We examined the patient safety risks after looking at the case of a 78-year old woman who suffered a pulmonary embolism (PE) whilst recovering from a stroke in hospital.
Following her stroke, she was treated with ‘clot-busting’ drugs (known as thrombolysis) and had an initial assessment to determine whether she was at risk of blood clots forming (the collective term for this is venous thromboembolism or VTE). Due to her immobility, the patient’s risk of acquiring a deep vein thrombosis (DVT) or PE was high.
It was noted on her chart that she should be fitted with what is known as an intermittent pneumatic compression (IPC) device rather than receive anticoagulants to reduce her risk of VTE as recommended by the National Institute for Health and Care Excellence (NICE). However, due to several factors, the device was never fitted and on day 19 of her rehabilitation in hospital she was diagnosed with ‘pulmonary emboli with saddle embolism’.
She received treatment for the clots and was eventually discharged 53 days after arriving at the NHS Trust to continue her recovery at home.
Assessment of care is key
Strokes are the fourth most common cause of death in the UK and around one in ten people die before they reach hospital. Our report emphasises that if patients do survive then the assessment of care in wards and units is key to prevent any further risk to life.
Our investigation focused on what happens after thrombolysis treatment is given and how VTE risk is managed as patients recover. Early on, we identified issues such as a low rate of IPCs being fitted despite their success in improving the survival rates of those who are not mobile after a stroke and their recommendation by NICE guidelines.
As the investigation progressed, we identified missed opportunities throughout the whole process of care. There is a lack of a national, stroke-specific assessment for VTE that considers the patient’s specific circumstances or determines the level of risk the patient has of blood clots forming.
Even if an assessment identifies IPC as a treatment, the case that we examined reflected a wider picture of confusion over how the devices are recorded i.e. on the patient’s chart and who then is responsible for fitting.
Our findings also show that national guidelines do not require a follow-up assessment or a check that the VTE preventative measure is in place.
As a result of the national investigation, we’ve made one safety recommendation to facilitate the development of a stroke specific assessment, a system for the associated treatment to be recorded using a tool to ensure that the relevant information is documented and, importantly, reviewed.
Dr Stephen Drage, HSIB Director of Investigations and intensive care unit consultant, said: “The time after a patient is admitted and treated for a stroke is incredibly precarious. It is important that any safety risks in the care process are mitigated to prevent life-threatening blood clots forming to give patients the best chance of making a full recovery.
“A number of barriers to the most effective aftercare emerged through our investigation and the safety issues impact not only all specialist units but any wards where stroke recovery takes place in the NHS. The recommendation we have made is aimed at ensuring that VTE risk is managed in a targeted way that ensures that patients are getting the right treatment at the right time.”
Read the report
For more information, download and read the management of VTE risk report.