Bradford Clinical Pathway for DVT

The critical analysis of the Bradford Clinical Pathway for Deep Vein Thrombosis (BDVT) will be performed by me. I will make recommendations by comparing the BDVT against the local DVT Pathways and the Institute for Health and Care Excellence (NICE) guideline and will then finally proceed to the conclusion

By definition Deep vein thrombosis (DVT) is a common but potentially fatal disorder occurs due to the deposition of thrombus or bad fat within a deep vein which results in partial or complete obstruction of the flow of blood (NICE,2018).DVT is considered to be the significant cause of mortality and disability with a incidence rate of 1 in 1000 people annually in England (Tovey and Wyatt,2003;Amin et al, 2011).

I chose the topic on DVT as it is a common problem in my practice field. Due to the magnitude of the problem, the redesigning of pathway and implementation of it was done in Bradford. Schriiver’s, Hoorn and Huiske (2012) stated that the BDVT pathway was developed to provide high quality, safe, more convenient and acceptable community-based services by reducing the cost of hospital admission and treatment and improving the outcomes for patients. There is a gap in the existing research regarding the detailed analyses on effect of pathway without its regular re-evaluation. However, the absence of updates at regular intervals resulted in the pathway that had become outdated. This phenomenon discouraged the implementation of BDVT in my practice as according to my point of view the national guideline may have changed, and new evidence-based practice may have been implemented for practitioners at the primary care. The following of outdated pathway will risk my practice to liability and litigation. Unfortunately, the fitness of the practitioner’s to practice cases could be represented by the effective practice by the practitioners which will eventually ensure safety of the patient and will offer continuous personal development within the area of practice. Therefore, it is a question of legal responsibility to question and challenge the reason behind the implementation of the outdated pathway within my practice area being an advance practitioner in this field.

The clinical pathways is considered to be a management tool based on the multidisciplinary approach and utilizes the evidence based practice for a specific group of patients in which the professionals introduces different interventions for the patient care service. Schrijver’s et al (2012) explained the theoretical benefit of pathways as follows: clinical pathways reduces the rates of patient complications, readmission, resource utilization, decreases the errors, enhances patient education, augments patient satisfaction level and effectively prevents the medical malpractice that leads to litigation. Ronellenfitsch et al (2019) acknowledged the substantial evidence-based benefits in terms of improvement of the clinical standard in surgery and suggested further research in all the aspects of clinical pathways usage to help practitioners, patients and the NHS.

The BDVT pathway is available in the electronic format so that it remains accessible to the relevant community of NHS organisations. It was developed by multiple professionals under the leadership of Dr. James Worsfold (Refer to appendix1.5). The pathway was last updated on February 2019. The amended pathway and the review reports are out of date due to irregular or lack of pattern reviews. Refer appendix 1.5). This appears to indicate that the pathway did not make regular and timely change or amendments following the variance documented report of the practices.

The Clinical pathway needs to be evaluated using the evidence-based tools to reduce variations within the clinical practice to improve the healthcare outcomes (Evans-Lacko et al, 2010). Therefore to reduce the variations the national and local guidelines has to be continuously updated by regular audits and evaluation. This process helps in the adhering to the treatment procedures by reducing the reluctance of the practitioners so that this pathway can be successfully implemented.

The advantage associated with BDVT are the reduction of unnecessary admission to hospitals, reduction of the costs of NHS and provided evidence-based local and national guidelines for decision making process for clinicians. Fay et al (2017) evidenced that the BDVT pathway prevented 81 unnecessary admissions to hospital which helped to achieve a saving of £26,000 in the first month. In addition to this, the study claimed 80% reduction in Medical admission unit (MAU) for the suspected DVT cases from estimated 1000 admission per year.

The result showed savings in the cost because of the availability of monoclonal antibody (d-dimer)which have been used in the General Medical Practice (GP) (Bright,2008). It costs £12.16 per unit and accurate result can be obtained within 10 minutes.

D-dimer test measures the degraded fibrinogen which rises during blood clotting phenomena (CKS, 2018). The test is 100 per cent sensitive and has a negative predictor value. Prior to the implementation of the D-dimer tests in the GP practice, only 15-20% patients who were referred to secondary care were confirmed with DVT (Bright, 2008). Further results showed that approximately 80% patients referred to secondary care were confirmed as negative cases of DVT. As a result of this, both the parameters such as the satisfaction of patients, and service efficiency get affected. Also, the condition would increase the unnecessary burden of work which causes reduction in the performance level and job satisfaction level of the staff members. The integration of the D-dimer test within the BDVT effectively optimises the usual NHS resources and therefore it can be considered as a cost-effective diagnostic parameter (Fancher, White and Kravitz, 2004). Ultimately the whole process helps to avoid the unnecessary referrals and improves patient’s experience level.

Assisting in the decision making process and reducing errors are theoretical advantages of implementing the Clinical pathway as it prevents the options that are conflicting with therapies. Therefore, practitioners clearly gain these advantages from BDVT in practice. The NICE guidelines has completely stratified the probability risks of using the D-dimer level and two-level Well’s score in combination (NICE,2015).The probability risk assessment for the two-level Well’s score effectiveness was evaluated in a cohort study including 598 patients. The result demonstrated that the two-level Well’s score effectively reduced the unnecessary duplex ultrasound scanning referral and also provided strong evidence to conduct this risk stratification in primary and secondary care setting equivalently.

