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  • HSIB: Management of venous thromboembolism risk in patients following thrombolysis for an acute stroke (13 October 2020)

    • UK
    • Reports and articles
    • Pre-existing
    • Original author
    • No
    • Healthcare Safety Investigation Branch
    • 13/10/20
    • Health and care staff, Patient safety leads

    Summary

    Crucial treatments missed in stroke aftercare could lead to fatal blood clots, the Healthcare Safety Investigation Branch (HSIB) highlights in their latest national investigation report.

    They 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. Strokes are the fourth most common cause of death in the UK and around one in ten people die before they reach hospital. The HSIB 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.

    Content

    The HSIB investigation focused on what happens after thrombolysis treatment is given and how venous thromboembolism (VTE) risk is managed as patients recover. They identified issues such as a low rate of intermittent pneumatic compression (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, HSIB 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 examined in this report 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.

    The findings also show that national guidelines do not require a follow-up assessment or a check that the VTE preventative measure is in place.

    Safety recommendation

    As a result of the national investigation, HSIB have 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.”

    HSIB: Management of venous thromboembolism risk in patients following thrombolysis for an acute stroke (13 October 2020) https://www.hsib.org.uk/investigations-cases/management-vte-risk-patients-following-thrombolysis-acute-stroke/final-report/
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