Preventing Hospital Acquired Thrombosis

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Preventing Hospital Acquired Thrombosis

• Simon Noble
• Peggy Edwards

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Preventing HAT

• The problem
• The solution
• The political agenda
• What's new.

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PE responsible for 10 of deaths in hospital.
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The problem
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Prolonged immobilisation

• post-partum thrombosis known since the middle
  ages (milk leg)
• car-travel related venous thrombosis in the 1930s

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During bombing of London in WWII, 6-fold increase
of pulmonay embolism in people seeking shelter
Reduced by replacing deck chairs by beds
(Simpson, Lancet 1940)
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Emma Christofferson
October 2000 28-year old woman dies from
pulmonary embolism shortly after arrival at
Heathrow airport, after a 20-hour journey from
Australia
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(The Mail on Sunday, 17/12/2000)
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(Daily Mail, 18/11/2000)
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(The Sunday Telegraph, 28/1/2001)
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Daily Mail 3/2/01
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The Guardian Thursday June 9th 2005
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Thromboprophylaxis in hospitalised patients

• House of Commons Health Committee 2005

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• 25,000 Deaths from Hospital Acquired DVT

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Thromboprophylaxis in hospitalised patients

• House of Commons Health Committee 2005

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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

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Within Wales

• 1000 lives campaign
• CMO risk assessment tool
• All Wales Guidelines

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Virchows triad

• Circulatory
• stasis

• Endothelial
  Hypercoagulable
• injury
  state

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Simple steps can make a huge change for care

• Risk assessment
• Thromboprophylaxis to those at risk

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Thrombosis risk

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

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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)

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Surgery

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  Circulatory stasis
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  - Anaesthetic
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  - Bed rest

• Endothelial injury
  Hypercoagulable state
• - Surgery -inflammatory processes

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Surgical prophylaxis

• In absence of contraindications use a
  combination of
• Pharmacological
• LMWH
• Fondaparinux
• Mechanical
• TEDs
• Footpumps
• IPCs

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Barriers to implementation

• DVTs! Never see them!
• Dangerous stuff that LMWH.
• Aspirin is much safer.

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General Medical patients

• Accounts for 30 all HAT
• Highest in
• Acute infections
• Heart failure
• Stroke

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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

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Hold on what about TEDs?
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No evidence in medical patients.

• All supporting studies in surgical patients.
• MEDENOX
• No additional benefit from adding TEDs

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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?

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CLOTS study

• Acute stroke patients n2518
• Full length TEDs vs usual care
• DVTE 10 vs 10.6
• No benefit from TEDs
• (NEJM 2009)

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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)

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Any surprises in the new guidelines?

• Aspirin is out!
• NICE has been developed with BOA so their
  response will be measured.

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Challenges

• Detecting rates of HAT
• Implementing guidelines
• Demonstrating benefit

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So how are we going to do it?

• 15th December
• City Hall
• Lifeblood 1000 Lives joint study day

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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

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Many thanks

• See you soon.