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

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

3. Derriford Hospital, Plymouth

4. 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

5. 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

6. 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!

7. 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.

8. 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
Asymptomatic DVT by screening.
Not known who will develop symptomatic DVT, therefore useful data.

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

10. 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

11. PE doesn’t occur in orthopaedic patients does it?

13. 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

14. 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.

15. 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!

16. 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.

17. Derriford Orthopaedic VTE Guidelines

18. 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.

20. 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

21. 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?

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

23. 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

24. 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.

25. 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

26. References
House of Commons Health Committee. The prevention of venous thromboembolism in hospitalized patients. Second report of session 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
Department of Health. Report of the independent expert working group on the prevention of venous thromboembolism in hospitalized patients. London: DoH, 2007.