Memorandum by Lifeblood: The Thrombosis
Charity (PS 15)
PATIENT SAFETY
EXECUTIVE SUMMARY
Lifeblood: The Thrombosis Charity is pleased
to respond to the House of Commons Health Select Committee Inquiry
into Patient Safety. As the Medical Director of Lifeblood and
a practicing consultant physician, I consult regularly with colleagues
from other disciplines and charities on matters of patient care
and health policy.
For the past five years, Lifeblood has been
campaigning for new guidelines for medical professionals to identify
and treat thrombosis—a condition that the Health Select
Committee identified kills in excess of 25,000 people each year
in the UK. This is more than five times the number who die from
MRSA and C.difficile and is the most common cause of hospital
mortality.
The majority of these deaths from hospital-acquired
deep vein thrombosis (DVT) can be prevented with simple yet effective
risk assessment. The medical term venous thromboembolism (VTE)
covers both deep vein thromboses and their consequences pulmonary
emboli, which can kill. VTE has a mortality rate of 30% when left
untreated, but this drops to just 2-8% with appropriate therapy.
We have been encouraged by policy progress in
this area over the past three years, particularly the Chief Medical
Officer's (CMO) Guidelines on the Prevention and Management
of VTE in Hospitalised Patients published in April
2007, which identified the need for urgent action to stem the
alarming number of deaths from thrombosis. The CMO's crucial recommendation
that every hospital patient should be given their own risk assessment
for VTE is testament to the importance of this issue. This guidance
could save thousands of lives.
However, we were concerned by the results of
an audit carried out by the All-Party Parliamentary Thrombosis
Group in November 2007. This report revealed that only one-third
of Acute NHS Hospital Trusts are following this advice and universally
risk assessing all hospital patients.
Given the scale of the condition and the lack
of evidence that best practice guidelines are being followed,
we believe that hospital-acquired DVT remains a public health
emergency. The US Health Agency for Research and Quality has identified
thromboprophylaxis for those patients at-risk as the number one
most important patient safety intervention. Despite the fact that
comprehensive best practice guidelines exist to both prevent and
manage episodes of VTE, these are being neglected by Acute NHS
Hospital Trusts and to this end, those in management of these
Trusts must acknowledge that some are posing an unjustifiable
risk to patient safety.
Whilst we hope that the publication of the CMO's
National VTE Risk Assessment tool will encourage Trusts to adopt
the CMO's April 2007 recommendations, we are concerned that Trusts
do not have sufficient incentives to fully implement this. We
believe that hospitals need to be audited on the uptake of VTE
risk assessment and the quality of their thrombosis protocols
or more ideally mandated to risk assess all adult patients on
admission. We are confident this will significantly reduce the
risk to patient safety and the overall number of preventable hospital
deaths.
In responding we have addressed areas that we
feel are of particular relevance to hospital acquired Venous Thromboembolism.
1. What the risks to patient safety are and
to what extent they are avoidable?
Venous Thromboembolism (VTE) is recognised internationally
as the number one safety issue in hospital care and the Health
Select Committee estimated it causes at least 25,000 deaths in
the UK alone[124].
This is greater than the numbers who die from MRSA and C.difficile
combined and the most common cause of hospital mortality[125].
It is also the most common cause of cardiovascular death behind
heart attack and stroke.
VTE is, however, preventable with simple yet
effective risk assessment and management: VTE has a mortality
rate of up to 30% when left untreated, but this drops to just
2-8% with appropriate therapy[126].
Furthermore, the US Health Agency for Research
and Quality has identified thromboprophylaxis for those at risk
as the number one most important patient safety intervention.
This was based on both the cost and clinical efficacy of the intervention[127].
We therefore welcomed the Chief Medical Officer's
Guidelines on the Prevention and Management of VTE published
in April 2007, particularly the crucial recommendation that every
hospital patient should be given their own risk assessment for
VTE.
However, it appears that despite the risk posed
to patient safety, the majority of Acute NHS Hospital Trusts have
failed to implement these guidelines. We were disappointed to
learn from an audit undertaken by the All-Party Parliamentary
Thrombosis Group in November 2007 that only one-third of Trusts
were universally risk assessing patients on admission to hospital[128].
