Please, please read –it’s long, but very important.I t might save some lives.

[HPNC]

I am a regular poster, but have changed my name. If you recognise me please don?t out me. My employers would not be happy that I have posted this.

A couple of weeks ago it was National Thrombosis Week.

Every year, in England, 25,000 ? twenty five thousand ? people die as a result of thrombosis.

That is more than the total deaths from HIV AIDS, breast cancer and road traffic accidents.

It is 25 times the number of deaths from MRSA.

Those 25,000 are the tip of a massive iceberg. They represent a fraction of the total number of people who suffer a thrombosis (blood clot, often called DVT or PE ?Pulmonary Embolism), often as a consequence of being admitted to hospital for medical or surgical treatment.

The single most effective patient safety intervention would be to assess a person?s risk of developing thrombosis when they are admitted to hospital, and to provide that person with the correct, appropriate treatment to prevent thrombosis occurring. (For example, correctly fitted stockings, plus or minus injections to reduce the risk of clotting).

The risk factors are well recognised and risk assessment is a straightforward process.

NICE have already established and implemented guidelines for prevention of thrombosis (thromboprophylaxis) in surgical patients.

NICE are currently drafting the guidelines for risk assessment and preventative treatment for all patients who are admitted to hospital. They will be implemented in 2009.

In April 2007 the Chief Medical Officer, Sir Liam Donaldson, wrote to the Chief Executive of every NHS Trust in England and Ireland stating that every Trust should establish a Thrombosis committee, and set up a system to risk assess every patient who is admitted to hospital, and that this should be mandatory.

By April 2008 only one third of NHS Trusts had taken any action. People are still suffering this horrible condition and still dying.

Please, if you possibly can, write to your local NHS Trust Chief Executive and ask what their Trust is doing to prevent patients dying unnecessarily from blood clots. Copy the letter to your MP.

If you, or a relative, are admitted to hospital for any reason, don?t just ask your doctor or nurse to wash their hands, ask them ?What is my risk of developing a blood clot, and what are you going to do to reduce my risk??

If you are pregnant, please ask your doctor and midwife the same question.

Thrombosis is still a leading cause of pregnancy-related death. If you are pregnant and are admitted to hospital for any reason (apart from straightforward labour and delivery) you should be risk assessed on admission.

We know what the power of mumsnet did for Waitrose baby bottom butter. I really hope we can achieve something here.

Thank you for reading, if you have managed to get this far.

There are a number of academics who feel that injections are the only effective means of prevention. But in practical terms, there are many, many people for whom the risks of bleeding with anticoagulant injections would outweigh the benefits.

NICE looked at risks and benefits, together with the recommendations of the National Patient Safety Agency, as well as all the existing research, and came up with recommendations that are a combination of the safest, most practical and cost-effective measures.

Risk assessment is vital, and it is shocking that only 1 in 3 Trusts are bothering to implement any sort of training, or policy.

If Trusts began to take this issue seriously, we would have the basis for more research and evidence gathering.

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Am not going away.

another bump

and thank you HPNC - i do use the airogym when i fly and i also have to inject myself with heparin

Glad to hear you have had good advice and care RubySlippers.

There is a lot to do just educating health professionals, as well as the public.

It's all about weighing risks and benefits isn't it?

I do have a niggly concern about anti-coagulants; understandably as dd was over heparinised due to an unclear prescription (U used as shorthand for Units interpreted as a 0 and hence given a 10x dose) I'm also aware of a child that died under the same circumstances. I understand that heparin is one of the drugs most commonly identified as causing harm.

This was 14 years ago though and stronger protocols are hopefully in place (well I know they are in dd's hospital)- are the more modern versions (Clexane) more 'user friendly'?

Exactly SMBK.

That is why Trusts should be setting up proper committees, and training staff etc.

The National Patient Safety Agency report identified very strongly the need for training, and for qualified/trained people to be prescribing these drugs.

The terminology used in prescribing is very important. Trusts should have clear guidelines and policies and training for new staff, so that there isn't confusion about different anticoagulants.

Consistency within Trusts, for example using the same drug, rather than several different ones, can improve safety.

Prefilled, single use syringes would also help.

Clear labelling and training in calculating dosage is also important.

I have even seen terms such as

Heparin/Clexane/warfarin and other brand names used interchangeably in correspondance between health professionals, where it is unclear exactly which drug the patient is actually on. This is very worrying.

The new generation of oral anticoagulants will be a real leap forward, but it takes time to get the trials done and the licences in place.

Have to go out now, but will check back later.

