Report from the Anticoagulation Working Group

Evidence for NICE shared learning award

Dr. Janet Shirley, RoyalSurreyCountyHospital NHS Trust

Contents

Report from the Anticoagulant Working Group, September 2007page 2

Final report from the anticoagulant working Group, March 2008page 7

Report for the Thrombosis Committee, Part 2 of the Hospital page 15

Transfusion Committee, august 2008

Report from the Anticoagulation Working Group

Reporting to:Clinical Governance Committee

Author:Dr. Janet Shirley

Date:September 2007

Contents Page

Executive summary1

Introduction 2

Progress 3

NICE clinical guideline no. 463

NPSA patient safety alert no. 184

Department of Health report5

Recommendations 5

References5

Appendix 16

Executive Summary

Three pieces of NHS guidance were published in March and April 2007:

NICE clinical guideline no. 46. ‘Venous thromboembolism: Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery.’
National Patient Safety Agency. Patient safety alert no. 18. ‘Actions that can make anticoagulant therapy safer.’
Department of Health. ‘Report of the independent expert working group on the prevention of venous thromboembolism in hospitalised patients.’

An Anticoagulation Working Group was convened. The group is chaired by Dr. Christopher Tibbs, Medical Director, and includes representatives from medical specialties, nursing, pharmacy, audit, IT and pathology. The aim of the working group is to review the guidance and agree the recommendations, decide how to implement them and look at the resources required.

Good progress has been made with:

Updating current trust guidelines
Producing new guidelines
Providing verbal and written patient information
Reviewing anticoagulant clinic procedures
Promoting safe prescribing practices
Standardising the anticoagulant drugs across the trust
Liaising with dental and primary care practitioners to promote safe practices
Planning the audit requirements

The next steps required include:

Implementing the new guidelines across the trust
Developing training and competency assessments for clinical staff in thromboprophylaxis and anticoagulation
Auditing current practice and the implementation of the new guidelines

The main barriers to progress identified are:

Lack of IT progress
Lack of sufficient audit and training support

The Anticoagulation Working Group therefore recommends that the trust:

Purchases and installs an anticoagulant dosing support software package
Employs a thrombosis practitioner to provide training, competency assessment and audit

Report from the Anticoagulation Working Group

1.0 Introduction

1.1Venous thromboembolism (VTE) is a major cause of morbidity and mortality in hospitalised patients. It causes approximately 60,000 deaths per annum in the UK. The figures for the Royal Surrey County Hospital NHS Trust are 32 in 2005/6 and 38 in 2006/7. The majority of these VTE related deaths were in medical inpatients with four being in surgical patients. There is a lot of evidence that the use of appropriate thromboprophylaxis significantly reduces deaths from VTE.

1.2The Anticoagulant Working Group was convened in May 2007 to look at how the trust would implement three pieces of NHS guidance.

NICE clinical guideline no. 46. ‘Venous thromboembolism: Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery.’ Published April 2007, implementation required by July 2007.

2.National Patient Safety Agency. Patient safety alert no. 18. ‘Actions that can make anticoagulant therapy safer.’ Published March 2007, action plan needed by July 2007 and implementation required by March 2008.

3.Department of Health. ‘Report of the independent expert working group on the prevention of venous thromboembolism in hospitalised patients.’ Published March 2007, no implementation date, guidance only at this stage.

1.3Membership of the group:

Christopher Tibbs, Medical Director, Chair

Janet Shirley, Consultant Haematologist

Paul Chappell, BMS3

Bhulesh Vadher, Chief Pharmacist

Helen Wilson, F1/F2 programme director

Bill MacAllister, Consultant Respiratory Physician

Helen Wilson, Foundation Programme Director

Jenny Faulkner, Matron

Claire Richardson, Matron

Sarah Westwell, Consultant Oncologist

Matthew Solan, Consultant Orthopaedic Surgeon

Mike Cavaye, IT Representative

Helen Brady, Audit and Service Improvement Manager

Jane Fagan, Clinical Governance Co-ordinator, Secretary

1.4The purpose of the group is to:

Agree the recommendations in the guidance
Decide how to implement the guidance
Look at the resources required for implementation of the guidance

1.5It was decided that the most practical way of carrying out the work was to divide into three subgroups, each one to review one of the guidance documents and report back on progress at intervals to the whole group.

