Developing a systems-based approach to VTE a UK perspective Dr Anita Thomas OBE, UK

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Developing a systems-based approach to VTE a UK
perspectiveDr Anita Thomas OBE, UK
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Developing a systems-based approach to VTE a UK
perspective

• Modern understanding of VTE
• Natural history
• Methods of prevention and
• treatment
• Professor Vijay Kakkar
• NHS research in 1970-80s
• Medical Research Council
• Low dose low mol wt heparins
• global gold standard treatment

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Developing a systems-based approach to VTE a UK
perspective
Health Committee
Health Committee
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Developing a systems-based approach to VTE a UK
perspective

• 2005 UK House of Commons Health Committee VTE
  Report
• Each year over 25,000 people in England die from
  venous thromboembolism (VTE) contracted in
  hospital
• More than combined total of deaths from breast
  cancer, AIDS and traffic
• accidents, more than twenty-five times the
  number deaths from MRSA
• Figures alarmingly high. Many of these deaths
  are preventable
• Safe, efficacious and cost effective method of
  preventing venous
• thrombosis not as widely administered as
  should be

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Developing a systems-based approach to VTE a UK
perspective
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Developing a systems-based approach to VTE a UK
perspective

• UK Governments formal response to Health
  Committee
• Government agrees with Health Committee that much
  more needs to be done - too many preventable
  deaths from venous thromboembolism in
  hospitalised patients
• Health Committees estimate of 25,000 deaths a
  year due to VTE is a serious issue which requires
  rapid and comprehensive action
• Welcome advice and information Health Committee
  provided

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Developing a systems-based approach to VTE a UK
perspective

• Recognise there is no systematic approach to
  identifying and treating those patients at risk
  from VTE in hospitals - significant room for
  improvement
• Not just people at risk from developing VTE in
  hospitals need to ensure robust risk assessment
  but also consider people with existing VTE
  conditions

Bergan et al NEJM 355 488-498
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Developing a systems-based approach to VTE a UK
perspective

• Chief Medical Officer (CMO) England, Professor
  Sir Liam
• Donaldson established an independent expert
  working group
• consider how current best practice and guidance
  can be promoted and implemented
• what resources might be needed to support
  delivery of strategy through existing structures
• include consideration of need to promote or
  clarify existing guidance
• on use of
• mechanical devices (foot-pumps)
• aspirin
• other pharmacological preparations (heparin or
  other antiXa agent)

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Developing a systems-based approach to VTE a UK
perspective

• The National Institute for Health and Clinical
  Excellence (NICE) working closely with CMOs VTE
  Implementation Working Group
• NICE recently published guidelines on VTE for
  surgical inpatients in England and Wales - in
  2009 are due to publish guidance for all
  hospitalised patients
• Suite of guidance will provide an important
  contribution to national VTE Strategy in England

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Developing a systems-based approach to VTE a UK
perspective

• VTE expert group considered best existing
  guidelines
• for thromboprophylaxis
• All medical patients
• Intermediate-risk surgical patients
• Low risk surgical patients

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Developing a systems-based approach to VTE a UK
perspective

• Report of the VTE expert group published by the
  Chief
• Medical Officer/Department of Health on 19 April
  2007

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Developing a systems-based approach to VTE a UK
perspective

• CMO announcement
• Every hospital patient must be assessed to
  prevent
• potentially fatal blood clots
• Widespread media coverage across England
• National newspapers
• The Times Guardian Daily Telegraph
  The Sun
• National online
• BBC.co.uk
• National regional broadcast
• BBC News 24 Sky News Radio Sky News BBC
  Radio 2 Heart 106
• Specialist magazines
• BMJ, Hospital Doctor, The House, Health Services
  Journal
• Regional newspapers

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National Specialist Media Coverage
The House Magazine 7 May 2007
The Daily Telegraph 20 April 07
The Times 20 April 07
The Guardian 20 April 07
BBC News Online 19 April 07
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Developing a systems-based approach to VTE a UK
perspective

• Key recommendations of the report
• A VTE risk assessment of every patient on
  admission to hospital in England
• Raising awareness and improving understanding of
  VTE by patients public and professionals
• Establishing exemplar centres to share best
  practice throughout the NHS and wider healthcare
  settings

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Developing a systems-based approach to VTE a UK
perspective

