PB0401 - A Review of Hospital Associated Thrombosis with Implementation of a Shared Learning Dashboard

Background: Hospital associated thrombosis (HAT), defined as new venous thromboembolism (VTE) event diagnosed during admission or within 90 days of discharge, is one of the leading causes of preventable hospital associated morbidity and mortality. 60% of all VTEs are related to hospitalisation.
It is important to identify HATs, which can be a multifactorial process, and perform root cause analysis (RCA) investigation to assess if potentially preventable, identify contributory factors/themes, implement actions, and share learning to prevent recurrence.

Aims: To review reported HATs and identify if HAT was potentially preventable, themes and contributory factors.

Methods: Retrospective review of reported HATs via local incident reporting system. HAT RCA investigation performed, using template proforma, to assess VTE risk assessment completion, pharmacological and mechanical thromboprophylaxis prescribing for at risk patients during admission and/or on discharge (if indicated and no contraindications). RCA establishes if HAT potentially preventable, identify any contributory factors and changes to current practice. VTE leads review RCA form for quality assurance and challenge where appropriate.

Results: During January to December 2023, 50 HATs reported across two hospital sites, with 8% HATs associated with another hospital admission. Refer to figures 1 and 2 for HAT incidence in month by hospital division, and those potentially preventable.
Contributory factors for potentially preventable HATs were:
• VTE risk assessment not completed on admission
• Omitted/delayed pharmacological thromboprophylaxis prescribing when indicated
• Omitted thromboprophylaxis dose(s) without clinical reason
• Thromboprophylaxis not prescribed on discharge when indicated for surgery type
• No follow-up/review when anticoagulation held

Conclusion(s): VTE risk assessment supports clinicians with decision-making on thromboprophylaxis to help reduce mortality, morbidity and costs of acute/long-term VTE effects to healthcare systems. A robust HAT process is required for identification, reporting and RCA investigation. A user-friendly HAT dashboard, disseminated quarterly, provides feedback on themes/contributory factors, education and awareness to prevent recurrence and ensure patient safety.