Preventing thousands of avoidable deaths from VTE

Professor Beverley Hunt discusses what the inclusion of VTE as a national CQUIN goal means for the NHS in 2010 and argues the challenge to make an impact and prevent thousands of avoidable deaths from VTE has only just begun

Thirty years ago Vijay Kakkar scored a significant medical breakthrough when he demonstrated that the use of postoperative low dose heparin could save as many as seven lives per 1000 operated patients

Three decades, and thousands of avoidable deaths later, the Department of Health has woken up to the extent and scale of VTE - hospital-acquired venous thromboembolism. VTE prevention has now been effectively mandated for hospital trusts in the 2010/11 NHS Operating Framework. For those of us campaigning for improved VTE prevention, 2010 heralds the potential for a genuine watershed in improved patient care.

It’s estimated that 25,000 people die each year in the UK from hospital-acquired VTE – the formation of deep vein thrombosis and the potentially fatal pulmonary embolism

But the good news is that prevention is simple and cost effective, with NICE most recently noting that while the recommendations for effective prevention of VTE is anticipated to cost an additional £21.9 million nationally, this is ‘more than offset’ by an anticipated reduction in deep vein thrombosis and pulmonary embolisms that is estimated to save £26.3 million nationally. High, therefore, on both the patient safety and efficiency agenda, VTE has a mortality rate of 30% which, when properly treated, reduces to between just two and eight percent.

Through the Quality Framework in the 2010 Operating Framework, VTE prevention has been declared a national goal as part of the commissioning for quality and innovation ( CQUIN) framework with the NHS Operations Board naming VTE as one of two nationally specified goals.

T he national goal is to ‘reduce avoidable death, disability and chronic ill health from VTE’ with the goal defined as ‘the percentage of all adult inpatients who have had a VTE risk assessment on admission to hospital’.

Significantly, a payment of 1.5 percent of the contract value will be triggered when trusts meet a goal of 90 percent of all adult inpatients risk-assessed. Therefore, a proportion of provider contract value is linked to improvements in VTE prevention, in effect mandating this proven best practice.

This is an enormous leap forward in the battle to reduce avoidable deaths from VTE. We are confident that because of the significant amount of PCT funding the CQUIN target represents, it will really concentrate the minds of trust management to prioritise VTE risk assessment – as this can unlock access to as much as £9 million in a large NHS foundation trust.

This advance follows years of clinical concern and campaigning. Most recently, the Academy of Royal Medical Colleges backed the need for action to reduce the prevalence of the condition. Indeed, such is the importance with which the issue is viewed that this is the first clinical programme that the Academy will be supporting the NHS to deliver.

The announcement also follows a call from almost 80 percent of NHS hospital trusts for government to mandate VTE prevention. This was a finding from the 2009 survey of the All Party Parliamentary Thrombosis Group which also found that over half of all trusts said that payment incentives would be the most effective way to achieve this. Mandating through CQUIN clearly therefore has clinician support.

Given the level of support for VTE prevention and the obvious patient safety and efficiency benefits, the announcement by NHS medical director Professor Sir Bruce Keogh that VTE prevention is the top clinical priority for improving quality and productivity in hospitals in 2010-2011 should be no surprise. Further still, that the NHS has identified VTE prevention as one of its priorities over the next five years is excellent news for patient safety.

Paramount to securing a reduction in the number of lives lost from avoidable VTE and the wasted millions on treating post-thrombotic syndrome will be ensuring those patients who are identified as being at medium- or high risk are given appropriate thromboprophylaxis, whether mechanical or pharmacological. The importance of this next step has been recognised in the CQUIN goal which expects that, ‘in line with good clinical governance’, providers will ensure patients receive thromboprophylaxis in line with national guidance.

Across the NHS a series of resources now exist which identify VTE prevention best practice – there really is little excuse for NHS managers and frontline staff not to change and improve their assessment procedures.

