The link between long-haul flights and blood clots is well known, however few people realise that any sustained period of immobility, such as through illness at home or a spell in hospital, can put them at risk of developing a blood clot (deep vein thrombosis or pulmonary embolus). In 2005 it was estimated that more people died from blood clot lodging in their lungs (pulmonary embolism) than those who died from road accidents, AIDS, breast and prostate cancer combined. (House of Commons Health Committee 2005). NICE Guidance (2010) estimated that blood clots or venous thromboembolism (VTE) causes around 25,000 deaths annually in England’s hospitals, yet with the correct treatment, as many as 60 per cent of those deaths can be avoided. In addition, treating long-term disabilities caused by non-fatal clots costs the NHS some £640 million pounds a year to treat. The impact on the lives of those who develop clots is considerable. Added to the worry of developing a fatal embolism and the heightened risk of developing further clots, VTE causes pain, discomfort and disruption to home/work life through increased hospital stay, follow-up appointments and regular blood tests. Some people may experience side effects from treatment, such as reduced mobility, and there is the possibility of developing post thrombotic syndrome, which can occur up to two years after developing the initial clot. Post-thrombotic syndrome is a condition where anything from pain and swelling, to varicose veins or brown and white pigmentation can occur in the leg after a clot. This is due to the permanent damage of the legs veins after a DVT, so that that the veins can no longer drain blood from the leg properly. If the situation is very bad, then ulcers may develop on the inner side of the leg above the ankle due to this area being susceptible to poor drainage.
In hospitals VTE is largely seen as occurring in surgical patients, whereas around 70% of patients affected are medical (NICE 2010). A variety of factors increase the risk of VTE in medical inpatients in particular: reduced mobility, age over 75, cancer, recent myocardial infarction, congestive cardiac failure, stroke, chronic obstructive airways disease and acute infectious disease. From this evidence the VTE project focused mainly on medical wards.
The 2 year VTE project began in June 2010 when Rotherham NHS Foundation Trust (RFT) highlighted VTE as a clinical priority. In April 2010 VTE NICE Guidance and VTE Quality Standards (NICE 2010a) were produced which all NHS Trusts were required to implement. This was linked to the Commissioning for Quality and Improvement Payments (CQUINS), where NHS Trusts were paid according to care given to patients. All Trusts had to demonstrate that patients were risk assessed for VTE and given the appropriate preventative treatment.
A VTE Steering Group was developed which was supported by stakeholders throughout the Trust who had a personal interest and passion for the care of patients at risk of or suffering from VTE. Members include the Director of Quality and Standards, medical consultants, anaesthetists, nursing staff, nurse specialists, pharmacists, and a patient representative joined the group to establish a patient and public voice. The integration of the Trust Steering Group and CLAHRC-SY project team enabled close collaboration, and promoted the ability to co-produce policies and procedures which has been vital to translating the VTE NICE guidelines and quality standards into practice.
The aim of the implementation project was to improve the multidisciplinary care and management of patients at risk of venous thromboembolism (VTE) through the implementation of National Institute for Clinical Excellence (NICE) guidance (NICE 2010), and the NICE VTE Quality Standards (NICE 2010a) in medical wards at Rotherham Hospital.
- To facilitate appropriate and timely evidence-based care provided by health care practitioners for patients at risk of VTE
- To facilitate and assess the effectiveness of patient education strategies related to VTE prevention, including the initial assessment, ongoing review, and discharge planning
- To develop and evaluate the effectiveness of a best practice champion in promoting timely and effective care on reducing the risk of VTE
- To conduct an economic analysis of the resource use costs/cost benefit analysis of implementing the NICE VTE guidance on medical wards compared to costs predicted by NICE
- To disseminate learning across the CLAHRC partnership organisations and to facilitate its uptake into undergraduate nursing, medical allied health professional curricula and continuing professional development.
A service improvement approach employing stakeholder and user involvement was used to assess the implementation of the NICE guidance on the management of VTE. The knowledge to action cycle (Graham et al 2006) was used to guide the process.
The following multi methods approach using qualitative and quantitative methods was used to evaluate the process of implementing the VTE guidance:
- audit of records
- questionnaires to assess knowledge
- interviews with staff and patients
- field notes and observation of intervention wards.
The evaluation comprised the following:
- Baseline data collection to measure the extent of current compliance with VTE and subsequent treatment given within 24 of admission.
- Baseline assessment of staff knowledge, skills and attitudes towards VTE management, adherence to the treatment through observation, and a questionnaire.
- Development of Patient Information for VTE, and an evaluation of patients understanding of this information.
- Economic modelling to estimate the potential cost of implementing the VTE NICE Guidance.
- Evaluating the outcomes for patients, staff through Root Cause Analysis (RCA) of hospital associated VTE.
- Repeated measures of adherence to VTE assessment and treatment, and staff knowledge of VTE at the start, midway, and end of the project.
- Reporting the findings to the Trust and other dissemination activities.
Patient and Public Involvement
An aim of the NICE Guidance (2010) is to raise awareness in the public as well as health care professionals, of the risks and of the serious short and long term consequences of VTE, and the existence of the safe and preventable treatments available. A key priority is that patients and their families are offered verbal and written information before and during treatment to prevent VTE, and that this should also be included as part of the discharge plan. Posters and a patient information booklet for VTE were developed and evaluated. A patient representative from Rotherham Hospital supported this development and evaluation.
Cost of Implementing NICE guidance
The NICE recommendations for practice (DoH 2010) suggest that a reduction in adverse VTE events will lead to reduced costs, and do include costing guidance and costing templates for acute hospitals to use. However implementing new guidance in an acute hospital requires an investment in resources of staff time and administration. To evaluate this economic evaluation of the costs involved in implementing VTE guidance in Rotherham was included in the project.