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

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 s Medical Research Council Low dose low mol wt heparins global ‘gold standard’ treatment

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

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

Developing a systems-based approach to VTE a UK perspective

UK Government’s 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 Committee’s 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

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

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 anti–Xa agent)

Developing a systems-based approach to VTE a UK perspective The National Institute for Health and Clinical Excellence (NICE) working closely with CMO’s 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

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

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

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

National & Specialist Media Coverage BBC News Online 19 April 07 The Times 20 April 07 The House Magazine 7 May 2007 The Daily Telegraph 20 April 07 The Guardian 20 April 07

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

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

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

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

Developing a systems-based approach to VTE a UK perspective Common Silent Difficult to predict Preventable High risk is identifiable High cost of inaction UK Government and CMO consider VTE a major patient issue

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

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

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

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

Developing a systems-based approach to VTE a UK perspective National VTE Strategy in England September 2007 to end of 2009 CMO’s VTE Implementation Working Group developing a national VTE risk assessment tool to be made available by Government to all hospitals (NHS and others)

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 -

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

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

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

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 England’s 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

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