High amongst these, NICE will be publishing their updated VTE guideline on 27 January, detailing fully the procedure for risk assessment and thromboprophylaxis for all hospital inpatients.

In addition, the NICE VTE quality standard will be launched. Best practice is detailed in the joint Department of Health / All-Party Parliamentary Thrombosis Group resource, VTE: A Patient Safety Priority, published in June 2009, and also in shared learning from the clinical leadership of those NHS trusts labelled ‘VTE exemplar sites’.

Indeed, with the National Litigation Authority considering inclusion of VTE in their indicators of risk for 2010, hospitals ignore this guidance at their own risk – and could bear financial consequences if they do.

Most trusts have thrombosis committees in place – a response to the 2005 Health Select Committee Report on hospital-acquired VTE and they are the perfect instrument to effect full risk assessment implementation.

Meeting the CQUIN goal will require multidisciplinary engagement. Both nurses and pharmacists are crucial in ensuring best practice procedures are complied with. This is particularly because of their ongoing ward presence (unlike the often short-term rotations of junior doctors).

For some thrombosis committees, experience shows that a dedicated DVT nurse can be critical in ensuring trust-wide policies are complied with and procedures are managed.

However, to deliver these results, it is essential that nurses are given the training and tools necessary to carry out risk assessments and, of course, this requires adequate funding.

Alternatively, IT solutions have been used, for example where health professionals admitting new patients cannot prescribe drugs or order pathology assays on electronic systems until a risk assessment for VTE has been performed first.

Having prioritised VTE, an ongoing challenge is to obtain reliable and accurate VTE metrics on the prevalence of the condition. This issue is being looked at by the chief medical officer in developing a VTE admissions code, enabling those who re-enter hospital following an inpatient stay to have their history tracked back to whether or not they were risk assessed and given appropriate thromboprophylaxis during their first hospital stay.

This in-depth review has also been promoted by the national CQUIN goal which expects providers to carry out root cause analysis on all confirmed inpatient cases of pulmonary embolism and deep vein thrombosis.

Indeed, the CQUIN goal notes that, following the publication of the forthcoming updated VTE NICE guideline, commissioners may require providers to provide audit data on prophylaxis as well as root cause analysis. This will help strengthen the numerical data on the prevalence of the condition.

A second strand of developing robust statistics on the occurrence of VTE is to determine the mortality rate of hospital acquired pulmonary embolism. Statistics released by the national statistician in May 2009 revealed that pulmonary embolism was the cause of death for between 16,000 and 19,000 people per annum between 2003 and 2007.

With the reduction in recent years in the rate of post mortems, this figure is likely to represent just the tip of the iceberg. VTE mortality continues to be under-reported and the challenge now is for coroners to identify those patients who do die from pulmonary embolism. That patients die unnecessarily from hospital acquired VTE is a public health scandal – that it goes unmeasured is also unacceptable.

The significance of hospital-acquired VTE becoming the clinical priority for quality and productivity for 2010, for both patients and the NHS, cannot be underestimated. Yet the real challenge has only just begun.

If we are to make real headway in reducing the estimated annual 25,000 deaths from avoidable hospital acquired VTE, we must ensure best practice is fully implemented and that financial incentives under CQUIN goals become more sophisticated and outcomes based. Whitehall has made its views clear – now the baton and the spotlight lies firmly with medical professionals and NHS managers.

Professor Beverley J Hunt is professor of thrombosis & haemostasis, King’s College, Guy’s & St Thomas’ NHS Foundation Trust, London and medical director, Lifeblood: The Thrombosis Charity

Kakkar et al (1975) ‘Prevention of Fatal Postoperative Pulmonary Embolism by Low Dose Heparin. An International Multicentre Trial’, The Lancet July 12:2

2 1House of Commons Health Committee (2004-05) The Prevention of Venous Thromboembolism in Hospitalised

Patients (HC 99)

3 http://www.nice.org.uk/usingguidance/benefitsofimplementation/costsavingguidance.jsp