1. 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

2. 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

4. 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

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

6. 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

7. 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

8. 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

9. 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

10. 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.
R ed questionnaire with reminder letter at 6 & 8 weeks
Closure date: Jan 6, 2009
Individual responses were kept confidential
Questionnaire completion was voluntary

12. 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

13. Centres completing survey

14. Is there a local thrombosis committee?

15. Have you audited the use of risk assessment?

16. 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

17. Which risk-assessment tool?
VERITY
PUSH
EXEMPLAR

18. Thromboprophylaxis guidelines?

19. Have you audited the use of prophylaxis?

20. 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

21. Local VTE education?

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

23. 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

24. 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)

25. 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

26. 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