Preventing hospital associated venous thromboembolismBMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l4239 (Published 21 June 2019) Cite this as: BMJ 2019;365:l4239
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The Editorial raises the question of the efficacy of the below knee elastic stockings upon which the NHS currently spends so much money. According to the 2016 Cochrane Review, nearly all reports on the use of elastic stockings relate to long leg stockings. Such reports are not therefore, strictly applicable.
The NHS is probably comforting itself that it is doing something even if that something is based on research that is somewhat irrelevant.
Competing interests: No competing interests
Re: Preventing hospital associated venous thromboembolism- Why clinicians should adhere to NICE recommendation.
Dalia Dawoud1,2, Gerard Stansby3, Ian Donald4, Sedina Lewis5, Carlos Sharpin5, Peter Barry6, Philip Alderson1
1National Institute for Health and Care Excellence (NICE), UK
2Cairo University, Faculty of Pharmacy, Egypt
3Newcastle University and Freeman Hospital, UK
4 Gloucestershire Royal NHS Trust, UK
5 National Guideline Centre, Royal College of Physicians, UK
6 University Hospitals of Leicester NHS Trust, UK
We read with interest this editorial, by B Hunt, published in the BMJ on 21 June 2019. In this, she highlights progress made in the UK towards the prevention of hospital acquired venous thromboembolism (VTE) through mandatory risk assessment, reporting and provision of prophylaxis and she calls on the WHO to adopt this systematic approach on a global level.
Over the last two decades, the National Institute for Health and Care Excellence (NICE) has played a central role in the efforts to prevent VTE associated with hospital admissions through publishing two clinical guidelines (2007 for surgical admissions,1 and 2010 for both medical and surgical admissions2) and an update of the latter in March 2018 (NG89).3 The 2010 guideline paved the way for the implementation of mandatory VTE and bleeding risk assessment on admission to guide prescribing of prophylaxis.2 This recommendation has been retained in the latest update with clear emphasis on the importance of reassessing risk when the patient’s condition changes. It is only by adhering to these recommendations that Trusts across the English NHS have managed to achieve the remarkable improvement reported by Hunt in her editorial.
Recommendations in NICE guidelines are based on the best available clinical and economic evidence, only prophylaxis regimens (dosage and duration) that are supported by this level of evidence have been recommended. Hence, in NG89,3 pharmacological prophylaxis with low molecular weight heparin for acutely ill medical patients and those admitted for abdominal surgery was recommended for 7 days, a duration that was found to be both clinically and cost effective, based on trial evidence and economic modelling. The latter takes into account all costs associated with its use including the cost of administration by a district nurse. Taking the above into consideration, we have been alarmed by Hunt’s statement that “most English trusts have pragmatically elected not to apply these changes to avoid higher costs for cash strapped trusts and extra work for district nurses.”. Hunt’s statement fails to highlight the downstream saving to be achieved from preventing both symptomatic and asymptomatic VTE events and their costly thrombotic consequences which negatively affects quality of life and includes post-thrombotic syndrome and chronic thromboembolic pulmonary hypertension. In fact, the highest costs that Trusts should aim to reduce is that resulting from inadequate VTE and bleeding risk assessment which leads to the administration of prophylaxis to those who do not need it at all.
Furthermore, Hunt stated that prophylaxis has been recommended “for “length of stay,” ………in the 2012 guidelines”, however; the 2010 guideline (CG92),2 which is likely to be the one meant by Hunt in this statement, did not specify length of stay as the duration of prophylaxis. More clarity about the duration of prophylaxis was included in NG89 as there were anecdotal reports that sub-therapeutic doses and durations have been used in practice. It is likely that these patients were at low risk of VTE and often should not be prescribed prophylaxis at all. Therefore, it was the NG89 committee’s decision to specify the evidence-based duration of LMWH prophylaxis (7 days) and to stress the importance of risk assessment, balancing the person's individual risk of VTE against their risk of bleeding and re-assessing this risk at the point of next consultant review or if the person’s clinical condition changes.
