients with a suspected/proven DVT but also education of all HCPs  re thromboprophylaxis

• We have formed a thrombosis committee looking at all aspects of thrombosis, both prevention and management.

• A risk assessment for VTE has been incorporated into the new nursing documentation, including the thromboprophylaxis recommendations.  The VTE risk is assessed by the admitting nurse and the result transcribed onto a VTE risk assessment sticker that has been added to the current drug chart, in order to inform the doctor of the VTE risk and thus enable appropriate prescription of LMWH if required.

• A patient alert has been added to the patient information system so that when a patient with a history of VTE is admitted the ward clerk is able to print out the alert and inform the doctor immediately.

• All HCPs are receiving education and awareness of VTE but this has still to be improved.

• We hope to print some new patient information leaflets which will, hopefully, encourage the patient to reduce the risk of VTE

• Patients who have a plaster cast fitted should have a risk assessment prior to fitting the cast and the development of a simple protocol is in hand.

• We hope to print a thrombosis newsletter which could be linked to the VERITY website and perhaps include audits from across the Trust and maybe link in with information from other Trusts?

• We wish to extend the DVT Service to at least two nurses in order to implement the above and to also improve the care given to the DVT patients but…..pigs might fly but we have to aim high!

In the main the NICE guidance has increased awareness of the problem of thromboprophylaxis.

There are clearly some issues with the current guidance which are being addressed

Bringing about change in any situation is difficult and will not happen overnight.

In order to prevent VTE there needs to be a continual educational programme, regular audit and feedback.

Watch this space!