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 and the response is 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.
Further to our recent correspondence in our capacity as Chair of the Joint Stroke Medicine Committee (hosted by the Royal College of Physicians of London: Professor Tom Robinson) and National Clinical Director for Stroke (NHS England and Innovation: Dr Deb Lowe), and on behalf of our colleagues at the Intercollegiate Stroke Working Party, responsible for the National Clinical Guidelines for Stroke and for the Sentinel Stroke National Audit Programme (Director: Professor Martin James; Associate Director: Dr Ajay Bhalla) , we are writing to provide a further and final update on our progress against the safety recommendation R/2020/090 contained in your report (dated October 2020).
As previously discussed, we would reiterate that it is beyond our remit to develop a stroke specific VTE assessment tool and system. However, Professor Martin James, as Chair of the Intercollegiate Stroke Working Party with responsibility for the National Clinical Guidelines will continue to review new evidence that informs guidelines for future iterations.
However, following consultation with the Intercollegiate Stroke Working Party and with the Joint Stroke Medicine Committee, we have developed the attached 'Best Practice Consensus for Reducing Venous Thromboembolism Post Stroke'. This document: (1) highlights the importance of venous thromboembolism in stroke, and references the existing guidelines for reducing risk; (2) details an 8-point checklist for best practice; and (3) cites two examples of best practice based on national comparative audit data. For your information, 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, with an initial presentation to Clinical Leads at their forthcoming meeting on Friday 19th February 2021. In addition, a link will be provided to the document from the Intercollegiate Stroke Working Party website.
Response received 15 February 2021
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