New blood clot standard designed to prevent deaths

With 10% of all Australian hospital deaths caused by largely preventable blood clots, a new standard of care has been launched to reduce the risks for patients.

Developed by the Australian Commission on Safety and Quality in Health Care, the first national Venous Thromboembolism Prevention Clinical Care Standard aims to address the threat posed by blood clots, which kill four times as many people than road accidents.

Each year 30,000 Australians develop blood clots^{1, 2} — known as venous thromboembolism (VTE) — in the deep veins of the leg (deep vein thrombosis) or in the lungs (pulmonary embolism), at a cost of $1.72 billion to the Australian health system.³

Many of these cases develop during or following a hospital stay, and an estimated 5000 people die each year as a result of hospital-acquired VTE.⁴ For those affected by pulmonary embolism, sudden death is the first symptom in almost 25% of cases.^{5, 6}

Launched at The Alfred Hospital in Melbourne, the new standard, which was informed by leading clinical experts and consumers, translates international guidelines and other evidence into clinical practice to reduce avoidable death or disability caused by hospital-acquired VTE.

Blood clots account for an estimated 10% of all hospital deaths in Australia³ — yet they are considered to be largely preventable, with intervention reducing the incidence of VTE by up to 70% for both medical and surgical patients.^7-11

Associate Professor Amanda Walker, Clinical Director at the commission, said that while illness, injury and surgery are associated with blood clot development, it is possible for anyone to develop VTE.

“This serious condition is largely avoidable with proper VTE prevention, so it is concerning that a recent Australian report⁴ found that fewer than half (44%) of clinical units surveyed assessed patients for their risk of developing VTE on admission to hospital,” said Associate Professor Walker.

“Of those who were assessed to be at risk, not all were offered VTE prevention. This clearly indicates that many patients who should be receiving preventative treatment for blood clots are not getting the care they need.”

Associate Professor Walker said the new standard offers guidance on appropriate blood clot prevention methods and the importance of ongoing care after the patient leaves hospital.

“We know that up to 60% of all VTE cases in Australia occur within 90 days of hospitalisation, and it can happen to both medical and surgical patients.⁶ We can do better and the new standard aims to support clinicians and health services to deliver quality care to prevent blood clots in hospital and following discharge,” she said.

“In fact, the evidence suggests that appropriate use of VTE prevention methods is the top intervention hospitals can make to improve patient safety.”¹²

Leading haematologist Associate Professor Huyen Tran, Head of the Haemostasis and Thrombosis Unit at The Alfred Hospital, said the standard will help close the gap between guideline recommendations and practice and procedures in the hospital setting.

He explained there are often signs that can indicate a person may be at risk of blood clots. “Patients who have symptoms like pain, tenderness or swelling of the leg, shortness of breath, coughing up blood or chest pain after a hospital stay should speak to their doctor about their concerns.

“Improved uptake of appropriate clot prevention strategies will help reduce the impact — on both patients and the health system.”

Patients with a hospital-acquired VTE remain in hospital for 21 days longer on average¹⁴ and each hospitalisation costs about $45,000 extra, excluding loss of productivity and efficiency costs.¹⁵

The new clinical care standard has been endorsed by the Thrombosis and Haemostasis Society of Australia and New Zealand, the Royal Australasian College of Surgeons, the Australian Orthopaedic Association, the Australian College for Emergency Medicine and other professional bodies.

The Venous Thromboembolism Prevention Clinical Care Standard and fact sheets for consumers and clinicians can be found on the commission’s website, here.

References

1. Ho WK, Hankey GJ, Eikelboom JW. The incidence of venous thromboembolism: a prospective, community-based study in Perth, Western Australia. Med J Aust. 2008;189(3):144-7.

2. Szabo F, Marshall C, Huynh DK. Venous thromboembolism in tropical Australia and in Indigenous Australians. Semin Thromb Hemost. 2014;40(7):736-40. Epub 2014/10/04.

3. Access Economics Pty Ltd for the Australia and New Zealand working party on the management and prevention of venous thromboembolism. The burden of venous thromboembolism in Australia, 1 May 2008. Access Economics Pty Ltd; 2008.

4. Clinical Excellence Commission. Safer systems better care - Quality Systems Assessment statewide report 2013. Sydney: Clinical Excellence Commission; 2014; Available from: http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0007/258685/hs14-020-cec-qsa-report-dv3.pdf.

5. Cohen AT, Agnelli G, Anderson FA, Arcelus JI, Bergqvist D, Brecht JG, et al. Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost. 2007;98(4):756-64.

6. Heit JA, Spencer FA, White RH. The epidemiology of venous thromboembolism. J Thromb Thrombolysis. 2016;41:3-14.

7. Falck-Ytter Y, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2_suppl):e278S-e325S.

8. Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, et al. Prevention of VTE in Nonorthopedic Surgical Patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e227S-e77S.

9. Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA, et al. Prevention of VTE in Nonsurgical Patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e195S-e226S.

10. Lau BD, Haut ER. Practices to prevent venous thromboembolism: a brief review. BMJ Qual Saf. 2014;23(3):187-95.

11. Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuunemann HJ. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl).

12. Shekelle P, Watcher R, Pronovost P, Schoelles K, McDonald K, et al. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Rockville, MD: Agency for Healthcare Research and Quality; 2013.

13. Heit JA, Melton LJ, III, Lohse CM, Petterson TM, Silverstein MD, Mohr DN, et al. Incidence of Venous Thromboembolism in Hospitalized Patients vs Community Residents. Mayo Clin Proc. 2001;76(11):1102-10.

14. Independent Hospital Pricing Authority (AU). Activity Based Funding Admitted Patient Care 2015–16 acute admitted episodes, excluding same day.

15. Independent Hospital Pricing Authority (AU). National Hospital Cost Data Collection 2015–16, acute admitted episodes, excluding same day.