Venous Thromboembolism Risk Assessment in Psychiatric Inpatients Audit

The aim of this audit was to study VTE risk assessment and management for psychiatric inpatients. We aimed to assess the use of VTE risk assessments and management of high-risk groups of psychiatric inpatients, and to identify and implement ways in which VTE risk assessment can be carried out more systematically.

Audit criteria follow the most recent NICE guidance on reducing the risk of hospital acquired VTE⁵.

Venous thromboembolism (VTE) is the primary cause of preventable deaths in hospital, with an estimated 25,000 deaths per year in the UK.^{1, 2} 55-60% of VTE cases occur during or following hospitalisation, with a significant cost burden on the NHS.² Identification of high-risk patients on admission to hospital is therefore crucial.

Inpatients on psychiatric wards may be at higher risk due to reduced mobility, poor fluid intake, restraint, catatonia, sedation and antipsychotic use.³ Evidence suggests that anti-psychotic use may be an independent risk factor for developing VTE.⁴ It is therefore imperative that a comprehensive VTE risk assessment is completed on admission and regularly reviewed.

NICE Guidance NG89 states: All acute psychiatric patients should be assessed to identify VTE and bleeding risk on admission, using a risk assessment tool. All patients should be reassessed during their admission and pharmacological VTE prophylaxis should be prescribed appropriately.⁵ The audit standard is accordingly a 100% rate of VTE assessments on admission.

We suspected that within our trust rates were much lower than this, based on historic audits and indications of current practice. We established a working group, including a haematologist, pharmacist, and representatives from inpatient services with the aim of establishing current practice and working together to improve this.

As a baseline assessment, a retrospective audit was conducted looking at all patients admitted to acute psychiatric wards, at two different hospital sites within the Trust.

The retrospective audit included the manual retrieval of data using the online clinical notes system and entered manually onto a spreadsheet for evaluation, using clinical information system numbers as identifiers only. No patient names were recorded.

In total 37/148 patient (25%) had a VTE assessment on admission. Differences in rates were variable between the wards; however at one site the older age adult wards had a much better record of completion 26/35 (74%).

Within the Trust in the last five years, 3 of 30 listed inpatient deaths of ‘natural causes’ were VTE related.

This is in keeping with VTE accounting for 10% of inpatient mortality: the number one cause of preventable hospital mortality. VTE assessments fell far short of the 100% target, and it was clear that systematic change was needed.

Following the results we:

• Presented findings at Trust-wide audit fair November 2019.
• Embedded a short discussion of VTE assessment in induction presentations and handbooks for junior doctors joining and working for the trust.
• Developed a new assessment tool in collaboration with haematology colleagues, more clearly applicable to the mental health setting and to be embedded within the inpatient physical health assessment (the primary document completed on admission.) This saves time for the admitting team, and also ensures that VTE assessment is completed as part of the primary assessment. The standalone document was also revised and remains available. In liaison with the Carenotes Service Improvement Leads this was incorporated into the clinical information system in May 2020, and awareness of this disseminated to colleagues via email to all doctors via Medical Education and within inpatient team settings.
• In the initial phase, we ensured that each ward included VTE assessments on nursing checklists for new admissions through liaison with senior nursing staff. Following the introduction of the embedded assessment, this additional check was not required but we provided a 'VTE on a page' explainer for nursing staff to reinforce the importance of VTE assessment and of alerting medical staff to indications of high risk or of suspicion of VTE.

Following implementation of the notes changes, and the campaigns described above, VTE assessments were re-audited as per the initial audit method.

On this re-audit, carried out in June 2020, 116/131 (89%) of patients had a VTE assessment on admission.

This audit and subsequent intervention resulted in a significant improvement in VTE risk assessment on admission. The new comprehensive assessment tool, embedded in the Inpatient-Physical Assessment, is now being used for all new admissions, and we expect the rate to continue to rise. As more patients are identified as requiring prophylaxis, the expectation is that we are able to reduce VTE related morbidity and mortality within the trust.

• Our implemented changes resulted in a significant improvement in VTE risk assessments completed on admission for psychiatric inpatients.
• Rates at this early stage were not yet 100% and it will be important to continue to reassess at intervals to ensure that VTE assessments are completed and to identify any difficulties with the new process. A change already identified is ensuring that the VTE assessment is a mandatory part of the assessment form, and a next step will be taking this back to clinical information system colleagues to ask for this change to be made on updates to the system.
• Changing the system - here, taking advantage of a form which is (almost) always completed on admission rather than relying on an additional form - has proved effective
• Collaboration with colleagues, particularly drawing on haematology and pharmacy expertise, as well as operational experience (medical, nursing and information systems colleagues) was vital. The VTE working group with representation from several disciplines allowed us to make recommendations in response to the data. Creating and implementing changes took some time, so taking other approaches (through discussion with medical and nursing teams) while changes to the information system were made was an important intermediary step.
• Within general hospitals VTE cases are reviewed to ensure compliance with assessment and treatment protocols and identify areas for learning and progress. With the support from the haematology service, we now aim to set up a robust system to identify morbidity and mortality due to VTE and to facilitate review of these to identify learning around preventable causes. This will link with trust incident reporting and include regular feedback to an identified team with understanding of VTE and VTE prevention.
  References

1. Thrombosis Statistics. [Internet]. 2018 [accessed 2018 Oct]. Available from: https://www.thrombosisuk.org/thrombosis-statistics.php
2. House of Commons Health Committee. The prevention of venous thromboembolism in hospitalised patients. London: The Stationary Office. [Internet]. 2005 [accessed 2018 Oct]. Available from: https://publications.parliament.uk/pa/cm200405/cmselect/cmhealth/99/99.pdf
3. Delluc A, Montavon S, Canceil O et. al. Incidence of venous thromboembolism in psychiatric units. Thrombosis Research. 2012;130(5):e283-2288
4. Zhang R. Dong L. Shao F. Tan X. Ying K. Antipsychotics and venous thromboembolism risk: a meta-analysis. Pharmacopsychiatry. 2011;44(5):183-8. DOI: https://doi.org/10.1055/s-0031-1280814. PubMed PMID: 21739416.
5. Interventions for people with psychiatric illness. Venous thromboembolism in over 16s: reducing the risk of hospital acquired deep vein thrombosis or pulmonary embolism. National Institute for Health and Care Excellence. NICE guideline [NG89] Available from: https://www.nice.org.uk/guidance/ng89/chapter/Recommendations#interventions-for-people-with-psychiatric-illness