Bleeding risk tools and guidance for the timing of administering anticoagulant prophylaxis around surgical procedures or other high bleeding risk intervals should also be part of a protocol. Protocols define best practice at the local level based on the best evidence available, with operational definitions that drive order set design, measurement tools, and other aspects of the quality improvement process.
Unfortunately, there is no consensus regarding the preferred VTE risk assessment tool. VTE risk assessment is essentially a tool. Patients are targeted for interventions to prevent VTE anticoagulant or mechanical prophylaxis and efforts to improve mobility based on the assessment of risk of a VTE event. The positive potential to reduce VTE must be balanced with the discomfort, bleeding, expense, and other adverse effects that could result from the prophylactic measures.
There is no consensus on the answer to the fundamental question, "How can hospitals assess VTE risk, then ensure adequate prophylaxis for patients who need it, while minimizing excess prophylaxis, in a practical, efficient way? Several reviews of risk assessment models are available in the literature. This guide focuses on the practical issues of implementation and utility in clinical practice. Risk assessment models that are in wide use, that are featured in guidelines, or that have demonstrated efficacy in actual practice or clinical trials will be reviewed.
While this chapter will not provide definitive guidance on the fundamental question posed above, it will give VTE improvement teams the context under which to make a reasonable and thoughtful decision about what will work best in their setting. In the absence of consensus on the best risk assessment model, one approach is to avoid this issue altogether and simply present a prompt to consider prophylaxis.
A list of options for prophylaxis is presented in the following example Figure 4. The Hierarchy of Reliability Table 1. A second approach is the "opt out" approach Appendix B.
This approach has an automatic default of anticoagulant prophylaxis and assumes the great majority of inpatients are candidates for it. Ordering providers can "opt out" if they specify the patient is at low risk, on therapeutic anticoagulation, or has contraindications to prophylaxis.
While this approach is appealing for the simplicity and effectiveness in inducing high rates of anticoagulant prophylaxis, it can easily result in over-prophylaxis, which is a particular concern in medical populations. Both ACP and AT9 guidelines 13 , 14 discourage the universal prophylaxis approach for this population.
On the other hand, opt-out mechanisms can be appropriate for some services with uniformly high VTE risk. For example, an orthopedic surgery service focused on total hip replacement might have default orders for their preferred anticoagulant and mechanical prophylaxis in place, or colorectal surgeons with high volumes of cancer surgery might have combination prophylaxis as a default. Qualitative models ascribe groups of patients to broad risk categories or "buckets" of risk that are linked to appropriate prophylaxis options for each group, without going through individualized point scoring.
These models tend to be relatively easy to use and have demonstrated success in the literature and unpublished experience in reducing HA-VTE. They have sometimes been criticized for being too simplistic and for setting too low a threshold for initiating prophylaxis.
This threshold varies among the different models, however, and can be adjusted to be more discriminating.
AT8 15 and most major international guidelines incorporate qualitative models, whereas AT9 now implicitly endorses the individualized, quantitative approach, which requires summing a cumulative point score over multiple risk factors.
These quantitative, or point-based, scoring systems may be devised by expert opinion and review of the literature; they can also be derived empirically. External validation in other populations, while desirable, has only been performed on a few models. Ideally, empirically derived models are scientifically sound and preferable to expert models, but the expert-derived models Caprini and Padua, for example are in more common use, and at least some of them have anecdotal evidence of effectiveness in clinical practice.
The complexity of the scoring systems varies, but in general, these models have often been criticized for being difficult to implement and use—and, to date, effectiveness in reducing HA-VTE has not been demonstrated.
Some of these models incorporate risk factors e. Others use only risk factors available at the time of admission to the hospital. The most widely used qualitative model in the United States is the "3 bucket" or University of California UC San Diego model, which is derived directly from tables in the AT8 guideline.
In the classic "3 bucket" model Figure 4. On the other end of the spectrum, patients with major, high-risk surgeries qualify for combination anticoagulant and mechanical prophylaxis.
Most medical and surgical patients fall into the middle category, qualifying for anticoagulant thromboprophylaxis, unless they have bleeding risk factors. In the original demonstration project at UC San Diego, this model was chosen after considering and rejecting more complicated individualized point-scoring systems that proved unpopular and had poor inter-observer agreement in pilot testing.
