Summary

Run by the Thrombosis team, this service provides a streamlined pathway for management of VTE, ensuring patients are seen promptly following diagnosis of VTE, and have appropriate investigations and treatment. Traditionally, management of acute VTE required admission to hospital often due to the complexities around anticoagulation treatment but is now much less problematic in the era of the novel oral anticoagulants (NOAC). Patients are provided with information on their condition and 24/7 contact details for the team and as a result of the programme we have significantly cut drug costs and bed days for patients with acute VTE. Patients have found that the service’s ‘one stop shop’ approach significantly minimises the number of outpatient appointments and it has been very reassuring for them to have a point of contact for any concerns related to their condition.

Challenge

Patients presenting with acute VTE (DVT and PE) have traditionally been admitted to hospital for several days for treatment with anticoagulation which until recently, has mainly been with low molecular weight heparin (LMWH) followed by warfarin. This is associated with a significant cost burden to the Trust and inconvenience to patients who may be suitable for out-patient treatment. The team proposed to use rivaroxaban instead of LMWH and warfarin in all patients unless they have cancer or have contraindications to rivaroxaban. In addition to the issues around anticoagulation, patients were often admitted under many different medical specialties so management often varied significantly depending on the admitting team.

Objectives

For the Thrombosis team to manage all suitable patients with acute VTE and to develop a streamlined service for management of patients to ensure patients with suspected VTE are managed appropriately. Also, to ensure there was a clear process for clinicians to follow, to easily identify patients suitable for outpatient treatment with rivaroxaban, and to educate clinicians regarding the use of NOACs.

Solution

The team undertook an audit of the costs of treating DVT over a 4 month period where LMWH and warfarin were used – highlighting savings in both drug costs (approximately £350 per patient) and in-patient stay (4.5 bed days per patient) which could be made. The team liaised with the Emergency department, Radiology, Pharmacy and the Acute Medicine Directorate to further agree and develop the pathway, then negotiated with GPs and the CCG to agree on management of these patients in the community. New guidelines for the Trust were created on how to investigate for suspected VTE, how to manage a newly-diagnosed VTE using rivaroxaban as anticoagulant of choice (if appropriate), how to manage bleeding in a patient on rivaroxaban and how to manage anticoagulation with rivaroxaban peri-operatively. The team developed a referral system with IT to ensure patients were referred following diagnosis, and raised awareness of the new process by educating staff. A dedicated Thrombosis nurse specialist is available to see patients at any time during the working week and patients can see a Thrombosis consultant within a week of diagnosis, after which they are followed appropriately.  

Results

Audit of management of VTE prior to implementation of the pathway showed up to 15 patients per month were potentially suitable for outpatient treatment of DVT with rivaroxaban and 5-10 patients with PE were suitable for OP management. The new service has now treated almost 300 patients – saving the Trust more than £100,000 - as well as saving on a significant number of bed days for patients who would have been admitted for management of PE. The major impact of the service for patients has been the ease of administration of rivaroxaban. Those patients who have previously been treated with LMWH/warfarin are delighted with the lack of need for monitoring and care with dietary vitamin K intake. They also praise the team for giving an explanation of their condition, what the investigations will entail and provision of information leaflets and contact details. Being diagnosed with a VTE can be an anxious time for many patients so they find having a point of contact very reassuring. 

Learnings

There were many significant challenges in trying to implement rivaroxaban as the recommended drug of choice in our ambulatory VTE service. Many clinicians and groups perceive the costs of the drug to be significantly higher than a traditional vitamin K antagonist and are particularly concerned over the lack of antidote. Constructing a sound business plan to demonstrate the cost savings is imperative and, once performed, makes it obvious to the parties involved that there are significant savings to be made. Education is a vital component since there are many of these new drugs available and clinicians not used to prescribing them regularly admit to not clearly understanding the novel anticoagulants.  

Evaluation

Referrals are continuing to increase as awareness of the service rises – almost twice the number have been received in the first 6 months of this year than in the whole of last year. The Radiology department send patients diagnosed with DVT directly to the department during normal working hours. The team regularly checks that patients are being investigated appropriately and audits drug-related complications, particularly bleeding.