Transcript Risk Assessment for VTE - King's Thrombosis Centre

VTE Risk Assessment
Dr Roopen Arya
King’s College Hospital
London
[email protected]
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
Health Committee: Key themes
Awareness
 National guidelines
 NICE guidelines (2007)
 Education
 Implementation
Risk assessment
Thrombosis Committees
Thrombosis Teams

Health Committee recommendations 2005

We recommend that procedures for counselling both medical
and surgical patients be supported by hospital specialist
thrombosis teams and included in the VTE guidelines developed
by NICE.

We recommend that all patients, both medical and surgical, who
are admitted to hospital undergo a risk assessment for venous
thrombosis.
CMO Recommendations April 2007

Published VTE expert working group’s guidance in full

Documented mandatory risk assessment for all hospitalised
patients

VTE risk assessment embedded in local risk management
structure

Improved public/professional understanding of VTE

VTE exemplar centres

Guidance on thromboprophylaxis
NICE clinical guideline 46: VTE
Key priorities for implementation

Risk assessment

Thigh-length graduated compression / anti-embolism stockings

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.

LMWH or fondaparinux continued for 4 weeks after hip fracture
surgery.
The way forward

Implementation of existing national guidance

National: Implementation working group
Develop a national risk assessment tool
Provide leadership
Exemplar Centres

Local:
thrombosis committees & teams
local guidelines
100% risk assessment
VTE Implementation Working Group
 Develop
a national VTE risk assessment
 Develop
Exemplar Centres
tool
 Raising
awareness
 Education
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 the 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
Risk Assessment for VTE
Identifying at-risk patient
Counselling at-risk patient
Prescribing
thromboprophylaxis
VTE risk assessment tool
Risk assessment is trigger for prophylaxis
 Evolve from existing guidelines
 Specialty-specific, procedure-specific
 Template that may be adjusted for local use
 Standards for implementation and audit
 Risk assessment – key performance measure

Risk assessment: practical aspects
Specialty-specific policy agreed by hospital
thrombosis committee, owned by specialties
 Individualised vs Group-targeted risk
assessment
 Appropriate evidence-based local guidelines
 Mechanical
Pharmacological prophylaxis
 Explicit guidance regarding aspirin

Risk assessment: key elements

Procedure-related risk of thrombosis

Patient-related risk of thrombosis

Bleeding risk & contraindications to prophylaxis

Linked to ACTION of thromboprophylaxis
Risk assessment: practical aspects

Who will perform VTE risk assessments?
Junior drs / nurses / pharmacists / patients

Stand-alone VTE RAM vs integration with other risk
assessments e.g. MRSA, falls, nutrition

Documentation:
Risk assessment forms / stickers / prescription charts /
wristbands

Computer alerts and prescriptions
VTE risk assessment
for medical patients
An Ideal RAM:
DVT Prophylaxis in Medical Patients


Accurately identify patients at risk of DVT
Predict correct risk level
– disease-specific and predisposing risk factors