2.0Progress so far

2.1.NICE clinical guideline no. 46. ‘Venous thromboembolism: Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery.’

2.1.1This guideline recommends that all surgical inpatients should:

Be assessed for their risk factors for venous thromboembolism (VTE)
Before surgery be given written and verbal information on the:
Risks of VTE
Effectiveness of prophylaxis
Be given prophylaxis for VTE appropriate for their risk factors and the type of surgery involved
On discharge be given written information about the signs and symptoms of VTE and the type of prophylaxis to be continued at home

2.1.2In response to this guidance the following have been completed:

Updated guidance on thromboprophylaxis for surgical inpatients in the ‘Local Clinical Guidelines (The red book), 17th Edition, August 2007
Patient information: Advice on reducing the risk of a blood clot
Guideline for thromboprophylaxis for inpatients undergoing surgery
Guideline for the use of graduated compression stockings

2.1.3Problems identified:

The orthopaedic surgeons do not all agree with the NICE guideline. They are awaiting a position statement from the British Orthopaedic Association. The group recommends that the trust should follow the NICE guideline for all surgical inpatients.
The guideline recommends thigh length graduated compression stockings. The evidence for the superiority of thigh length stockings compared to knee length stockings is not compelling and there is a lot of evidence that patient compliance is poor with thigh length stockings. Indeed this is the experience at the trust. The group recommends that the wording in the ‘Guideline for the use of graduated compression stockings’ should allow nursing staff to use knee length stockings.
Training is required for medical and nursing staff. This has significant resource implications.
Implementation of the guidance requires regular audit and again this has significant resource implications.

2.1.4Next steps

Approval of the new trust guidelines,‘Guideline for thromboprophylaxis for inpatients undergoing surgery’ and ‘Guideline for the use of graduated compression stockings’ at the Clinical Governance Committee
Implementation across the trust of the new guidelines
Training of staff in the new guidelines
Regular audit of the implementation of the NICE guideline no. 46
Approval by the Patient Information Group of the patient information leaflet, ‘Advice on reducing the risk of a blood clot from surgery.’
Providing patients with the leaflet at pre-assessment

2.2National Patient Safety Agency. Patient safety alert no. 18. ‘Actions that can make anticoagulant therapy safer.’

2.2.1This alert contains recommendations with significant implications for teaching and training within the trust and for clinical audit. The main recommendations contained within it are:

Ensure that all staff caring for patients on anticoagulant therapy have the necessary work competences. Any gaps in competence must be addressed through training to ensure that all staff may undertake their duties safely.
Review and update written procedures and protocols for anticoagulant services to ensure they reflect safe practice and that staff are trained in these procedures.
Audit anticoagulant services using the British Society of Haematology/NPSA safety indicators. The audit results should inform local actions to improve the safe use of anticoagulants and should be communicated to clinical governance and drug and therapeutic committees.
Ensure that patients prescribed anticoagulants receive appropriate written ad verbal information.
Promote safe practice with prescribers and pharmacists to check that patients’ blood clotting (INR) is being monitored regularly and that the INR level is safe before issuing and dispensing repeat prescriptions.
Promote safe practices for co-prescribing clinically significant interacting medicines for patients already on oral anticoagulants.
Ensure that dental practitioners manage patients on oral anticoagulants according to evidence based guidelines.
Amend local policies to standardise the range of anticoagulant products used.
Promote the use of written safe procedures for the administration of anticoagulants in social care settings.

2.2.2An action plan has been produced (appendix 1) to address these recommendations. Significant progress has been made with most of them. Currently the trust has a score of 25.2 out of 56. It is hoped that by the implementation date of 31st March 2008 all the recommendations will have been achieved.

