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.
The reference event in this investigation is the case of a 78-year old woman who suffered a pulmonary embolism whilst recovering from a stroke in hospital.
Following her stroke, she was treated with thrombolysis and had an initial assessment to determine whether she was at risk of blood clots forming.
This investigation looks at the management of venous thromboembolism (VTE) risk for patients that have suffered an acute stroke and received thrombolysis. VTE is the collective term for the formation of blood clots, including deep vein thrombosis (DVT) and pulmonary embolism (PE). Thrombolysis is a treatment for some types of stroke with ‘clot-busting’ drugs.
This investigation looks at:
- The management of VTE risk in inpatients following thrombolysis for an acute stroke.
- Detection of medical problems (that impact on VTE risk) occurring in inpatients following thrombolysis for an acute stroke.
We made one safety recommendation to the Joint Stroke Medicine Committee and NHS England and NHS Improvement as a result of this investigation.
On 12 January 2021 we received an interim combined response from the Joint Stroke Committee and NHS England and NHS Improvement,, and an updated combined response on 15 February 2021, both of which are shared below.
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.
Response from the Chair of the Joint Stroke Committee on behalf of colleagues at the Intercollegiate Stroke Working Party (responsible for the National Clinical Guidelines for Stroke and for the Sentinel Stroke National Audit Programme and NHS England).
We are in the process of finalising an A4 'Best Practice in the Reduction of VTE Following Stroke', which can be laminated, prominently displayed, and used in all stroke services in England/ UK.
This is in addition to NHS England revising its general VTE guidance. A toolkit will be developed as part of this process.
Our document will address three key areas:
- Background to VTE risk following stroke and the use of IPC devices (with reference to primary research and evidence-based guidelines)
- Specific advice ('top tips') to ensure consistent implementation of current guidelines in clinical practice; these 'top tips' covering the key points to be considered in the development of a tool as highlighted in HSIB's report
- Exemplars from two sites with a consistent record (as evidenced by their SSNAP return) of demonstrating best practice
We presented this document at the Intercollegiate Stroke Working Party meeting and the next Integrated Stroke Delivery Network Clinical Lead meeting in January 2021. It will also be circulated to the Joint Stroke Medicine Committee in February 2021.
We feel that these are essential steps to ensure broad ownership of the proposal by the stroke community and support a successful implementation.
Response received 12 January 2021
Combined response received from the Chair of the Joint Stroke Committee on behalf of colleagues at the Intercollegiate Stroke Working Party (responsible for the National Clinical Guidelines for Stroke and for the Sentinel Stroke National Audit Programme) and NHS England..
We are writing to provide a further and final update on the progress we’ve made on addressing your safety recommendation.
As previously discussed, it is beyond our remit to develop a stroke specific VTE assessment tool and system.
However, the Chair of the Intercollegiate Stroke Working Party, who has responsibility for the National Clinical Guidelines, will continue to review new evidence that informs guidelines for future iterations.
In addition, we have developed a 'Best Practice Consensus for Reducing Venous Thromboembolism Post Stroke', following consultation with the Intercollegiate Stroke Working Party and with the Joint Stroke Medicine Committee.
(1) highlights the importance of venous thromboembolism in stroke, and references the existing guidelines for reducing risk
(2) details an eight-point checklist for best practice
(3) cites two examples of best practice based on national comparative audit data. 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.
It was also presented to clinical leads in February 2021, and a link will be provided to the document from the Intercollegiate Stroke Working Party website.
Response received 15 February 2021
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