Reliably exclude patients without a beneficial
risk:benefit ratio
 Evidence based and validated
 Methodologically transparent
 Simple to use in clinical practice
KCH guidelines for medical thromboprophylaxis
VTE risk assessment
for surgery
Post surgical risk of DVT
Type of operation
Incidence of DVT
Knee surgery
75%
Hip fracture surgery
60%
Elective hip surgery
50-55%
Retropubic prostatectomy
40%
General abdominal surgery
30-35%
Gynaecological surgery
25-30%
Neurosurgery
20-30%
Transurethral resection of prostate
10%
Inguinal hernia repair
10%
Incidence of DVT according to
length of surgery and age
Incidence of DVT (%)
Length of surgery (hours)
1–2
20
2–3
46.5
>3
62.5
Age (years)
40–60
20.1
61–70
36.4
> 71
62.5
Borow M, Goldson H. Am J Surg. 1981;141:245-51.
Incidence of DVT (%)
The greater the number of risk factors,
the higher the risk of DVT
60
 50%
50
36%
40
30
 24%
20
10
n = 197
n = 152
n = 48
0–1
2
3
0
Total risk factor score
(based on number of risk factors*)
*Risk factors included age > 40 years, obesity, malignancy, recent surgery,
and history of VTE.
Wheeler HB. Am J Surg. 1985;150:7-13.
Levels of VTE risk in surgical patients without
prophylaxis
Risk
ICS1
ACCP2
Highest
Patients > 60 years with
additional risk factors
 Surgery in patients with multiple risk factors
 THA, TKA, HFS
 Major trauma, spinal cord injury
High
–
 Non-major surgery in patients > 60 years
or with additional risk factors
 Major surgery in patients > 40 years
or with additional risk factors
Moderate
Major surgery for benign
disease in patients > 40
years
 Non-major surgery in patients aged
40–60 years or with additional risk factors
 Major surgery in patients < 40 years
with no additional risk factors
Low
Minor surgery without
additional risk factors
 Minor surgery in patients < 40 years
without additional risk factors
ACCP = American College of Chest Physicians; HFS = hip
fracture surgery; ICS = International Consensus Statement;
THA = total hip arthroplasty; TKA = total knee arthroplasty;
VTE = venous thromboembolism.
1Nicolaides AN,
2Geerts
et al. Int Angiol. 2006;25:101-61.
WH, et al. Chest. 2004;126(3 Suppl):338S-400S.
Frequency of VTE/PE according
to risk
Events
Low risk Moderate
(%)
risk (%)
Calf vein
thrombosis
2.0
High
risk (%)
Very high
risk (%)
10-20
20-40
40-80
Proximal vein
thrombosis
0.4
2.4
4.8
10-20
Clinical PE
0.2
1-2
2-4
4-10
0.4-1.0
1-5
Fatal PE
0.002
0.1-0.4
Chest 1998;114:531S-60S
VTE Risk Assessment for Adult Surgical Patients
Patient name:
Hospital no:
Please fill in this form, sign and file in notes
Prescribe appropriate prophylaxis on drug chart
DOB:
Risk
Category
Surgery
HIGH
MODERATE
LOW
Tick
Recommended Prophylaxis
Hip fracture, hip or knee
arthroplasty
Major trauma /spinal cord
injury
Major surgery with
additional risk factors (ARF)
Major surgery upto age 59
years with no ARF
Minor surgery with ARF
Enoxaparin 40 mg daily
+
TED stockings
+/Sequential compression device
Minor surgery with no ARF
Early mobilisation
Tick
Enoxaparin 40 mg daily
+
TED stockings
Additional Risk Factors (ARF)
Age >60 years
Personal or family history of VTE
Thrombophilia
Active cancer or treatment
Acute exacerbation of heart failure
Recent MI or ischaemic stroke
Acute on chronic respiratory disease
Sepsis
Contraindications
Enoxaparin
Creatinine >175 mol/l (CrCl< 30ml/min)
use unfractionated heparin 5000 u BD
Active bleeding
Thrombocytopenia (platelet count<50)
Known bleeding disorder
Previous HIT or allergy to enoxaparin
On therapeutic anticoagulation
Tick Additional Risk Factors (ARF)
Tick
Acute inflammatory disorder
Pregnancy and the post partum period
Hormone therapy e.g. HRT/COCP
Obesity (BMI >30kg/m2)
Immobility
Travel>3 hrs within 4 weeks of surgery
Nephrotic syndrome
Varicose veins
Tick Contraindications
Tick
Mechanical measures (TEDs / SCD)
SCD contraindicated if acute DVT present
Severe peripheral vascular disease
Severe dermatitis
Leg oedema
Leg deformity
Peripheral neuropathy
Recent skin graft
Doctor’s name
Doctor’s signature
Timing:
Duration:
Date
Thromboprophylaxis should start 6 hours post op and at 6pm daily thereafter.
Epidural/spinal analgesia - placement or removal of catheter should be delayed for 12 hrs after
administration of enoxaparin. Enoxaparin should not be given sooner than 4 hrs after catheter
removal.
At least 10 days prophylaxis is recommended for all high risk orthopaedic patients.
Extended prophylaxis (28 days) is recommended for elective hip replacement and hip fracture
patients.
Extended prophylaxis is recommended for selected high-risk general surgery patients e.g. major
cancer surgery.
2
High BMI (>30 mg/m ): use enoxaparin 40mg twice daily (or enoxaparin 60 mg bd if body weight >150kg)
Sequential compression device (SCD): Consider in high-risk patients & those unable to receive LMWH due to
high bleeding risk.
Electronic Alerts to Prevent VTE
in Medical Patients
Freedom from
DVT or PE (%)
100
98
Intervention group
96
94
92
Control group
P<0.001
90
88
0
No. at risk
Intervention group
Control group
30
60
90
Time (days)
1,255
1,251
977
876
900
893
853
839
Kucher N, et al. N Engl J Med. 2005;352:969-77.
Conclusion
•
Thromboprophylaxis
guidelines
Risk assessment
tools
•
Varied approaches:
one size DOES NOT fit all
•
Local leadership + agreement by users &
thrombosis committees essential
•
National guidance on risk assessment will be available