2.2.3Problems identified

There is a significant resource required to deliver the training and competency assessments to the relevant clinical staff (this includes all doctors, pharmacists and nursing staff). All the educational supervisors will need to be competent in order to train and assess their junior doctors. Pharmacy staff and nurses will also require training and assessment.
The safety alert contains significant audit requirements. Not all of these can be delivered using the trust’s current systems. Unlike most other trusts in England there is no computerised system for prescribing and recording anticoagulant treatment. This means that audits will have to be conducted using labour intensive manual systems. Also it is not possible to correlate pathology INR results with which patients are on anticoagulant therapy. Two manual audits are planned that will capture most of the information required as a ‘one off’ but it will not be possible to carry out regular audits to monitor progress without IT support.There are technical problems with linking the anticoagulant software package installed at FrimleyParkHospital with the IT systems at the Royal Surrey. The IT department are trying to find a way round this. Once this has been solved a business case will need to be developed to fund it.

2.2.4Next steps

Produce a training package for clinical staff.
Produce competency assessment tools for clinical staff.
Plan and deliver training and competency assessments.
Carry out the two planned audits.
Obtain and install a computerised anticoagulant dosing and recording package.

2.3Department of Health. ‘Report of the independent expert working group on the prevention of venous thromboembolism in hospitalised patients.’

2.3.1This report recommends:

A documented mandatory VTE risk assessment of every hospitalised patient on admission.
All medical patients should be considered for thromboprophylaxis measures.
All surgical/orthopaedic patients should be managed according to the NICE guideline.

2.3.2This is therefore an extension of what is required for surgical inpatients under NICE guideline number 46. The recommendations in this report are not mandatory at the present time and have no required implementation date. The Anticoagulant Working Group decided to wait until good progress had been made with the other two pieces of guidance before looking at this one. The first meeting of the subgroup for this guidance is scheduled to take place in October 2007.

3.0Recommendations

The Anticoagulant Working Group recommends the following actions to the trust:

The trust accepts this report as representing the progress made with these three pieces of NHS guidance.
The trust recognises that every effort has been and is being made to comply with and implement the guidance within current resources.
To enable the audit requirements to be met further resource is provided:

an anticoagulant dosing and recording software package is purchased and installed
a dedicated person is identified to carry out the audits

To enable the training and competency assessment requirements to be met further resource is provided:

a dedicated person is identified to carry out this work

Items 3 and 4 above could be delivered by the appointment of a thrombosis practitioner with a remit similar to that of the trust’s transfusion practitioner. Staff with a nursing, pharmacy or laboratory background would have suitable knowledge and skills for such a post. Most trusts in England employ an anticoagulant practitioner to manage the anticoagulant clinic. At the Royal Surrey this work is currently managed by the consultant haematologists. Therefore the trust does not have someone in post who can take on this work.
A regular report should be made to the Clinical Governance Committee detailing progress with implementation and presenting audit results.

4.0References

‘Venous thromboembolism: Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery.’ NICE clinical guideline no. 46, April 2007.
Patient safety alert no. 18. ‘Actions that can make anticoagulant therapy safer.’ National Patient Safety Agency, 28 March 2007.
‘Report of the independent expert working group on the prevention of venous thromboembolism in hospitalised patients.’ Chief Medical Officer, Department of Health, March 2007.

Final Report from the Anticoagulation Working Group

Reporting to:Clinical Governance Committee

Author:Dr. Janet Shirley

Date:March 2008

Contents Page

Executive summary1

Progress 2

NICE clinical guideline no. 462

NPSA patient safety alert no. 183

Department of Health report5

Risk assessment5

Recommendations 6

References 6

Appendix 1, Summary of progress on Action Plan

for Implementation of NPSA alert and NICE guidance7

Executive Summary

This is the second and final report from the Anticoagulant Working Group, chaired by Dr. Christopher Tibbs, on the implementation of the three pieces of NHS guidance published in March and April 2007:

NICE clinical guideline no. 46. ‘Venous thromboembolism: Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery.’
National Patient Safety Agency. Patient safety alert no. 18. ‘Actions that can make anticoagulant therapy safer.’
Department of Health. ‘Report of the independent expert working group on the prevention of venous thromboembolism in hospitalised patients.’

