Minutes of NBT Thrombosis Committee
Monday 14th December 2015
Severn Room, Brunel Building, Southmead Hospital
Present
Jason Kendall (Chairman), Fiona Blain, John Ho, Maggie Alger, Jasek Szymanski, Anthony Timoney, Sue Bacon, Jackie Adams.
Apologies
Tom Roe, Amor Bautista, Joanna Crofts, Mehool Acharya , Johanna Payne, Gordon Halford, Alex Hodsman, Sharyn McKenna, Andy Weale
Minutes of the last meeting
Jasek was concerned re the lack of documentation of the discussion of GP care’s obstetric pathway. He then discovered he had omitted to print the relevant page from the minutes.
NOAC decision aid. The action to continue work on it was wrongly attributed to JH. FB had agreed to do it.
Matters arising
LMWH guidelines. Were discussed at November Medicines Governance meeting. Dr Janet Birchall (Consultant Haematologist) has been involved in updating the guidelines. She would like to incorporate UHB’s guideline for bariatric patients into the NBT one. This will alter the dosing regime for bariatric patients & will include anti Xa monitoring.
An opinion on the proposed guideline is also needed from the Renal Directorate. FB is planning to meet with Dr. Albert Power to discuss further.
Heparin Induced thrombocytopenia.
A Trust argatroban chart is required, & a copy will need to be added to the guideline. Pharmacy are looking for one.
Still no progress with the addition of 4Ts to ICE. Pathology are preparing for the implementation of a new system ‘Clinisys’ which is taking priority over other work. JA to continue to follow up. Action JA
Addition of NOAC names to WHO checklist. No further update. Tom Roe has left the Trust, handing over the role as VTE Lead for surgery to Haytham Sumrien. JA to contact him & ask re progressing this issue. Action JA
VTE information on discharge. Ann Marie Francis (Project Manager – Lorenzo) has left the Trust. JK will contact Eric Loveday for an update. Action JK
Trust Thrombosis Guidance Document The updated version was discussed at the Clinical Effectiveness Committee meeting in October. Some minor amendments were required, which have been made by JA / JK. The Document now needs to be sent back to CEC for Chairman’s approval. Action JA
Investigations following unprovoked VTE
NICE guidance on this (CG144) to be incorporated into Trust VTE guideline Action JA / JK
Radiology will be working on guidance document for Drs requesting further imaging, for unprovoked VTE, in January. Action LC
AAU checklist for VTE patients
Needs to be re written following changes in ambulatory care. Action JH
Revised pathway available;
http://sharepoint/sites/medicine/mau/ambulatory/Documents/DVT%20pathway.ppsx
VTE risk assessment of patients with lower limb injuries
This need to take place in A&E, on the day of injury, rather than in the fracture clinic the following day. MA will circulate the risk assessments she has collected & organise a meeting to discuss further. Action M Alg
NOAC decision aid
FB is working on this, & reminded people that it is for VTE patients. Action FB
A decision aid for AF patients is already available on the BNSSG website;
‘BNSSG Newer Oral Anticoagulants Decision Aid July 13’
http://www.bnssgformulary.nhs.uk/Local-Guidelines/
GP Care Physio referral pathway. JS has not received any feedback from Dr. Flanagan. There was discussion as to whether the document has now been superceded by the revised AAU pathway (link above), particularly as GP Care may not be able to organise same day clexane. JS to liaise with JH / KF to progress further. Action JS, JH
New exemption cohorts
Musculoskeletal patients undergoing image guided injections in the operating theatre have been aproved. JA to inform Phil Martin & Zara Mason Action JA
Upper limb surgery patients were not approved.
Discussion topics
NBT VTE in Pregnancy Guideline. Dr Crofts was not able to attend the meeting, so discussion of the revised guideline was postponed again.
GP Care Community Obstetric pathway. Comments from NBT’s Obstetricians re the suitability of the document are still awaited. GP care cannot start accepting referrals of pregnant women until their protocol has been approved. JS expressed frustration at the lack of progress with this, but will continue to request feedback. JK also to request. Action JS, JK
Exemplar Status project. This is progressing slowly
JA asked for ideas to demonstrate that patients
1) Receive written & verbal VTE information on admission & discharge
2) Are reassessed for VTE / Bleeding risk during admission
Suggestions included;
· Reviewing consent forms to see whether Surgeons record VTE as a risk of surgery Action JA
· Asking Pre Op Assessment & Day Surgery areas for evidence that they provide information. Action FB
· Adding VTE leaflets to the clerking folders compiled for patients admitted to AMU. Action JH
· Auditing use of the discharge checklist. Action JA
· Obtain copies of daily checklists which require VTE review, eg. ITU, vascular Action JA
· Use clerking proformas / operation notes to demonstrate the VTE is reviewed on post take ward rounds / post operatively Action JA
· Review completed RCAs for evidence of reassessment Action JA
The VTE discharge leaflet ‘The risk of DVT & PE after leaving hospital’ needs to be reviewed by patients to complete the approval process. SB will ask the Discharge Lounge Staff to use it with the patients they discharge & obtain feedback. JA will send a copy to GH for his comments. Action SB, JA
Targets
1) 95% of patients risk assessed on admission for VTE / bleeding risk.
