1. IMPLEMENTING GUIDELINES AND REDUCING PATIENT RISK OF VENOUS THROMBOEMBOLISM IN A LARGE UK TEACHING HOSPITAL Sharron Millen, Head of Clinical Pharmacy and Juliane Kause, Consultant in Acute Medicine and Critical Care, Southampton University Hospital NHS Trust, Southampton, Hampshire (UK ) Background Venous thromboembolism (VTE) causes an estimated 25,000 preventable deaths 1. As a result prevention and management of VTE is promoted within the NHS 2. The National Institute of Clinical Excellence (NICE) has issued guidance 3 on the use of thromboprophylaxis in surgical patients but not yet in medical patients. Anticoagulants are the cornerstone of successful prophylaxis and are one of the classes of medicines most frequently identified as causing preventable harm to patients as recognised by the National Patient Safety Agency (NPSA) 4. In recognising this area as a national priority, Southampton University Hospitals Trust (SUHT) established a Thrombosis Committee, developed local guidelines and formalised a structure to implement them. To ensure that the guidelines were being used effectively an audit was conducted with the aim to determine whether patients are risk assessed and prescribed appropriate thromboprophylaxis. Method Southampton is one of the largest teaching hospitals in the south of England, serving a population of 500 000 from diverse backgrounds. Every year the 7500 staff employed by the trust, treat 115000 in-patients and day patients including 40 000 emergency admissions. Specialist services at the trust include: neurosciences, cardiac services and children’s intensive care. Data was collected during October 2006 and October 2008 from representative clinical areas: emergency department, acute medicine, general medicine, cancer care, gynaecology, surgery and orthopaedics. For each of these areas 30 patients were reviewed using an electronic audit tool, gathering the following information: patient demographics, risk assessment documentation, thromboprophylaxis modality and if pharmacological thromboprophylaxis: indication, dose, frequency and duration of heparins. Compounding factors influencing thromboprophylaxis were also recorded: admission diagnosis, length of stay, renal failure, contraindications to enoxaparin, systemic anticoagulation and antiplatelet medications. Oct 2006Oct 2007Oct 2008 SUHT thrombosis committee TP Nurse Specialist March 2008 Trial of risk assessment stickers Nov 2007April 2008 NICE Surgical guidelines ACCP Medical guidelines CMO request for thromboprophylaxis NICE Medical Guidelines SUHT Trust Induction Core Medical Education Results Our audit included 163 patients in the first cycle (1) and 186 patients in the second cycle (2). There were comparable patient demographics in both data sets. Risk assessment documentation, including risk factors for VTE, was poor. Risk assessment document completion improved from 8% (n1=13) to 24% (n2=45) between audit cycles, largely due initiation of prescribing being supported by aide memoire stickers. Thromboprophylaxis given improved from 12% (n1=19) to 83% (n2=155) between October 2006 and October 2008. However, the percentage of appropriate thromboprophylaxis given was smaller: The discrepancies occurred due to the dosages of low molecular weight heparins and the false assumption that patient on antiplatelet medication do not require the usual protocolised thromboprophylaxis. At the same time, hypersensitivity and contraindications to Low Molecular Weight Heparins (LMWH) were poorly documented Concurrently, enoxaparin usage increased by 28% in our hospital. Confusion about co-prescribing of LMWH with oral antiplatelet drugs, such as aspirin and clopidogrel was widespread. However when LMWH were prescribed this followed our guidelines. Expected duration of thromboprophylaxis prescribing was only well documented in elective orthopaedic and elective surgical patients. Conclusion Within our organisation prescribing of LMWH is improving but not yet achieving the national standard. Expected duration of thromboprophylaxis was well documented in elective orthopaedic and elective surgical patients. Actual prescribing followed guidelines. Particular attention must now focus on risk assessment and it’s documentation. It appears that in those patients, whose risk assessment was documented, accurate prescribing occurred frequently, whereas the errors associated with choice, dose and duration of LMWH occurred in those patients without any risk assessment documentation. Confusion about co-prescribing of LMWH with oral antiplatelet drugs, such as aspirin and clopidrogel was widespread, and was captured in written comments from staff during the audit process. Additional training and education are required, focusing on risk assessment and correct dosage in particular. We have implemented further education since this audit and have already seen improvements in our thromboprophylaxis compliance. Implementation of electronic prescribing systems and patient involvement by own risk assessment would aid this process. References Quotes Doctors: “Normally documented in notes, although maybe I should document reassessment” “Not doctors role” “Patient already on Aspirin and Clopidogerel.” Pharmacist: “Takes time, often have too many jobs to do” “ Don't feel it is my clinical decision-I may be unaware of pts risk factors” Nurses: "I thought the Dr's did it" "I don't complete admission notes" “Leave it to the medical team-but flag it up to them" "Didn't know there was one" (risk assessment) "not on ward at time of assessment" 1. Report of the independent expert working group on the prevention of venous thromboembolism in hospitalised patients. DOH; Gateway Ref 7666, March 2007 1. 2. Letter from Sir Liam Donaldson. DOH; Gateway Ref 6855, April 2007 2. 3. Venous Thromboembolism. Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients undergoing surgery. ISBN 0-9549760-3-7, 3. April 2007 (NICE) 4. 4. NPSA alert. Ref NPSA/2007/18, March 2007