Work has been completed on:

Updating current Trust guidelines
Producing new guidelines
Providing written patient information
Reviewing anticoagulant clinic procedures
Promoting safe prescribing practices
Standardising the anticoagulant drugs across the Trust
Liaising with dental and primary care practitioners to promote safe practices
The audit requirements in the NPSA alert for 2007/08
Rolling out the Trust thromboprophylaxis policy
Training the junior doctors
Developing the competency assessments for medical staff in thromboprophylaxis and anticoagulation
Putting forward the business case for a thrombosis practitioner to support audit and training in anticoagulation and thromboprophylaxis across the Trust and to support the haematology consultants in delivering the service

Work is in progress on:

Installing the software for computerised assisted dosing support to the anticoagulant clinic
A baseline audit of thromboprophylaxis across the Trust

Work outstanding is:

Auditing the implementation of the new guidelines across the Trust
Ongoing audit of anticoagulation and thromboprophylaxis
Training nursing and pharmacy staff in anticoagulation and thromboprophylaxis
Competency assessing all staff involved in anticoagulation and thromboprophylaxis

The main barrier to further progress is:

Lack of sufficient audit, training and competency assessment support

It is highly likely that one of the new targets in the Annual Health Check for 2008/09 will be ‘VTE prophylaxis in the form of risk assessment on admission to hospital’. This work will not be possible without extra support and the Anticoagulation Working Group therefore recommends that the Trust employs a thrombosis practitioner. A risk assessment indicates that there is a significant risk to the Trust if the appointment is not made.

Report from the Anticoagulation Working Group

1.0Progress

1.1.NICE clinical guideline no. 46. ‘Venous thromboembolism: Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery.’

1.1.1In response to this guidance the following have been completed or are in progress:

Updated guidance on thromboprophylaxis for surgical inpatients in the ‘Local Clinical Guidelines (The red book), 17th Edition, August 2007 – completed.
Patient information: ‘Advice on reducing the risk of a blood clot for inpatients undergoing surgery’ – completed.
Guideline for thromboprophylaxis for inpatients undergoing surgery - completed.
Guideline for the use of graduated compression stockings – completed.
Baseline audit of thromboprophylaxis with low molecular weight heparin across the Trust - in progress.
Training of F1 ad F2 doctors currently in post – completed.
Implementation of the Trust thromboprophylaxis policy completed by:
Circulating the new guideline for surgical patients to all consultant surgeons and relevant ward sisters.
Providing thromboprophylaxis posters for all ward areas.
Desk top alert on the Trust computers.
Risk assessment tool developed for patients attending surgical pre-assessment.
All patients attending pre-assessment to be given the patient information leaflet, ‘Advice on reducing the risk of a blood clot from surgery’.

1.1.2Problems identified:

Ongoing training and competency assessment is required for medical, pharmacy and nursing staff. This has significant on-going resource implications.
The Trust is not using TED stockings. The brand being used is Carolon. This was chosen following a Surrey and Sussex NHS Supply tender on behalf of the trusts in Surrey and Sussex. The clinical studies on graduated compression stockings have been carried out on TEDS and the Anticoagulation Working Group has concerns about how clinically effective other brands are because there is limited independent clinical comparison between the main anti-embolism stockings. Carolon stockings meet the compression standards required by the British Standard BS 7672, 1993, are CE marked and meet the Medical Devices Directive standards. To change back to TED stockings would increase costs by about 18.5% or £11,382 per annum.
Training is required for staff in applying anti-embolism stockings, particularly for the thigh length stockings which should be used where possible.
Implementation of the guidance requires regular audit and again this has significant resource implications.
The orthopaedic department have reached agreement on how they will manage thromboprophylaxis for their patients. Whilst inpatients will be managed according to the NICE guidance the extended thromboprophylaxis will consist of aspirin or Warfarin rather than low molecular weight heparin. This may put pressure on the anticoagulant clinic which has limited capacity.

1.2National Patient Safety Agency. Patient safety alert no. 18. ‘Actions that can make anticoagulant therapy safer.’