From April ’15, data submission to NHS England occurs 3 monthly, although the Trust will continue to monitor progress monthly.
April - June average figure 94.7% (95.12% as of 14/9/15)
July – Sept 94.9% 95% not yet achieved
Oct 92.7%
Target not achieved within the required time frame. There is a potential £200 fine for every breach & the CCG are becoming increasingly concerned.
Next submission due January ‘16. Current figures;
Nov 93.84%
Dec 91.6%
Big I VTE data was discussed. The issues with coding & external providers continue, but figures suggest a slight decline in risk assessment by clinicians aswell. Patients admitted from outpatients & those transferred from other hospitals are particularly likely to be missed, as clerking proformas containing the VTE risk assessment form are not routinely used for these groups. VTE leads were reminded that a generic VTE risk assessment form is available on the VTE Hub here & were asked to examine data from their Directorates, raising concerns with colleagues at both ward level & at meetings. Action all
FB suggested that junior Drs reminded of the importance of VTE risk assessment, & reassessment, at one of their teaching sessions. Pharmacy deliver some of these, so can arrange. Action FB, DK
Data from September needs to be reviewed, as it looks likely that the 95% target will not be achieved for that month. VTE leads were asked to audit 10 sets of notes deemed fails by coding to see whether the coding was correct. Action all
Concerns were raised again regarding the difficulties of getting notes & the standard of those that do arrive. Filing is poor & it is difficult to find information & follow the patient’s journey .
Accessibility of the ‘Big I’ is another issue, particularly the time it takes to open the data sets. JK will find out whether old data can be archived & whether this would reduce the time taken to open data. Action JK
2) 90% of patients, whose VTE risk assessment indicates a requirement for thromboprophylaxis (TP), receive it.
No data
Hospital acquired VTE report & RCA report – attached
The CCG have indicated that they are no longer happy with only a proportion of hospital acquired VTE (HAT) being investigated using RCA. From 2016 all HATs will need to be investigated, in line with Service Condition 22 of the NHS Standard Contract 2015/16. This states ‘the provider must:
“Perform Root Cause Analysis (RCA) of all confirmed cases of pulmonary embolism and deep vein
thrombosis acquired by patients while in hospital (both arising during a current hospital stay and where there is a history of hospital admission within the last 3 months, but not in respect of patients admitted to hospital with a confirmed venous thromboembolism but no history of an admission to hospital within the previous 3 months)...”
NHSLA report – attached
Safety Thermometer report
Apr (0.6%) / May (0.9%) / Jun (0.1%) / Jul (0.5%) / Aug (0.7%) / Sept(0.4%) / Oct
(0.7%) / Nov
(0.1%)
Episodes of VTE harm / 6 / 9 / 1 / 4 / 6 / 4 / 7 / 1
Harm free care (%) / 97 / 96 / 94 / 95 / 93 / 95 / 94 / 95
Anticoagulation.
Dabigatran. The antidote Idarucizimab has been approved for use in Europe.
Adverse events
Adverse events regarding the following have been reported;
· Warfarin charts are not sent to the Anti coagulation Management Service when patients are discharged
· Co prescription of LMWH & dabigatran. The SPC for the use of dabigatran to treat acute VTE requires 5 days of LMWH before commencing dabigatran. The 2 medications should not overlap.
· Warfarin being prescribed for patients with VTE & active cancer. LMWH is currently the recommended treatment for this group of patients, although the use of rivaroxaban is becoming more common.
· NOACs being prescribed without consideration of e gfr
· Incorrect doses of NOACs being prescribed, eg the AF dose of a NOAC being prescribed for VTE & vice versa
Any other business.
SB. Has raised the non achievement of VTE targets at JCNC in an attempt to further increase awareness of the issue around the Trust
FB. Going on maternity leave from the end of Jan’16. Dilesh Khandia will take over as pharmacy lead on the committee
There is an interface between Lorenzo & DAWN (the warfarin dosing software used by the Anti coagulation Monitoring Service at NBT). FB will pass the details to SB
JS. Bayer have agreed to fund a Nurse who could be shared between GP Care & NBT – role yet to be defined. JH wondered whether other drug companies would also contribute, as has been offered in the past.
GP care have incorporated apixaban into their DVT pathway.
Lorna Rose will be transferring to a new role within GP Care. Her replacement is Sam Wilding.
Date of next meeting.
Tues 15th March, 12.00 – 14.30. Severn Room, L5 Gate 14, Brunel Building
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