1. Risk assessment for VTE
Dr Roopen Arya

2. VERITY & VTE risk VERITY risk factor data
VERITY thromboprophylaxis data
Thrombosis prevention in the NHS
Risk assessment & risk scores
The way forward

10. VERITY and thromboprophylaxis
Most cases present after discharge
Data highlight risk in medical and surgical patients
Variation in thromboprophylaxis

11. Thrombosis prevention in the NHS
House of Common Health Committee Report March 2005
Government response July 2005
CMO publishes Independent Expert Working Group report April 2007
NICE guidance re: surgical patients April 2007

12. Health Committee: Key themes
Awareness
National guidelines
NICE guidelines (2007)
Education
Implementation
Risk assessment
Thrombosis Committees
Thrombosis Teams

13. Government response to Health Committee report July 2005
CMO communication re: existing guidance
Independent VTE experts working group:
review evidence & guidelines
framework for implementation
make recommendations to CMO
Discuss with NICE a separate clinical guideline covering patients excluded from the scope of current guidance.
CMO to write to relevant bodies involved in medical education regarding necessary changes in curricula.

14. Independent VTE Expert Group
Quickly assess available guidance
Consider use of mechanical devices and clarify the role of aspirin
Consider VTE awareness and education
Better monitoring systems to improve data on VTE outcome and mortality
Make recommendations regarding implementation of thrombosis prevention

15. CMO Recommendations April 2007
CMO communication: published VTE Expert Working Group’s guidance in full
1. Systems, processes and knowledge base
Documented mandatory risk assessment (all hospitalised patients)
VTE risk assessment embedded in CNST
Improved public/professional understanding of VTE (communication, information, education)

16. CMO Recommendations April 2007
1. Systems, processes and knowledge base (cont)
VTE demo sites (strategy, educational material, develop national risk assessment strategy, advice)
Core Standards from DOH to ensure compliance with risk assessment
HCC monitors standards
Evaluate impact on patient: systematic approach to ensure compliance, communication strategy, better outcome measures, raise awareness)

17. CMO Recommendations April 2007
2. Thromboprophylaxis Strategy (Medical)
All medical patients considered for thrombo-prophylaxis as part of mandatory risk assessment
Particularly > 4 days in hospital, Reduced mobility
Heart failure, Resp failure, Acute infection, Inflammatory illness, Cancer
Regimen:
UFH/LMWH(preferred)
Aspirin not recommended
Mechanical not recommended (no current evidence)

18. CMO Recommendations April 2007
2. Thromboprophylaxis Strategy (Surgical)
All high risk surgical/orthopaedic patients managed according to NICE guidance
Intermediate risk surgical: mandatory risk assessment
GCS+heparin
Not aspirin
Low risk surgical: early mobilisation only

19. NICE clinical guideline 46: VTE Key priorities for implementation
Risk assessment
Patient information
Thigh-length graduated compression / anti-embolism stockings
Patients shown to wear them correctly
Intermittent pneumatic compression or foot impulse devices may be used as alternatives or in addition to AES.

20. NICE clinical guideline 46: VTE Key priorities for implementation
In addition to mechanical prophylaxis, patient at increased risk of VTE because they have individual risk factors and patients having orthopaedic surgery should be offered LMWH.
Fondaparinux, within its licensed indications, may be used as an alternative.
LMWH or fondaparinux continued for 4 weeks after hip fracture surgery.
Suitability of regional anaesthesia considered.
Early mobilisation after surgery.

21. Risk Assessment & Clinical Governance
The highest ranking safety practice was the appropriate use of prophylaxis to prevent VTE in patients at risk.
AHRQ “Making Health Safer: A Critical Analysis of Patient Safety Practices” 2001
We recommend that every hospital develop a formal strategy that addresses prevention of thromboembolic complications. This should generally be in the form of a written thromboprophylaxis policy especially for high risk groups.
ACCP guidelines “ Prevention of VTE” 2004

22. Risk Assessment & Clinical Governance
Identifying at-risk patient
Counselling at-risk patient
Prescribing
thromboprophylaxis

23. Individual Risk Assessment for Internal Medicine Patients
Ischaemic stroke with paralysis
Acute decompensation of COPD with ventilation MI
Heart failure NYHA III + IV
Acute decompensation of COPD without ventilation
Sepsis
Infection/acute inflammatory disease: bed rest
Infection/acute inflammatory disease: non-strict
bed rest
Central venous lines or port system
No acute risk
Class of exposing risk 3 3
Increased risk 2 2 1
Low
risk 1 1 2 3
Class of predisposing risk
No basic risk
Dehydration
Polycythaemia or
thrombocytosis
Varicosis
VTE in family
HRT
Obesity
Age 65 years
Pregnancy
Oral contraception
Nephrotic syndrome
Myeloproliferative
syndrome
2 risks from
category 1
Thrombophilia
History of VTE
Active malignancy or
3 risks from
category 1
2 risks from
category 2 1 2 3
COPD: chronic obstructive pulmonary disease HRT: hormone replacement therapy
Lutz L et al. Med Welt 2002;53:231–4

24. KCH guidelines for medical thromboprophylaxis

25. Venous thromboembolism risk score
Kucher, N. et al. N Engl J Med 2005;352:

26. Risk score for VTE Clinical Feature Score
Active cancer (treatment ongoing or within 6 months or palliative) 3
Personal history of VTE
Thrombophilia
Recent major surgery 2
Advanced age (≥ 75 years) 1
Obesity (BMI >29)
Bed rest
Hormonal therapy (OCP/HRT)
Kucher, N. et al. N Engl J Med 2005;352:

27. Risk score for VTE
The computer program alerted physicians to the increased risk for VTE and more than doubled the
rate of prophylaxis (14.5% to 33.5%)
Overall rate of VTE at 90 days was reduced by 41%
Kucher, N. et al. N Engl J Med 2005;352:

28. Risk score analysis using VERITY
Retrospective analysis of risk score in VERITY population aiming to validate this as a decision aid to enable use of thromboprophylaxis.
Risk score applied to complete population (VTE +ve and VTE –ve patients)
Examine risk factor profiles in our patients and reveal existing levels of thromboprophylaxis.

30. The way forward
Implementation of VTE Expert working group & NICE guidance
National: Implementation working group
Develop a national risk assessment tool
Provide leadership
Local: thrombosis committees
local guidelines
100% risk assessment
Role of VERITY