New care standard highlights GPs’ importance in prevention of blood clot deaths

Amanda Lyons

12/10/2018 2:47:33 PM

GPs can play a key role in prevention of deaths from venous thromboembolism after hospitalisation, which is a much more serious problem than many people may realise.

VTE risk is far higher after hospitalisation than after flying.
VTE risk is far higher after hospitalisation than after flying.

Blood clots caused by venous thromboembolism (VTE) can be a silent killer, and they occur with concerning frequency in Australia.
‘There are up to 5000 deaths a year from blood clots,’ Associate Professor Amanda Walker, Clinical Director of Clinical Care Standards for the Australian Commission on Safety and Quality in Health Care (ACSQHC), told newsGP.
‘The challenge is that sometimes the first sign of a VTE or pulmonary embolism is collapse and sudden death.’
Dr Sally Cockburn, a GP and radio host and presenter known as Dr Feelgood, knows this stark fact only too well from her own experience of pulmonary embolism earlier this year.
‘We were all taught that first of all you’re going to get the DVT [deep vein thrombosis] with the hot, swollen leg, and then you’re going to get the pain in the chest – but I didn’t have any of those signs,’ she told newsGP.
Thankfully, although Dr Cockburn was at home alone, she was awoken by her dog and so was able to call emergency services and be transported to hospital. Now, she wants to help prevent others from going through the same experience – or worse.
‘I really wanted to get back and step up to the plate, because more people die from a pulmonary embolism than die in road trauma,’ she said.
The goal of preventing death by VTE is what underpins the new Venous thromboembolism prevention clinical care standard (the care standard), launched yesterday by the ACSQHC.

L–R: Dr Sally Cockburn, Associate Professor Huyen Tran and Associate Professor Amanda Walker at the launch of the ACSQHC’s new VTE clinical care standard.
One of the most important facts Associate Professor Walker wants the care standard to get across is that the highest risk for VTE is not airline travel, as is commonly perceived, but hospitalisation – and this risk applies across all age groups.
‘The risk in flying is only four times your normal risk, but your risk in hospital is 100 times more, so we shouldn’t be calling this economy class syndrome, we should be calling it hospital syndrome,’ Associate Professor Walker said.  
However, while the risk of VTE rises during a hospital stay, it also remains for quite a long time afterwards, making it a very relevant health threat once a patient has returned to the community.
‘Those risks extend into the post-hospital period for up to three months, so between half and three quarters of all clots in the community occur in a three-month period post-hospitalisation,’ Associate Professor Walker said. 
This extended risk period makes GPs, as health professionals in the community, key players in the prevention of VTE.
‘We have a bigger role in this than is recognised,’ Dr Cockburn said. ‘If [VTE] is sometimes not happening until three months after hospital, that’s more than into our patch.’
Associate Professor Walker is hopeful that the new care standard can help prevent deaths caused by blood clots with its recommendations for improved recording of patients’ VTE prevention plans while they are in hospital, and then improved transfer of that information from hospital to primary healthcare after the patient is discharged.
‘There’s not been an awareness that risk of VTE extends after hospitalisation for up to three months, so if you don’t know that, you don’t hand over about it,’ Associate Professor Walker said. ‘And often the VTE prevention plans would last while the person was in hospital, but not following.’
Another core aspect of the care standard is an update of the list of medicines used in VTE prophylaxis, which have changed significantly in recent years. To document this information, the standard includes two appendixes, one on medicines that affect bleeding risk and the other on VTE prevention medicines.
‘Clinical care standards often just tell you what to do and don’t give you the information about medicines, assuming that people will be able to source it easily somewhere else,’ Associate Professor Walker explained. ‘But we’ve made a point of making sure this is easily accessible [in the care standard].’
The appendices include not just the names of VTE prevention medicines and information about pharmacokinetics and pharmacodynamics, but also about their monitoring requirements, which can be especially helpful for GPs in assessing patients for any problems that may arise as a result of their VTE prevention plan.
‘So if a GP gets a patient who comes home on a particular VTE prophylaxis treatment, they can look up the monitoring requirements and check what they might need to know,’ Associate Professor Walker said. ‘And the same for the direct oral anti-coagulants, and other oral anti-coagulants and some of the anti-platelet drugs.
‘So the care standard just consolidates good, sound, practical information.’
The care standard also contains information aimed at patients, to help them understand their VTE risks post-hospitalisation and the necessary monitoring process. Dr Cockburn appreciates this consumer information, and hopes the standard can help raise awareness among both health professionals and the general community about VTE risk.
‘We all know what to do to avoid road accidents – we don’t drink, we keep our eyes on the road, we wear a seatbelt. And we’ve got more deaths from pulmonary embolism, so what do we do to avoid that?’ she said.
‘I’d love to see awareness of pulmonary embolism and thrombosis up there with all the other risk factors.’
Associate Professor Walker agrees, and hopes the release of the standard will help to facilitate change that will save lives.
‘How many hundreds of thousands of hospital admissions are there around the country, every year, that are then going back to their GP afterwards?’ she said.
‘If we can improve that transition for this issue where the consequences of it going wrong are disastrous, there’s a real opportunity to make a big difference.’

ACSQHC Australian Commission on Safety and Quality in Health Care blood clots deep vein thrombosis DVT hospitalisation pulmonary embolism venous thromboembolism VTE

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