Orthopaedic Thromboprophylaxis: Experience from Derriford Hospital Tim Nokes Consultant Haematologist Derriford Hospital, Plymouth

Overview The scene! What are the risks? ‘Agenda for Change’ Implementation Pitt falls ‘Closing the loop’

Derriford Hospital, Plymouth

Derriford Hospital 1150 beds, one site, local population 450,000 16 Orthopaedic surgeons Thrombosis Committee since mid 2006 Nurse-led DVT clinic since mid 2002 Hospital Doctor Award for thromboprophylaxis in Orthopaedic surgery

DVT clinic Nurse-led clinic 106 new referrals per month (mon-fri) 360 attendances per month Biggest contributor to Verity Database Uses Verity as local audit toll & for comparisons to other hospitals

What is the burden of Hospital VTE? The prevention of VTE in hospitalised patients Health Select committee, March 2005 ‘It kills over 25,000 people a year, costs the NHS £640 million but is largely preventable through cheap and effective drugs’. ‘Venous Thromboembolism (VTE) is a killer that most of us remain unaware of. Yet currently it's responsible for more deaths than breast cancer, AIDS and traffic accidents combined, and twenty-five times the number of deaths from MRSA’. DH produced response to the select committee report in July 2005: Including setting up of thrombosis committee and development of Expert working group (Chaired by Anita Thomas). Report completed Sept 07 NICE issued guidelines on prophylaxis for VTE in surgical patients (April 07), Expert working group document published in same week!

The absolute risk of VTE in Hospitalised patients. ACCP 2004 Incidence of Hospital-acquired DVT: 10-80% 10 fold increase in symptomatic VTE in hospitalised patients 25-33% affect proximal veins. 10% Hospital deaths attributed to PE VTE recognized as most serious complication in many patient groups. Increasing prevalence: aging population, more cancer, complex surgery & other treatments ACCP document is recognised as world leading doc on VTE prophylaxis. Soon to be reviewed.

Table 4 – Absolute Risk of DVT in Hospitalised Patients (ACCP, 2004) Patient Group DVT Prevalence % Medical Patients 10 – 20 General Surgery 15 – 40 Major gynaecologic surgery Major urological surgery Neurosurgery Stroke 20 – 50 Hip or knee arthroplasty, hip fracture surgery 40 – 60 Major trauma 40 – 80 Spinal cord injury 60 – 80 Critical care patients 10 - 80 Asymptomatic DVT by screening. Not known who will develop symptomatic DVT, therefore useful data.

Patients referred to Derriford DVT clinic following orthopaedic surgery (within 6 weeks)  

DVTs in local Orthopaedic patients! Confirmed symptomatic DVTs in orthopaedic patients, totalled a mean of 2.3 patients (1-7) each month over a two year period

PE doesn’t occur in orthopaedic patients does it?

The Orthopaedic scene UK - very varied approach to VTE risk assessment and management. Derriford Hospital – no standardised VTE management strategy. Wide variations in practice causing confusion

Recognition of the real risk in Orthopaedic patients (‘A4C’) Data from the local DVT clinic, identified an association with Orthopaedic surgery Deaths in orthopaedic patients (coroner interest) Documentation of a lack of standardisation, from audit of practice.

Setting-up standardised practice Identify an orthopaedic VTE champion! Comprehensive literature review. Obtain agreement for a unified approach from Orthopaedic surgeons Establish a multidisciplinary team: Orthopaedic surgeon, Haematologist, Anaesthetist, medical clinician and pharmacists (local + community) Meet the Coroner!

Risk Stratification Assumed risk in all patients undergoing orthopaedic surgery. All patients to receive a standard prophylactic regimen. Very-high risk patients (those with previous or strong family history of VTE, active cancer or gross obesity) were assigned a more intensive regimen.

Derriford Orthopaedic VTE Guidelines

Innovation! Patients in Plaster casts (POP) have increased risk for VTE but previously received no prophylaxis. Patient self-assessment questionnaire devised to assist compliance in fracture clinics and ED.

Further Drivers to Change NICE. Clinical Guideline No 46: April 23rd 2007 Reducing the risk of VTE in patients undergoing surgery. DH Expert working group on VTE prophylaxis in hospital inpatients: April 23rd 2007 Currently based at Derriford Hospital IPC = intermittent pneumatic compression VFP = venous foot pumps

Pit-falls Continued Compliance Other providers complying with NICE Extended prophylaxis & the community Deep-rooted concerns about bleeding in TKR Need for ongoing audit Who drives this on the ground?

Extended prophylaxis LMWH – red coded drug Other providers complying with NICE District nurses swamped No specific funding! HIT monitoring Committee set up to drive

Closing the Loop Recent data from DVT clinic shows DVTs <1 per month in orthopaedic patients We are told that protocols adhered to! Clearly ongoing audit needed Review of policies also needed – use of Aspirin questioned Further use of data from Verity required to verify effectiveness

Summary & Take Home Messages Standardised VTE risk management in orthopaedic surgery is feasible. Step-wise Data related to local VTE occurrences, helped drive the process. And has shown reductions Assign risk to all patients (including those in POP) Involvement of a multi-professional team. Liase closely with community teams to ensure smooth application of extended prophylaxis.

Acknowledgements Jonathon Keenan, Orthopaedic Surgeon Orthopaedic ward & OP senior nurses Tom Gale, Anaesthetist Zara Lester, Sister in charge, Derriford DVT clinic Charlotte Carvell, Pharmacist All staff associated with DVT clinic, Derriford Hospital Radiology, Pharmacy & Haematology labs, Derriford Hospital

References House of Commons Health Committee. The prevention of venous thromboembolism in hospitalized patients. Second report of session 2004-5. London: DoH, 2005. National Institute for Health and Clinical Excellence. Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery. April 2007. http://guidance.nice.org.uk/CG46. Department of Health. Report of the independent expert working group on the prevention of venous thromboembolism in hospitalized patients. London: DoH, 2007.