• Recommended effective preventative measures
• For medical patients, particularly those at
  increased risk, low dose heparins
• For intermediate surgical risk patients (or any
  surgical patients with concomitant medical
  conditions) low dose heparins and graduated
  stockings
• Low risk surgical patients do not require
  specific prophylaxis
• Aspirin is not recommended for medical patients
  or for intermediate and low-risk surgical
  patients

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Developing a systems-based approach to VTE a UK
perspective

• Government announces a national strategy for VTE
• June 2005 Government published response to Health
  Committee on the prevention of venous
  thromboembolism in hospitals
• Established an independent expert working group
  to make recommendations on developing a national
  strategy on the prevention and treatment of
  venous thromboembolism (VTE)
• Report and recommendations of the expert group
  presented to the CMO in July 2006

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Developing a systems-based approach to VTE a UK
perspective

• It is clear from the expert group's report that
  introducing a VTE risk assessment for all
  patients on admission has the potential to save
  thousands of lives every year
• We have therefore established an implementation
  working group which will develop a national risk
  assessment tool, and will provide leadership both
  within the NHS and the wider healthcare sector to
  assess what needs to be done to ensure that a VTE
  risk assessment of every patient on admission to
  hospital becomes a reality

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Developing a systems-based approach to VTE a UK
perspective
UK Government and CMO consider VTE a major
patient issue

• Common
• Silent
• Difficult to predict
• Preventable
• High risk is identifiable
• High cost of inaction

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Developing a systems-based approach to VTE a UK
perspective

• COMMON
• 25,000 VTE hospital deaths 50,000 hospital
  community in England
• 1 in 5 medical patients develop VTE if no
  prophylaxis
• Around 1 in 4 of all VTE (hospital and community)
  occur in medical patients in hospital

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Developing a systems-based approach to VTE a UK
perspective

• SILENT
• DIFFICULT TO PREDICT
• Less than 1 in 10 fatal pulmonary emboli
  diagnosed before death

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Developing a systems-based approach to VTE a UK
perspective

• AT RISK
• Medical patients
• ¾ of all fatal PEs occur in patients admitted for
  non surgical reasons
• Admission with acute medical illness increases
  risk x 8
• Risk often unrecognised by clinicians
• Immobility Older patients Chronic Disease
• Risk profile similar to heart disease and stroke
• Surgical patients
• Immobility Individual risk Procedures

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Developing a systems-based approach to VTE a UK
perspective

• COSTLY
• Lives and long term illness of people of all ages
• Total cost of managing VTE around 640m (appx
  936m Euros) in UK each year
• At least 68m (appx 100m Euros) paid or
  outstanding for litigation re VTE related
  conditions over last 10 years

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Developing a systems-based approach to VTE a UK
perspective

• National VTE Strategy in England
• September 2007 to end of 2009
• CMOs VTE Implementation Working Group developing
  a national VTE risk assessment tool to be made
  available by Government to all hospitals (NHS and
  others)

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Developing a systems-based approach to VTE a UK
perspective

• Hospitals in England risk assess all patients on
  admission by end of 2009
• Exemplar VTE sites (hospitals, Primary Care
  Trusts) promote best practice
• Current exemplar VTE hospitals Kings College
  Hospital London (NHS) and the London Clinic
  (Independent Sector)
• Information on national risk assessment tool and
  exemplar sites to be made available on Department
  of Health VTE web pages - www.dh.gov.uk/vte

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Developing a systems-based approach to VTE a UK
perspective

• Encouraging high quality research and innovation
  within the NHS
• Providing leadership by working closely with key
  stakeholders including professional bodies and
  societies

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Developing a systems-based approach to VTE a UK
perspective

• Catalyst for patients and patient representative
  organisations to influence VTE prevention at
  hospital level.
• VTE Implementation Working Group in England
  partnered with Plymouth Hospitals NHS Trust and
  the Thrombosis Research Institute, London

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Developing a systems-based approach to VTE a UK
perspective
Patient admitted to hospital
What will success look like?
Professional workforce aware of VTE risks Able
to institute timely prophylaxis
Individual patient risk of VTE assessed
Appropriate preventative strategy implemented
Evaluation of outcome
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Developing a systems-based approach to VTE a UK
perspective

• Prevention of VTE is emerging as a major patient
  safety issue across Europe
• CMO for Englands VTE Implementation Working
  Group welcomes the opportunity to share our
  experience and learn from those of other European
  countries
• Developing and implementing a national strategy
  to reduce the many thousands of avoidable deaths
  from VTE in hospitalised patients

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Developing a systems-based approach to VTE a UK
perspectiveDr Anita Thomas OBE, UK