Source · HSSIB Patient Safety Investigation
Management of venous thromboembolism risk in patients following thrombolysis for an acute stroke
Published 5 May 2021
Launched 7 February 2019
Published
HSIB Legacy
Acute
Every year in the UK over 100,000 people have a stroke. Patients who are admitted to hospital for any reason, including stroke, are assessed for their risk of developing blood clots in their veins which may arise due to being less active than usual.
Summary
1 recommendation
3 observations
1 of 1 responded
Safety Recommendations
R/2020/090
NHS England
It is recommended that the Intercollegiate Stroke Working Party with support from the Joint Stroke Medicine Committee and NHS England and NHS Improvement develop a stroke specific venous thromboembolism (VTE) assessment tool and system for ordering the associated treatment for patients who have suffered a stroke. HSIB recommend that the Intercollegiate Stroke Working Party supports development of a tool that ensures that important information is recorded and reviewed at appropriate intervals. The following points should be considered in the development of this tool: The aetiology/type of stroke (ischaemic and haemorrhagic). A record of the individual risk factors for VTE that are identified. Contraindications for VTE treatment measures. The VTE preventative treatment recommendation. The record of administration of that treatment. The reason that treatment is not administered. Patient’s level of mobility and activity (in relation to IPC administration). Frequency of IPC devices checking. Record of patient’s consent and understanding of risk/benefits of intervention, including patient’s decision.
The addressees declined to develop a full VTE assessment tool due to remit, instead creating a 'Best Practice Consensus' document with an 8-point checklist, awaiting final sign-off and planned for implementation via networks.
Response received 15 February 2021
Further to our recent correspondence in our capacity as Chair of the Joint Stroke Medicine Committee (hosted by the Royal College of Physicians of London: Professor Tom Robinson) and National Clinical Director for Stroke (NHS England and Innovation: Dr Deb Lowe), and on behalf of our colleagues at the Intercollegiate Stroke Working Party, responsible for the National Clinical Guidelines for Stroke and for the Sentinel Stroke National Audit Programme (Director: Professor Martin James; Associate Director: Dr Ajay Bhalla) , we are writing to provide a further and final update on our progress against the safety recommendation R/2020/090 contained in your report (dated October 2020). As previously discussed, we would reiterate that it is beyond our remit to develop a stroke specific VTE assessment tool and system. However, Professor Martin James, as Chair of the Intercollegiate Stroke Working Party with responsibility for the National Clinical Guidelines will continue to review new evidence that informs guidelines for future iterations. However, following consultation with the Intercollegiate Stroke Working Party and with the Joint Stroke Medicine Committee, we have developed the attached 'Best Practice Consensus for Reducing Venous Thromboembolism Post Stroke'. This document: (1) highlights the importance of venous thromboembolism in stroke, and references the existing guidelines for reducing risk; (2) details an 8-point checklist for best practice; and (3) cites two examples of best practice based on national comparative audit data. For your information, this document still awaits final sign-off by NHSE. Importantly, we have agreed the implementation of this 'Best Practice Consensus for Reducing Venous Thromboembolism Post Stroke' through the Integrated Stroke Delivery Networks, with an initial presentation to Clinical Leads at their forthcoming meeting on Friday 19th February 2021. In addition, a link will be provided to the document from the Intercollegiate Stroke Working Party website. Response received on 15 February 2021.
Safety Observations
Observation 1
Observation
There is no validated venous thromboembolism (VTE) risk assessment tool in the UK that produces a stratified risk for predicting a patient’s likelihood of developing a deep vein thromboembolism or pulmonary embolism. If it is not possible to produce a stratified VTE risk assessment, it may be beneficial to consider amending the title of the published VTE risk assessment tool in NICE guideline NG89 (National Institute for Health and Care Excellence, 2018). This would reflect its true purpose as a prompt for clinicians to develop an appropriate treatment plan rather than creating the perception that it produces an assessment of risk.
Observation 2
Observation
It would be beneficial for future venous thromboembolism (VTE) guidelines in relation to stroke to explicitly state when further VTE assessments are required during a patient’s stay in hospital.
Observation 3
Observation
The advantages of multidisciplinary team (MDT) working are well known. It would be beneficial for organisations to ensure that stroke units are structured to ensure the optimal functioning of the MDT. To achieve this requires strong leadership, planning and a culture that empowers and encourages staff to speak up when issues arise. Stroke care involves many healthcare disciplines and in order for them to work efficiently and achieve the best results for patients, it may be beneficial to have formalised, tested and practised joint working with escalation routes known by all.
HSIB identified the following local considerations
Consideration for commissioners
It would be beneficial for local commissioners to agree a scheduled programme of audits to ensure that patients assessed for risk of acquiring a venous thromboembolism (VTE) receive appropriate mechanical or pharmacological prophylaxis.
Considerations for trusts
It would be beneficial for trusts to review and amend their local procedures for the ordering and fitting of intermittent pneumatic compression (IPC) devices to allow any trained and competent person to fit them at the earliest opportunity. It would be beneficial for trusts to give patients who have had a stroke and their families/carers information about anticoagulation and VTE prevention, in particular the importance of IPC devices. They would then have the correct information to help them decide on whether or not to wear IPC devices.