Assessing the uptake of national initiatives to improve venous thromboembolism patient care in the UK Roopen Arya, Aidan McManus, Shankaranarayana Paneesha, Nicholas Scriven, Tim Nokes, Tim Farren, Anthea Nieland, Peter Rose, Sue Bacon, Denise O'Shaughnessy, for the VERITY Investigators

The last 5 years has seen an enormous increase in awareness and change in perception of VTE prevention It is the change in perception of VTE to a patient safety issue that has impacted enormously on health care system’s approaches to VTE prevention In England, there is now a National VTE Prevention Programme in place, mirroring activities in other western health care systems

Background UK - patients at risk for VTE (in 2007) Cross-sectional survey in 32 countries across 6 continents – Medical patients (37,356) – Surgical patients (30,827) Assessment of prevalence of VTE risk in the acute hospital care setting (ACCP guidelines) – Medical patients (15,487) – Surgical patients (19,842) Proportion of at-risk patients who received prophylaxis – Medical patients (42% [40% ACCP-recommended]) – Surgical patients (64% [59% ACCP-recommended]) Lancet 2008;371:387 4

Background UK - patients at risk receiving prophylaxis (in 2007) Lancet 2008;371:387 5

National risk assessment audit Second annual audit of acute NHS Hospital Trusts (2008) 99% of Acute NHS Hospital Trusts are aware of the CMO & NICE clinical guidelines on VTE prevention 70% of Acute NHS Trusts are undertaking a documented mandatory risk assessment for all hospital inpatients 86% of Acute NHS Hospital Trusts have a thrombosis committee responsible for the management of DVT patients 87% of Acute NHS Hospital Trusts offer staff some form of education regarding hospital-acquired DVT risk assessment

Study objective To survey current VTE practice with respect to risk assessment, thromboprophylaxis, audit and education in UK centres with a specialised interest in VTE management VERITY centres VERITY PUSH initiative centres VTE Exemplar centres To review the findings in the context of aspects of VTE treatment practice Compliance with NPSA on anticoagulation O/P management of PE

Survey participants VERITY (Venous Thromboembolism Registry) VTE registry – outpatient VTE treatment Records patients presenting with suspected and confirmed VTE Data on demographics, management & outcomes Extensive risk factor data PUSH initiative - consecutive patients with 26 week follow-up

Survey participants VTE Exemplar Centres Resource for demonstration of best practice Based within hospitals or networks with an existing track record of excellent VTE management Expanded role including quality control, audit and education Mechanism in place for VTE risk assessment Audit trail – evidence of prevention management across organisation

Methods Data collection VERITY Steering Committee developed a questionnaire of 23 questions to examine practice in the diagnosis, treatment and prevention of VTE We identified a nurse or physician at each centre who were part of the leadership team in VTE management Mailed package with 2-page questionnaire, personal letter and stamped return envelope in early November 2008. Re-mailed questionnaire with reminder letter at 6 & 8 weeks Closure date: Jan 6, 2009 Individual responses were kept confidential Questionnaire completion was voluntary

Results Centres participating in the survey VERITY Exemplar PUSH Hospitals (n=52) VERITY 47 PUSH 9 Exemplar 7 38 9 2 5 Lancet 2008;371:387 12

Centres completing survey

Is there a local thrombosis committee?

Have you audited the use of risk assessment?

Have you audited the use of risk assessment Have you audited the use of risk assessment? - If yes, % patients risk assessed 60% (n=9) centres responded 95 92 90 80 50 16 VERITY PUSH EXEMPLAR

Which risk-assessment tool? VERITY PUSH EXEMPLAR

Thromboprophylaxis guidelines?

Have you audited the use of prophylaxis?

Have you audited the use of prophylaxis Have you audited the use of prophylaxis? - If yes, % patients receiving appropriate prophylaxis 90 83 45 50 37 10 VERITY PUSH EXEMPLAR

Local VTE education?

VTE treatment practice Compliance with NPSA on anticoagulation 92 % compliant or mostly compliant O/P management of PE 38% provide service

VERITY Centre with no local Thrombosis Committee Compliance with NPSA on anticoagulation Complete compliance O/P management of PE Yes Risk assessment audit/prophylaxis audit No/no Local VTE education No

Discussion Survey response was disappointing National audit vs. specialist centre audit: Thrombosis committees VTE education = Risk assessment Risk assessment audit was low Risk assessment completion was low (97% of centres used >1 risk assessment tool)

Discussion Limitations Survey does not provide ‘real data’ but physician or nurse perception Concern that errors of omission, confusion, false memory are committed Our own biases may have influenced the survey by our feelings affecting the survey wording We can’t comment on non-respondent practice bias

Conclusions Prophylaxis & risk assessment rates vary widely across the UK, even in centres of national excellence (exemplar centres) Prophylaxis practice is more advanced than risk assessment (too many risk tools?) Risk assessment tools are in place Disconnect between advanced VTE treatment practice and prevention practice Healthcare system must support universal risk assessment of all hospitalised patients