Hence, we urge clinicians to continue to adhere to NICE recommendations including those relating to risk assessment, re-assessment, choice and duration of prophylaxis to ensure that the positive outcomes of this systematic, NHS-wide VTE prevention effort continue to be realised.
1. NICE. Venous thromboembolism (surgical). NICE Clinical Guideline 46. 2007. https://www.nice.org.uk/guidance/cg46
2. NICE. Venous thromboembolism: reducing the risk for patients in hospital. NICE Clinical Guideline 92. 2010. https://www.nice.org.uk/guidance/cg92
3. NICE. Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism. NICE guidance 89. 2018.https://www.nice.org.uk/guidance/ng89
Competing interests: I was part of the technical team who developed NICE guideline NG89
The term thrombosis was introduced by Galen in the last century, who expressed that this was not more than the obstruction of the light of a glass by a thrombus; in turn, the eminent German pathologist Rudolf Ludwig Karl Virchow (1821-1902) stated that this abnormal vascular situation occurs conditioned by 3 factors: alterations of the vessel wall, changes in the blood circulating inside it and decrease in the blood velocity.
The term thromboembolic disease encompasses different forms of thrombosis. In fact, venous thrombosis and pulmonary embolism are so inextricably linked that today we consider 2 aspects of the same clinical entity: venous thromboembolic disease (VTD).
The increase of this condition and its complications favored the activity in the search of diagnostic and therapeutic means aimed at solving this disturbance.
A large number of situations may favor the development of a VTD, among these, the best known are: advanced age, pregnancy and puerperium, prolonged immobilization, obesity, smoking, neoplasms (especially, prostate tumors , pancreas, lung, breast and ovary), myeloproliferative syndromes, inflammatory bowel disease, infections, autoimmune diseases, nephrotic syndrome, diabetes mellitus, surgery (especially orthopedic or trauma), hormone replacement therapy , oral contraceptives and central venous catheters. The above factors can act alone or together with a predetermined genetic substrate that increases the risk.
During pregnancy and puerperium, important alterations occur in various organs and systems, particularly those related to the functioning of renal and cardiovascular hemodynamics. The hemostatic process also undergoes notable changes during pregnancy, since it has been shown that the complications related to this stage of the woman often present haemostatic disorders that are expressed by hemorrhagic, thrombotic episodes, or both, which have a marked influence in maternal mortality; also, there is a decrease in venous tone, reduction of blood flow and "mechanical" obstruction by the gravid uterus, with the subsequent ecstasy, favored by multiple risk factors.
Early and accurate diagnosis, appropriate treatment, including supportive measures and anticoagulation, can prevent the complications of deep vein thrombosis: a pulmonary embolism or, in the longer term, a chronic venous insufficiency of the affected limb.
This condition is frequent in pregnant women, either alone or as a complication resulting from another morbid process, constitutes a reason for admission to the intensive care ward of some hospitals, and has been investigated in other countries with encouraging results regarding its diagnosis and treatment. The early identification of risk factors, their possible modifications and the establishment of timely therapeutic measures will prevent the appearance or minimize the complications of VTD in pregnant or puerperal patients associated with hospitals.
The VTD associated with hospitals, especially a vulnerable group: pregnant and puerperal women. It constitutes a health problem, neglecting them implies violating ethical and humanistic problems implicit in the daily medical performance in our hospital centers where prevention can win the battle to the complications of the venous thromboembolic disease and even tear fertile women from the jaws of death.
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Competing interests: No competing interests
A reduction of 15.4% in hospital related DVT/PE translates to a modest reduction of DVT/PE (from 6 in 10000 to 5 in 10000 patients, based on the data provided in the article).
When one considers the great organizational effort (quoted in the editorial) and the risk of bleeding (not sufficiently quoted in the editorial), issues of opportunity cost should be raised.
Also, in our hospital (and I doubt we are alone), the trend in overcharged admission units is to apply prophylaxis unselectively, behind the classical acute «medical» admission suggested by NICE. Some of these patients are frail, and represent social rather than medical acute admissions. These same individuals are prone to falls, and trusts may be called to defend the use of prophylaxis in the event of head trauma.
Competing interests: No competing interests