There is little awareness of venous thromboembolism (VTE) in the public arena.1
The most commonly known causes are travellers’ thrombosis and its association with oral contraception, both frequently referred to in the media. These, however, are uncommon causes of thrombosis compared to the risk associated with hospital admissions for either medical or surgical conditions.1
Most hospitalised patients have one or more risk factors for VTE.2–6
Mortality owing to VTE after hospital admission is more than 10 times the number caused by Staphylococcus aureus
(MRSA, methicillin-resistant S aureus
) and is greater than the combined total of deaths from breast cancer, AIDS and road traffic incidents each year in the UK.7
Public ignorance is not surprising when healthcare professionals also underestimate the extent of VTE.8
Thus, VTE is a substantial healthcare problem, resulting in significant mortality, morbidity and economic cost.9
In 2005 VTE was estimated by the Health Select Committee to cost the National Health Service (NHS) £640 million a year to manage.
There is evidence to show that around 60% of people undergoing hip or knee replacement will suffer a deep vein thrombosis (DVT) without preventative intervention9
and that DVT has a mortality rate of 30% when left untreated.1
Figures from numerous studies also demonstrate a risk reduction for VTE of up to 70% for medical and surgical conditions: cancer, orthopaedic surgery, general surgery and acutely ill medical admissions.10
As a result, in April 2007 National Institute for Health and Clinical Excellence (NICE) published a clinical guideline offering best-practice advice for reducing the risk of VTE in inpatients undergoing high-risk surgery and latterly for all surgical procedures.12
The Chief Medical Officer also announced the publication of a VTE risk assessment tool recommended for all patients admitted to hospital in England14
(19 September 2008). New NICE guidelines were introduced in January 2010 covering all patients aged 18 years and over admitted to hospital (including day patients).15
The guidelines include medical, surgical and cancer patients and recommend risk assessment for VTE and risk of bleeding be undertaken for all patients at admission (and repeated after 24 h) and appropriate prophylaxis be provided where indicated.15
Further, the Royal College of Obstetricians and Gynaecologists produced a Green-top Guideline regarding the prevention of VTE during pregnancy, birth and following delivery.16
In addition, VTE is one of the four Quality Standards to be developed by NICE. These standards offer quality measures such as the number of patients aged 18 years and more who have been admitted to a hospital and the number who received a VTE assessment.17
The standards are also used for the basis of Commissioning for Quality and Innovation (CQUIN) agreements with trusts and as from June 2010 the CQUIN payment framework requires all acute trusts in the UK to risk assess 90% of patients admitted for VTE to receive 1.5% for their funding. Finally, the Care Quality Commission is responsible for monitoring the trusts’ performance on the new Quality Standards throughout the UK and will be collecting data each month on VTE risk assessments as well as visiting the trusts and interviewing staff of their performance.
Alongside these initiatives, an All Parliamentary Thrombosis Group (APPTG) undertook a survey of 173 acute NHS hospital trusts in 2007 to elucidate awareness of the problem and the action being taken. The survey found that implementation was poor despite almost universal awareness of the guidance.18
The survey demonstrated that only one-third of the hospital trusts were implementing mandatory risk assessments on every patient admitted, another one third were educating patients on admission and discharge and the remaining one third were educating the staffs regarding thromboprophylaxis. A further APPTG survey in 2008 showed a marked improvement with 70% of trusts now stating they were undertaking risk assessment on all patients. However, this means that one third of trusts are still not assessing the risk in a structured manner. The survey also showed that patient information around the risk factors for VTE is poor. This survey was superceded in 2010 and found a continued low general awareness of VTE. The report called for a VTE public awareness campaign. In addition, the majority of trusts were unable to provide monthly data on the percentage of patients at risk of VTE who received appropriate prophylaxis.19
The APPTG reports suggested that there is a role for primary care trusts (PCTs) and that patient and public education will play an important role. Primary healthcare professionals are in a good position to deliver VTE education to patients and empower patients with the knowledge to request a risk assessment on admission to hospital. However, we do not know patients’ attitudes towards education and information. Will highlighting the need for thromboprophylaxis to patients result in a reduction in events or will it have an unfavourable clinical outcome?
A study in 2007 of 460 patients, used a standardised questionnaire to determine patients’ preferences to consent to low-molecular-weight-heparin (LMWH) prophylaxis following an orthopaedic surgery.20
The patients were educated concerning the risk of heparin-induced thrombocytopenia (HIT) with LMWH. (HIT is a life-threatening, immune-mediated prothrombotic adverse drug effect that occurs less often with LMWH than with unfractionated heparin in orthopaedic surgery patients). Patients appreciated receiving information about the potential adverse effects of heparin prophylaxis. The specific information about HIT did not lead to treatment refusal with all patients chosing to receive the drug. Over 90% of patients welcomed the information and felt it appropriate to be informed.
When considering patient barriers to VTE prophylaxis, diabetes studies have shown the desire to avoid injectable drugs and LMWH therapy may therefore introduce concordance issues.21
Healthcare professional barriers to initiating VTE prophylaxis may be manifold. Knowledge-to-practice translation issues are extremely important for the successful integration of thromboprophylaxis into the community.
There is little evidence to suggest that care pathways are always successful for disease management. A Cochrane review of in-hospital care pathways stated that there was insufficient evidence to support their routine implementation, no reduction in hospital length of stay was seen.22
A further evaluating pathways for chronic obstructive airway disease, congestive cardiac failure, myocardial infarction and pneumonia had similar conclusions.23
There has been no evidence of the use of care plans for prophylaxis in the community. However, one study evaluated a heart failure programme of care in the community using an integrated multidisciplinary team and an educational package for patients including advice on disease recognition and compliance.24
This study had more positive outcomes in terms of decreased length of stay in hospital and readmission rates.