Conclusions and recommendations
1. We
are concerned that the number of post-mortems being performed
has decreased since Alder Hey. As a result the true cause of death
is not being determined in many cases. We recommend that the Department
encourage the increased use of post-mortems where appropriate.
This would enable accurate identification of the cause of death
in more patients and more reliable assessment of the current incidence
of death through VTE, thereby providing a base from which to monitor
progress. (Paragraph 14)
2. Many surgeons and
physicians are not aware of the incidence of VTE, especially in
recently discharged patients and, therefore, are not administering
thromboprophylaxis. We recommend that when a patient who has recently
been discharged from hospital develops VTE the original surgeon
and/or physician should be notified by letter of the incident.
Notification should be made by either the primary care physician
treating the recently discharged patient, or if the patient is
re-admitted to hospital, by the secondary care physician. Notification
should also be made in the case of death through PE of a recently
discharged patient.. (Paragraph 33)
3. We recommend a
review of the tariffs to ensure that they do not act as a barrier
to the appropriate use of thromboprophylaxis. (Paragraph 39)
4. We note that the
ACCP has recently produced its seventh revision of guidelines
and SIGN introduced their guidelines in 1995. It is astonishing
that there has been no development of national guidelines in England
and Wales. (Paragraph 40)
5. The current variations
in the administration of thromboprophylaxis indicate that surgeons
and physicians are unaware of the extent of VTE and how readily
and safely it can be prevented. (Paragraph 41)
6. We recommend that
VTE and its prevention, including the implementation of, and
adherence to, guidelines relating to thromboprophylaxis, counselling
and risk assessment, be given more prominence in undergraduate
medical education, Continuing Professional Development (CPD),
and other relevant aspects of medical and paramedical training.
We further recommend that the Royal Colleges bring forward proposals
to this end as well as to raise awareness of the problems of VTE.
In addition, NHS Trusts should ensure that all physicians and
surgeons receive training about the subject. We make recommendations
about the role of the Healthcare Commission in audit and implementation
below. (Paragraph 43)
7. The scope of the
guidelines for VTE which NICE is preparing are too limited. Many
groups of patients who are at considerable risk of VTE are excluded.
We recommend that NICE extend the scope of the current project
to include both medical patients and patients undergoing low risk
procedures who are themselves at high risk from VTE. If NICE considers
that surgical and other patients should not be covered by the
same set of guidelines, we recommend that the Department commission
NICE to develop guidelines for the excluded groups in parallel
with its current work.. (Paragraph 48)
8. In view of the
urgency of the situation that leads to more than 25,000 deaths,
many of them avoidable, it is unacceptable to wait until 2007
for any attempts to reduce deaths from VTE. We therefore recommend
that the currently accepted consensus guidelines are circulated
by the relevant bodies including the Royal Colleges, the British
Orthopaedic Association, hospital specialist thrombosis teams
and Trust Drug and Therapeutics Committees to clinicians so that
they can seriously consider whether to implement them immediately.
(Paragraph 49)
9. 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. (Paragraph 52)
10. We recommend that
all patients, both medical and surgical, who are admitted to hospital
undergo a risk assessment for venous thrombosis. (Paragraph 53)
11. Systems must be
put in place to ensure that the NICE VTE guidelines are implemented.
We reiterate the recommendations we made in our inquiry into the
National Institute of Clinical Excellence in 2001-02 that the
Government should: a) institute practical systems and structures
to improve the NHS's capacity to implement NICE guidance, including
the possibility of designated individuals within the NHS trusts
and strategic health authorities to liaise with NICE to facilitate
implementation of the guidelines; and b) ensure the systematic
monitoring of the implementation of NICE guidance. We also recommend
that computer reminders are built into the electronic prescribing
system of the National Programme for Information Technology to
aid physicians in the prescription of thromboprophylaxis and to
remind them of guidelines for the prevention of VTE. We further
recommend that the Healthcare Commission undertake, as part of
its audit process, an investigation into the availability and
use of venous thromboembolism prevention protocols in each hospital,
including appropriate counselling and risk assessment. It should
also audit the training for and awareness of thromboprophylaxis
and venous thrombosis in hospitals. (Paragraph 58)
12. We recommend that
a thrombosis committee be established in each hospital, with a
specialist thrombosis team. They should be modelled on the existing
Blood Transfusion teams and committees. So that these teams are
established and operate effectively a basic standard of expectation
(skeleton) should be issued by the Department pending the publication
of NICE guidelines. (Paragraph 63)
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