In contrast, this risk assessment model was considered intuitive and easy to use. Direct observations revealed that it could be filled out in a few seconds, and there were high levels of inter-observer agreement.
Integration into order sets, coupled with multifaceted interventions, resulted in marked improvements in protocol-defined adequate prophylaxis from 58 percent to 98 percent and reduced HA-VTE by 40 percent in medical and surgical populations without any increase in detectable bleeding or heparin-induced thrombocytopenia.
A wide variety of other hospitals have enjoyed improved prophylaxis and reduced HA-VTE with a multifaceted approach that included variants of this VTE risk assessment model. This includes published results 19 , 21 and many unpublished results. Some of these site success stories are available PDF File, This model was updated Figure 4. Note that medical patients without active cancer or past history of VTE must have reduced mobility and an acute illness to qualify for prophylaxis.
The audit support is based on the key recommendations of the guidance and includes criteria and data collection tools. The guide to resources provides an overview of information directly related to the guidance either in terms of background, such as government policy documents, or practical help, such as pathways or toolkits.
This CPD activity consists of 5 multiple-choice questions MCQs designed to test your knowledge on venous thromboembolism in primary care—you will then be prompted to reflect on your learning.
Dr Anil Kamat shows how the NICE interactive pathway on VTE distils current guidance and support for the diagnosis, treatment, and management of this preventable condition.
Site powered by Webvision Cloud. Skip to main content Skip to navigation. All patients admitted to hospital should be assessed for risk of VTE. No comments. Who is at risk? Patients admitted for surgery, or because of injuries, should generally be considered as being at increased risk of VTE if they meet one of the following criteria: 3 They will be undergoing an operation in which the anaesthetic and surgical time is more than 90 minutes, or 60 minutes if surgery is on the pelvis or a lower limb They are an acute surgical admission with inflammatory or intra-abdominal condition with expected significant reduction in mobility They have one or more of the risk factors listed in Table 1.
Table 1: Assessing the risks of venous thromboembolism and bleeding 4 Patients who are at risk of VTE Medical patients If mobility significantly reduced for? Patients should be reassessed for risks of VTE and bleeding within 24 hours of admission and whenever the clinical situation changes to: 3 ensure that the methods of pharmacological VTE prophylaxis are suitable and being used correctly identify any adverse events resulting from prophylaxis.
Principles of care Dehydration in patients should be avoided and individuals should be encouraged to return to full mobility as soon as possible.
Methods of VTE prophylaxis Mechanical The choice of mechanical VTE prophylaxis should be based on clinical condition, surgical procedure, and patient preference. The NICE guideline recommends any one of: 3 anti-embolism stockings thigh or knee length foot impulse devices intermittent pneumatic compression devices thigh or knee length. Patient discharge The guideline emphasises the importance of providing patients with information about VTE and prophylaxis.
They should also be provided with information about: the correct and recommended duration of use of VTE prophylaxis at home the importance of using VTE prophylaxis correctly and continuing treatment for the recommended duration the signs and symptoms of adverse events related to VTE prophylaxis the importance of seeking help and whom to contact if they have any problems using the prophylaxis.
Therefore, it is important to ensure that patients: understand the benefits of wearing them understand the need to remove them for personal hygiene are able to replace them, or have someone available who will be able to do this for them look out for adverse effects, such as skin marking, blistering or discolouration, particularly over the heels and bony prominences.
Conclusion The NICE guideline aims to ensure that, at the same time as managing the presenting complaint of a patient admitted to hospital, clinicians also assess the risk of VTE and provide effective and appropriate prophylaxis. Acknowledgements The authors would like to thank Carlos Sharpin, National Clinical Guideline Centre, for comments and input on drafts of this article.
NICE implementation tools NICE has developed the following tools to support implementation of Clinical Guideline 92 on Venous thromboembolism: reducing the risk—reducing the risk of venous thromboembolism deep vein thrombosis and pulmonary embolism in patients admitted to hospital. Slide set The slides are aimed at supporting organisations to raise awareness of the guideline and resulting implementation issues at a local level, and can be edited to cater for local audiences.
