Reducing VTE risk in cancer surgery

Despite no changes to the existing infrastructure or additional funding, a multidepartmental team at the Sheffield Teaching Hospitals NHS Trust (STH) was able to coordinate provision, monitoring and audit of extended thromboprophylaxis in both inpatient and outpatient settings within nine months of publication of the guidance. The aim of the project was to promptly develop a safe local policy for extended thromboprophylaxis and heparin-induced thrombocytopaenia (HIT) monitoring for patients undergoing major abdominal and pelvic surgery for colorectal cancer. The STH team included haematologists, surgeons, pharmacists and nursing staff. A move locally to enhanced recovery and early post surgery hospital discharge reduced pharmacological thromboprophylaxis to as little as two doses in hospital, adding an even greater imperative to the need for extended prophylaxis outside hospital. Such a multidisciplinary service would demand careful planning and clear communication with primary care colleagues to coordinate the service. The concern was that no patient was put at increased risk because of failure to promptly identify HIT or bleeding. Progress of the new service would be assessed from the outset by Prospective Interface Audit of hospital and community care, and the interface between the two. Formal patient and GP feedback surveys were used to identify successes, barriers and practical problems to enable prompt and targeted change to current practice.

Careful planning

 The project objectives were to deliver training for all existing and new medical staff within the Colorectal Surgical Unit at STH and to identify all patients appropriate for extended pharmacological thromboprophylaxis and ensure this is made clearly visible in those patients records so that all medical and nursing staff involved with their care are aware. It was also important to designate pharmacist and nursing leads on colorectal wards to ensure patients are trained in enoxaparin self-administration if required. The Trust also needed to ensure clear communication with primary care teams for safe administration of enoxaparin and HIT screening follow-up. A Prospective Interface Audit was started from Day 1 of implementation, together with regular re-audit and patient and GP surveys to identify barriers to implementation and target future changes to practice to specific needs. Finally, it was important to ensure that provision of the service would not delay discharge from hospital. The colorectal team at STH had previously investigated providing extended prophylaxis as patients presented with thromboembolism after discharge from hospital. However, prior to publication of the guidance, this had not been possible due to perceived cost constraints within the community. Guideline publication made delivery of this service possible. Prior to the introduction of the service, patients who had undergone major abdominal cancer surgery received enoxaparin thromboprophylaxis only during their inpatient stay, which could be as little as three days with enhanced recovery. Providing extended thromboprophylaxis for 28 days in this patient group has demonstrated a 60% relative risk reduction (8% vs 12%, n=343, 95% CI 10%-82%) in venous thromboembolism, with no significant increase in post-operative bleeding. Such evidence is reflected in the NICE guidance, advising provision of extended thromboprophylaxis to candidate patients. Extended thromboprophylaxis carries a risk of HIT, which necessitates monitoring between days 5-7 and 10-14 of thromboprophylaxis.