The prevention and management of VTE can consequently be seen
as a `systems failure.'
The clinical diagnosis of Deep Vein Thrombosis
(DVT) is unreliable and patients who present with a DVT are associated
with increased morbidity and mortality. This is why it is crucial
that hospitals put emphasis on the prevention rather than the
treatment of VTE.
As mentioned, hospital acquired thrombosis contributes
to significantly more deaths than hospital acquired infections,
yet, by comparison, public awareness is still relatively low,
along with central government resources to tackle this problem.
This is a clear example of how the role of public perception of
risk is determining NHS policy.
2. WHAT THE
CURRENT EFFECTIVENESS
IS OF
THE FOLLOWING
IN ENSURING
PATIENT SAFETY:
a. local and regional NHS boards, and other
organisations providing NHS services (including primary and community
care, and mental health services)
By not guaranteeing the risk assessment of every
patient admitted to hospital, boards of Acute NHS Trusts and Strategic
Health Authorities are not effectively safeguarding patient safety.
This cannot be attributed to a lack of awareness; the All-Party
Parliamentary Thrombosis Group revealed that 99% of all Acute
NHS Trusts surveyed were aware of the CMO's April 2007 recommendations[129].
b. systems for incident reporting, risk management
and safety improvement
Systems for reporting episodes and mortality
from VTE are currently inadequate. VTE is chronically under-reported
which is why many within the medical field view it as a peripheral
area. Under-reporting can be attributed to the decline in the
number of post-mortems following the Alder Hey scandal. Consequently
an accurate cause of death is often not determined and the death
is recorded as having another cause.
Under-reporting can also be attributed to the
fact the majority of VTE episodes develop days or even weeks after
a patient has been discharged from hospital. As a result, the
healthcare professional who was responsible for the patient's
care in the first instance is unlikely to see the patient again
and adequate systems are not in existence at many hospitals to
inform them that a patient who has been under their care has suffered
an event.
The development of a better system of reporting
by Trust management will form an important part of establishing
a patient safety culture and changing the attitudes of clinicians
towards thrombosis, particularly within Orthopaedics where many
surgeons still do not acknowledge the high incidence of hospital-acquired
DVT. We recommend that Acute NHS Trust boards review their hospitals'
internal reporting mechanisms for VTE. We also recommend more
post-mortems are performed when the patient has died at home but
has recently been in hospital.
c. national policy
As a patient safety care issue, we believe that
it would be appropriate for VTE risk assessment and best practice
management protocols, to be contained within the Operating Framework
alongside hospital-acquired infections. Given the scale of the
problem, we believe that to neglect VTE within the Operating Framework
is to neglect a commitment to patient safety.
d. the National Patient Safety Agency and
other bodies
The argument for VTE prevention does not just
make good clinical sense but also economic sense. VTE not only
causes death, but has a high morbidity with post-thrombotic syndrome
and the chronic complications such as recurrent leg ulcers that
this can cause, which add further costs to the NHS. The total
cost (direct and indirect) to the UK for the management of VTE
is estimated to be £640 million[130].
In addition, where patients suffer a fatal thrombosis while under
the care of a hospital, this can have expensive legal repercussions
for the NHS Litigation Authority.
e. education for health professionals
At present, adequate education for health professionals
is not made available by Acute NHS Hospital Trust Boards. It is
critical to win the hearts and minds of all staff so that patients
at every point of entry are risk assessed and managed effectively.
Without the support of front line staff, effective uptake of VTE
risk assessment cannot be secured. It is important that management
is not just telling staff what to do, but also explaining why
implementing VTE prevention protocols is beneficial to the patient.
Lifeblood believe this would contribute to improved uptake of
risk assessment and increase appreciation of hospital acquired
VTE as a patient safety hazard. As the Health Select Committee
has also previously recognised, this needs to be extended.