Audit support Audit support has been developed to support the implementation of the NICE guideline on venous thromboembolism. Guide to resources The guide to resources provides an overview of information directly related to the guidance either in terms of background, such as government policy documents, or practical help, such as pathways or toolkits.
Feedback suggested that the intervention was not communicated clearly enough and the stamp added extra work. Although PDSA 1a obtained encouraging results, PDSA 1b demonstrated that adding additional work to an already busy theatre environment was likely to be met with resistance and thus was not wholly successful. It also revealed that a safety net was needed for assessments missed in theatres to be picked up on the wards postsurgery.
They clearly displayed the trust VTE prophylaxis guidelines to facilitate informed assessment and highlighted the poor assessment rates currently achieved. On the day they were placed, staff were informed of their purpose.
This suggests that posters are not effective forms of communication and can go unnoticed. In hindsight, a formal face-to-face education session in conjunction with the posters may have been more appropriate. All statistical tests were done in R and graphs and charts were constructed using Excel. Figures missing from the full cohort were first admitted to the private surgical unit. Run charts were generated from the data see figure 2.
There were days where no patients were admitted represented by no marker point , which demonstrates normal variability in urology and should not affect reproducibility of the methodology.
They show some evidence of improvement with proportionally more points above the median after intervention. The median was generated from the baseline audit 5—18 September and days without a marker point are those where no patients were admitted. This may suggest raised awareness of the VTE assessment among doctors and could indicate higher assessment rates during surgery as opposed to reliance on the ward.
Despite increased VTE risk assessment rates among the direct surgical group, unfortunately this project did not meet the stated aim.
There are several reasons for this both within the system and the study design that can provide lessons for future quality improvement projects. First, the project highlighted the need for effective communication. One reason for this was a large staff body and difficulty in communicating face-to-face, with an email more easily overlooked.
This may have led to misunderstanding of the intervention and little incentive to comply. PDSA 2 was communicated to staff members on the wards present at the start of the intervention thus relying on them to communicate the message, an unrealistic expectation leading to an unsustainable transference of information. To improve, interventions should be clearly explained face-to-face in a series of staff meetings or handovers as repeated spaced repetition is known to be an effective and sustainable form of learning.
The second lesson is that driving change on an established routine is very challenging. To make someone amenable to change, it needs to be easy without adding work and regarded with high importance. Staff attitudes are key in generating sustainable change and this should have been a greater focus in the project. This change process was also limited by pre-existing negative views on the EPR assessment and frustration at having to prescribe on different software.
Information was given on posters to raise the profile but face-to-face education would have been more effective at highlighting the effects on patient safety. However, this project also demonstrates that educational measures alone are not sufficient. The trust ban on IT projects hindered other interventions such as linking assessment and prescription systems that could have tackled the problem at its heart.
Furthermore, an IT-based version of PDSA 1a and 1b such as a pop-up alert on EPR while surgeons upload operation notes would have more effectively grabbed attention and boosted sustainability by eliminating the need to replace stamps. Failing improvement, firmer interventions may be necessary with either reprimands or rewards associated with intervention uptake to ensure compliance.
Ideally, PDSA 1b would have been built on further, creating a permanent change on the WHO checklist meaning patients could not leave the theatre without completed assessments. Although the project team did not have the authority to make this change, it has been reported to those that do.
Table 2. Characteristics of the RAMs. Name of RAM. Risk factors. Weighing points of risk factors. Defined cutoffs for risk groups. Table 3. Characteristics of the studies describing the RAMs developed using individual patient data. First author, year quality score by authors of SR. Reference systematic review.
Study design and study type sample size. Data source. Population sample size. Outcomes and methods of diagnosis. Follow-up time.
Table 4. Characteristics of the studies describing the RAMs developed using consensus approaches. Study type. Literature search and methods used. Target population sample size. Table 5. Findings from comparative studies of RAMs identified in the systematic reviews. Comparative studies no. VTE incidence. This work was supported by ASH. Costs of venous thromboembolism associated with hospitalization for medical illness.
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