In this article...

• NICE Guidelines
• Health Committee Guidelines
• Cost impact for the NHS
• Conclusion

In 2005, there was a result of growing awareness that venous thromboembolism (VTE) was a serious issue and progress could be made in respect of patient safety if basic prophylaxis was adopted.

At that time it was reported by the House of Commons Medical Committee that each year over 25,000 people in England alone, die from VTE contracted in hospital. This is more than the combined total deaths from breast cancer, AIDS and road traffic accidents and more than twenty-five times the number of people who die from MRSA.

VTE became known as the Cinderella issue as a result of the little attention devoted to it and internationally it became known as the silent killer.

The main danger in terms of a VTE is that a blood clot form in the lower limb or pelvic veins and can then become loose. If this lodges in the lungs then it will cause a Pulmonary Embolus (PE) which often kills immediately. Patients who do survive will mostly require intensive care as a result. If a PE is not encountered then a VTE itself may develop chronic swelling and leg ulceration. If this morbidity is taken into account together with the deaths caused then it can be seen that this is a very real and immediate health issue.

As a result of the 2005 Health Committee report the Chief Medical Officer, Sir Liam Donaldson commissioned a further Health Committee report upon the prevention of VTE in hospitalised patients generally and asked that NICE to report upon reducing the risk of VTE in patients undergoing surgery. Both reports have now been published bringing patient’s safety and VTE management clearly into the spotlight.

In a Claims Online article in 2005 I reported that VTE claims would become increasingly difficult to defend. From 2007 we will either need evidence that the new guidance has been followed or a good reason why it has not been followed to successfully defend VTE claims in the future.

Back to top

NICE Guidelines

The much awaited NICE guidelines for reducing the risk of VTE in patients undergoing surgery was published in May 2007 www.nice.org.uk (CGO46).

The guidance is specifically tailored for reducing risk of VTE by type of surgery. In summary there are three separate strategies as follows:

		Most patients should be offered compression stockings and inflatable boots during surgery.
		Blood thinning medication (Heparin) should be given to orthopaedic patients and other high risk surgical patients.
		Regional anaesthesia instead of general anaesthesia should be considered.
		Patients to be mobilised as soon as possible after surgery.

Health Committee Guidelines

Historically the risk of VTE in medical patients has been overshadowed by the known risks relating to surgical patients. The recommendations given by the working group commissioned by Sir Liam Donaldson relate to all hospitalised patients, medical and surgical and can be found at www.dh.gov.uk (073963). The recommendations are designed to work with the NICE Guidelines published in May. In summary the recommendations are:

		All medical patients should have a mandatory risk assessment and be considered for thromboprophylaxis.
		The VTE assessment to be embedded within the Clinical Negligence Scheme for Trusts.
		Improvement of public and professional understanding of VTE.
		All high risk surgical patients managed according to the available evidence.
		Compliance with such standards to be monitored by the Healthcare Commission.
		Department of Health referral of healthcare institutions who have no VTE protocols to local thrombosis demonstration centres.

Cost impact for the NHS

Ignoring for a moment the tragic loss of life and morbidity for the survivors of this disease it is important to consider the cost implications of the recommendations made in the recent guidance. NICE have provided a costing report in terms of implementing the recommendations that they have made which of course relates to surgical patients only. Assessments have been made in respect of the financial consequences of dealing with patients as a result of VTE and PE’s against the costs of the prophylaxis. There is an estimated cost saving to the NHS of £4.441 million pounds in respect of surgical patients only. If the cost saving of treating medical patients is also taken into account the saving could be significantly more.

There must be few examples in the NHS where there can be such significant progress made in terms of patient safety where instead of an increase in cost to the NHS there is in fact a cost saving.

Conclusion

The key to all the current guidance is that every hospitalised medical or surgical patient now requires a mandatory risk assessment for VTE. 2007 will mark a turning point in respect of achieving a high standard of patient safety relating to avoidance of VTE with the potential of also achieving some significant financial savings for the NHS. With the current published guidance the NHS needs to take up the challenge to ensure that the statistical data of between 25,000 to 31,000 deaths due to VTE is very much a thing of the past.