10 March 2020

Blood Clot Management at University Hospitals Plymouth   

Huw Rowswell
Nurse Consultant University Hospitals Plymouth NHS Trust

University Hospitals Plymouth (UHP) is a large teaching hospital of around 1000 beds covering a direct population of 450,000 people and offering tertiary services to almost two million people. In 2019 there were 769 venous thromboembolism (VTE) events diagnosed with 315 DVT and 454 PE and of the total 183 (24%) met the criteria to be termed hospital-acquired thrombosis.

The management of thrombosis depends upon where the diagnosis is made; the location of the thrombosis and who manages the anticoagulation and patient follow up. In 2019 there were 144 events (46% of all DVT) that were diagnosed in the nurse led DVT clinic which was set up around seventeen years ago by a haematology and a medical consultant. They take referrals predominantly from general practitioners (GP) for suspected DVT and a smaller number from the emergency department. Patients are assessed in the clinic, a brief history and bloods are taken and if the scan is positive the condition is managed within the clinic to start anticoagulation therapy and follow up is arranged either within the clinic, referral to haematology for a three month review or by the patient’s GP.

Historically, treatment was primarily was with warfarin and the patient was taught to give their own low molecular weight heparin and not discharged from the clinic back to the GP until their warfarin was within therapeutic range. In 2019 there were 21 new prescriptions of warfarin covering all new VTE events. Now of course, most deep vein thrombosis (DVT) events are managed using direct oral anticoagulants (DOAC’s). Patient group directives are also used to supply anticoagulant medicines dependent upon a patient’s choice.

As a nurse consultant, part of my role is to collect data on all cases of hospital-acquired thrombosis (HAT) and to carry out a basic root cause analysis to ensure appropriate preventative measures were in place prior to the diagnosis. This is achieved by looking at all the targeted radiological investigations comprising of; Doppler ultrasounds, Computed tomography pulmonary angiograms and ventilation perfusions scans to identify positive events. Once a new VTE is identified this is cross checked with the patient management system to see if it meets the HAT criteria then a basic RCA is carried out. In the majority of cases no issues or omissions are identified so real time feedback is then given to the discharging team especially as the thrombosis may be managed by a different team or service. I also examine what treatment has been initiated to treat the thrombosis to ensure it is appropriate and dosed correctly. Particularly when DOAC’s were first prescribed there were often issues seen with incorrect loading doses or duration of anticoagulation - particularly for unprovoked events. My role was to review such issues and ensure the correct medication and dosage was given.

In addition, I try to speak to any inpatients who have started treatment with anticoagulation after a new thrombosis diagnosis to help answer any questions or concerns they may have. Audit is carried out across the hospital to look at whether patients are receiving appropriate VTE prophylaxis and feedback is given to teams where poor compliance is noted. Finally, I ensure that a 3-6 month follow up as per NICE guidelines has been arranged to look at whether there is a need for long term treatment after the thrombosis has been treated. I work as part of the haematology team to then see these patients to identify the risk vs benefit of long-term anticoagulation treatment against the risk of bleeding associated with this medication. Referrals to this clinic will come from all over the hospital and the plan is to have a shared decision with patients giving advice and the likely risks associated with the two options.

As a committee member, with a remit around education and website management, of the clinical leaders of thrombosis (CLOT) I help to organise a session at the British Society of Haematology Annual Scientific Meeting which this year is on Wednesday the 29th April from 8.45am to 10.15am looking at anticoagulation in 2020. The three speakers are exploring the topic of prescribing anticoagulation in extremes. This will include prescribing for children, renal impairment and extremes of weight. The second talk is from a Cardiologist who will delve into the issues of what to do when starting anticoagulation on cardiac patients already on anti-platelet agents. The final talk will be on the recent National Confidential Enquiry into Patient Outcome and Death report looking at Pulmonary Embolism (PE) management across the United Kingdom and how we can improve care. These discussions promise to contribute to an interesting session hopefully providing answers to some questions or issues that often arise during the management of new thrombotic events.