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Cochrane database (2000, Amaragiri and Lees) states, in a large (n=795) orthopaeic study, no benefit found when stockings used.

Thanks - wasnt aware of extent of risk - wow. After my c section I was given 3 days of injections but no stockings. Had no problems though remember a moment when my legs filled with fluid on the second day. Am expecting again in my 40's and a c-section quite probable. Can I insist on treatment - injections and stockings - or if they dont as a rule do I just have to go with it? In a new city so not aware of practise yet.

interestingly tinzaparin is only licensed for use for 7 days i was told by a pharmacist (must look this up to confirm), my question was, what about thise patients who are imobile and in hozy for longer than the golden 7 day cut off?
In my experience, some patients are on it for the duration of thier hospital stay AS well as TED stockings/flow tron boots.

That's one study in one group of patients. You can always get a study to back up your case, but it might be better to look overall and see the results of several studies to come to a reasoned conclusion. The more recent HTA:

Towards evidence-based guidelines for the prevention of venous thromboembolism: systematic reviews of mechanical methods, oral anticoagulation, dextran and regional anaesthesia as thromboprophylaxis
P Roderick,1 G Ferris,1 K Wilson,2 H Halls,2 D Jackson,2 R Collins2 and C Baigent2*

1 Health Care Research Unit, University of Southampton, UK
2 Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), University of Oxford, Oxford, UK

Main results
Mechanical compression methods reduced the risk of DVT by about two-thirds when used as monotherapy and by about half when added to a pharmacological method. These benefits were similar irrespective of the particular method used (graduated compression stockings, intermittent pneumatic compression or footpumps) and similar in each of the surgical groups studied. Mechanical methods reduced the risk of PVT by about half and the risk of PE by two-fifths.

Sorry for the long quote, but it is really important to understand that the NICE guidelines have been put together from ALL the evidence, not just a single study in one group of patients having orthopaedic surgery.

The majority of patients who succumb to thrombosis are medical patients, not surgical.

The American College of Chest Physicians also endorse the use of stockings.

i wondered where she had got her info from.

weighing up the risk of pe/dvt it is high in any immobile patient and so this countersupports the argument to continue for longer than 7 days surely?

Highlander, I really don't want this to turn into a debate about clinical trials and evidence.

My OP was to make the point that

-25,000 people die from thromboembolic disease every year, in England alone.

-many thousands more, who do not die, are left with long or short term health problems.

-there are NICE guidelines in place for Surgical patients, but only one third of NHS Trusts are implementing them.

-the CMO has written to every NHS Trust instructing them that they must put in place thrombosis committees to oversea and provide measures, including adequate, trained and qualified staff to risk assess every patient, including medical patients, who constitute the majority of those who suffer thrombosis during or after admission to hospital. This is in advance of the NICE guidelines for medical patients which will be published next year.

-Only 1 in 3 Trusts are acting on his instructions.

I am trying to raise awareness of this state of affairs, in the hope that if people who read this, or their relatives are admitted to hospital, they will feel confident to ask about their risk, and hopefully will get proper care.

ok, so talk to me about it, im asking fro your opinion.......

With regard to tinzaparin, licenses are granted according to the research that has been done. It does not necessarily mean that the drug is unsafe for use off licence.

For example, it is used long term in pregnant and post natal patients. It is explained to the patients that it is not licensed, but that all things considered it is likely to be the best and safest option.

There is a massive study on the safety of anticoagulation in pregnancy going on at the moment.

It comes down to known risks and benefits.

not unsafe for the patient no...but what about the administration of a drug not licenced? what about your registration?

deanychip - sorry, were you asking me to elaborate, or were you talking to another poster? It is taking me so long to type, i am not sure.

no, talking to you, although you have been whipped up by the lady with the research in ortho pts

I will find out the correct information about that, deanychip, and come back to you.

Legally, no heparin is licensed for use in pregnancy, but it would be unethical not to treat patients, due to the risk of death from PE.

In practice, where this situation occurs, it is accepted practice to use unlicensed (ie drugs licenced for the same condition in other groups of patients) when there is sufficient consensus among the physicians treating the patient.

The royal college of Obstetricians and Gymaecologists have agreed that Heparin preparations, including tinzaparin can and should be used to treat thrombosis in pregnancy.

I know this information is on their website, but haven't located it ATM.

A similar situation arises with cardiac drugs used to treat children. There is no choice in the matter, because there are almost no clinical trials involving children, so the drugs only have a license for adults. However, you can't just not treat children, so the same sort of consensus applies.