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VTE Prevention

Royal Stoke University Hospital, UHNM NHS Trust

Reducing VTE risk in acute stroke patients

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Following the positive results of our clinical audit within our acute stroke unit, the geko™ device is now in routine use and has marked a significant change to our nursing practice. The audit has shown a need to use the geko™ when other VTE prophylaxis strategies are contraindicated or impractical. This pathway enhancement ensures that all acute stroke patients now have another VTE prophylactic intervention option where previously patients would have had no other intervention available to them.

NICE guidance (NG89 2018) and Royal College of Nursing guidance (2016) recommend Mechanical Prophylaxis [MP] using Intermittent Pneumatic Compression (IPC) as the primary intervention to reduce the risk of Venous Thromboembolism (VTE) in stroke patients. However, Intermittent Pneumatic Compression (IPC) is not possible in all patients-namely due to contraindication and intolerance of this modality.

In addition to IPC, we introduced a new VTE prophylaxis strategy into our hyper-acute stroke pathway which included the geko™ device. NICE recommend this device as an alternative anti-stasis strategy for this patient group when IPC cannot be prescribed. This new strategy included mandatory 4 hourly reviews to maximise patient comfort and compliance of both MP interventions.

The effect of this enhanced pathway was reviewed in a prospective retrospective clinical audit of VTE incidence across all interventions including drug prophylaxis. We assessed and quantified the unmet need served by the geko™ device as well as its compliance and ease of use for the nursing team.

We reviewed 1000 patients admitted to the Stroke Unit at Royal Stoke University Hospital between 1 Nov 2016 and 3 Mar 2018. In line with the above UK guidelines patients unable to mobilize independently were prescribed IPC in addition to standard measures, e.g. hydration, mobilization, and aspirin where indicated, unless patients were palliative, fully anticoagulated, or refused the intervention.

Patients who could not use IPC (intolerance, falls risk, out of stock) were switched to the geko™ device. If any patient became intolerant to IPC they were switched to the geko™ device as a secondary intervention.


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This data shows that 688 patients required a mechanical intervention. In terms of the unmet need for MP 29.5% of these patients were contraindicated or became intolerant to the primary intervention of IPC. These patients were instead prescribed the geko™device and would otherwise have had no additional intervention available to them.

VTE incidence at 90 days follow-up

Intervention DVT PE
IPC alone 6 5
IPC geko™  secondary 1 0
The geko™  device alone 0 0
Drug Prophylaxis 1 0
Prophylaxis deemed unnecessary 1 0
Refused mechanical prophylaxis 0 1

 

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Comparison of this audit to our previous clinical practice

  • The new strategy of increased surveillance and use of the geko™ device where indicated resulted in a low overall incidence of symptomatic VTE of 1.5% (9 DVT & 6 PE).
  • Retrospective analysis of previous clinical practice showed an overall rate of 28 VTE events or 2.8% (6 DVT & 22 PE). A significant reduction in the potentially fatal complication of PE.

 

Audit summary

  • The enhanced VTE pathway, including the geko™ device and 4hr mandatory patient checks to maximise MP compliance, has dramatically reduced the incidence of VTE in acute stroke patients (1.5% Vs 2.8%)
  • The VTE incidence in high risk immobile patients requiring MP was 1.9% which is lower than the 6.6% in a comparable patient population in the CLOTS-3 study
  • The unmet need for MP was quantified at 29.5% of all patients. These patients were prescribed the geko™ device as an alternative intervention.
  • The geko™ device was well tolerated by patients with no adverse events reported. The nursing staff found the device easy to use.
  • This audit suggests that the geko™ device is as effective as IPC in this pathway when IPC cannot be prescribed.

IPC, and immediate and targeted use of the geko™ device to ensure continuous anti-stasis therapy for all high-risk stroke patients.

The geko™ device is cost saving

NICE guidance (MTG19) recommends use of the geko™ device when other prophylactic methods cannot be used and estimates a cost saving of £197 per patient when the device is used for a period of 6 days2. The cost saving in the acute pathway is £237 for a period of 9 days1.

The CLOTS-3 paper3 provided the evidence underlying the NICE guideline recommendation for IPC as first line VTE prophylaxis.

 

Benefits

Zero

No DVT or PE reported in patients treated with the geko™ device, as the primary VTE prophylaxis.

29.5%

Real world data shows up to 29.5% of acute stroke patients who were prescribed a mechanical intervention needed geko™ VTE prophylaxis.

£237

NICE guidance estimates a cost saving of £237 per patient.

References

  1. J. Williams1, C. Roffe1, I. Natarajan1, C. Moss1, C. Lambert1, L. Richards2. The use of the geko™ device and the activation of the foot and calf pumps for prevention of venous thromboembolism in patients with acute stroke. 1. University Hospital of North Midland NHS Trust, Acute Stroke Unit, Stoke on Trent, United Kingdom. 2. Undergraduate School of Medicine- Keele University, Stoke on Trent, United Kingdom.
  2. NICE Guidelines (MTG19). Published date June 2014.
  3. M. Dennis; P. Sandercock; J. Reid; C. Graham; J. Forbes; G. Murray. Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS 3): a multicentre randomised controlled trial. Lancet. 2013; 382(9891):516-24.

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