3. WHAT THE
NHS SHOULD DO
REGARDING
PATIENT SAFETY
As a preventable patient safety hazard that
is the commonest cause of hospital mortality, Lifeblood believes
that the NHS must face the challenge of implementing recognised
VTE best practice at the earliest opportunity. This will require
a multifaceted approach and efforts at every level of the NHS.
Firstly, it is evident to us that Acute NHS
Trusts will require incentives to improve the uptake of risk assessment.
As with protocols to prevent hospital-acquired infections, we
believe that VTE risk assessment should be mandated and included
in the Operating Framework.
In addition, we recommend that the Healthcare
Commission assess hospitals on the uptake of risk assessment and
the quality of their thromboprophylaxis protocols and include
these as indicators in its annual health check. Compliance visits
to Acute NHS Trusts would provide an incentive for Trusts to ensure
all is being done to prevent VTE in their hospitals, as it currently
does with the national hygiene code.
However, this alone will not improve the uptake
of risk assessment. Trusts will need to entrench their protocols
through education for clinicians and healthcare professionals,
which clarify the rationale for intervening in this way. This
is why Lifeblood supports the approach of the National Patient
Safety Campaign, which concentrates on educating healthcare professionals
not only about the intervention but also the rationale behind
the intervention. We would ask that a VTE intervention is adopted
by the National Patient Safety Campaign at the earliest opportunity.
The patient can also be involved in managing
their risk of VTE. We recommend that the NHS engage with Lifeblood
in a public awareness campaign so that patients and their family
are mindful of their risk when entering hospital and prompted
to request for a VTE risk assessment. We believe that hospital-acquired
thrombosis should have the same, if not greater priority level
in the mind of the patient as hospital-acquired infections. In
addition, we also recommend that elective patients be sent a pre-admission
questionnaire, which would assist in the uptake of VTE risk assessment.
There is also a role for primary care to play
in managing a patient's risk of VTE. As VTEs are most likely to
occur after the patient has been discharged, the GPs should be
educated about the risks. They also have access to their medical
records with details of their risk assessment and prophylaxis.
If the patient subsequently dies in the community as a result
of a VTE, the GP should be encouraged to communicate this back
to the health professional who was responsible for the patient's
care whilst in hospital.
RECOMMENDATIONS
Lifeblood recommends that the following actions
are undertaken to address patient safety concerns:
— VTE risk assessment be mandated at
the earliest opportunity and included in the Operating Framework
— The Healthcare Commission to include
the uptake of VTE risk assessment and quality of hospitals' thromboprophylaxis
protocols as indicators in its annual health check
— Pre-admission VTE risk assessment
questionnaires to be introduced for elective patients
— The National Patient Safety Campaign
to acknowledge the evidence of the US Health Agency for Research
and Quality and adopt VTE intervention at the earliest opportunity
— The boards of Acute NHS Trusts to
ensure that all staff are educated not only in the Trusts' VTE
prevention and management protocols, but also the rationale for
the intervention
— All boards of Acute NHS Hospital
Trusts to review their systems for internal reporting of incidents
of VTE
— The NHS to engage in a public awareness
campaign to highlight the risk of hospital acquired VTE to the
patient
— After patients are discharged from
hospital, primary care should play an effective role in managing
a patient's risk of developing VTE.
Professor Beverley J Hunt
September 2008
124 House of Commons Health Committee. The Prevention
of Thromboembolism in Hospitalised Patients, Second report of
session 2004-2005. Back
125
National Office of Statistics. Available http://www.statistics.gov.uk/cci/nugget.asp?id=1067 Back
126
Task Force Report: Guidelines on diagnosis and management of acute
pulmonary embolism. Torbicki, EJR, et al. Eur Heart
Journal 2000; 21, 1301-1336 Back
127
www.ahrq.gov/downloads/pub/advances2/vol3/Advances-Flink_57.pdf-2008-07-30 Back
128
http://www.dvtreport.com/ Back
129
http://www.dvtreport.com/ Back
130
House of Commons Health Committee. The Prevention of Thromboembolism
in Hospitalised Patients, Second report of session 2004-2005. Back
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