Two-level Well’s score was included in the BDVT in order to assist clinician in decision making for referral (Refer appendix 1.1 & 1.4). BDVT states definitive points in regard to the practitioner regarding the referral of patients for confirming the suspected prognosis. High risk patients (either well score 2 or more or Positive D-dimer) needs to be referred for Ultrasound scan to secondary care along with the risk stratification result. All referred patients with confirmed DVT will be arranged outpatient appointment within 3 weeks. This will provide an opportunity to explore the preference of patients to be treated in GP practice or out-patients clinic. The practice have considerably reduced cost and improved the patient satisfaction level. This BDVT had not only simplified the referral criteria in the pathway but also had simplified the following procedures and optimised the referral system to improve performance by standardisation of care. The use of the standardised pathway had reduced the duplication and reduced the variation in the health service process delivery with the improved communication on referral system between primary and secondary care.

Another example demonstrating about BDVT supporting the clinician decision making process and reducing errors focused about the presence of exclusion group patients as stated within the pathway. The exclusion group includes patients with malignancy, infection, pregnancy, post-surgery, inflammation/trauma, disseminated intravascular coagulopathy or renal impairment. This is because the D-dimer test appeared to be raised in these groups of patients and therefore provided inaccurate reading. These patients need to be urgently referred to rule out diagnosis without any risk stratification. Having this approach of clear guidance will help the advance practitioner while making any immediate decision. This had not only improved the satisfaction level of the patient, but also helped in the buiiding of further confidence among the advance practitioners concerning their independent performance and also regarding their ability to ensure safety of the patients.

One of the main disadvantages for BDVT is it only utilizes 10-minutes appointment to complete numerous strictly specified steps. DVTs may be asymptomatic or presented with expected common symptoms such as unilateral leg pain, asymmetrical leg swelling, dilation or distension of superficial veins and the discoloration of skin (NICE,2012). If the case is a suspected DVT, then, physical examination combining with the general medical records of the patient, should be performed to assess the patient and in this way an alternative cause should be excluded. Some of these alternative causes are cellulites, baker’s cyst, haematoma and acute arterial Ischaemia. (CKS,2018)

The nature of the 10 minutes appointment acts as an indicative factor for lack of coherence for BDVT. Musellim et al (2017) argued that physical examination performed within a limited period may lead to defective and erroneous diagnosis with poor level of patient satisfaction. Performance of physical examination and recording the general medical history for the suspected DVT is necessary to exclude differential diagnosis during the diagnosis process due to the existing similarities in the signs and symptoms with alternative causes.

The expected physical examination for DVT according to the guidance of BDVT lacks clarity as this examination procedure is only used to rule out the alternative causes (SIGN, 2010).Therefore, the success of the physical assessment depends on the presenting symptoms and practitioner’s clinical discretion. For example, the patient presenting the symptoms of unilateral leg along with swelling of thigh should be examined by recording the perimeter of the leg 10cm below the tibial tuberosity to evaluate the probability of DVT and the patient expressing the symptoms of localised pain along with the deep venous system should be gently palpitated along the path of deep venous system from groin to abductor canal and in the popliteal fossa. Depending on other clinical manifestations, reviewing of the full blood count may be required to assess the bleeding risk or Liver function tests to assess abnormalities associated with underlying provoking factors or measuring vital signs to build better understanding of the status of the body’s vital functions. After the completion of these assessments, the clinicians are expected to perform two-level well score to determine clinical probability of the condition and the score aids to stratify patients into DVT unlikely and DVT likely groups and D-dimer blood test is used in conjunction.

In my experience, I faced difficulty in completing the whole process of the BDVT within the given time. The various processes such as carrying out the clinical examination, reviewing the clinical tests and making the clinical decision to refer the patient are very difficult within the span of 10 minutes. The D-dimer test alone takes 10minutes to generate the result (Biopanda, 2020).Schrijvers et al (2012) stated that with the shortage of time the probability of correct diagnosis gets reduced. This also leads to poor communication between patients and practitioners. Poor communication could reduce the patient satisfaction level and which in turn leads to loss of confidence and perhaps litigations.

Shared decision Making (SDM) is stated in NHS long term plan’s commitment to make personalised care across the health and care system. SDM provides choice and control over the way the care is arranged and delivered depending on the personalised needs of the patient. NICE stated that patients should be supported and empowered to make informed choice and it had to be tailored according to the individual needs and preferences of the patients. The poor communication process can significantly limit patient’s ability to involve in decision making process which leads to poor adherence to treatment regimes, increased visits to practice, disputes and litigation (McDonald, 2016). These factors compromise the patient safety aspect and contribute significantly to the healthcare professional job dissatisfaction.

Pathways can be viewed as more practical and efficient decision supporting tools which include the current updated guidelines designed to achieve different goals (Abrahams et al, 2017). The main purpose with BDVT is to refer the more likely probability for secondary care setting which will confirm the diagnosis and reduce the unnecessary work burden. One of the disadvantages in this pathway is the adaption of personal preference. One of the approaches to assess the probability of DVT is to complete D-dimer testing. Patients with needle phobia or those who refuse to provide the blood samples via finger prick test due to their personal belief and religion cannot be included within the pathway and therefore it will be challenging for the practitioner to implement SDM

While considering BDVT with the neighbouring city pathways, it is important to consider the risk factors associated with DVT and the patient co-morbidities. There is strong evidence that the prevalence of DVT varies significantly among different ethnic groups, genetic, physiologic and clinical basis but these differences remain largely undefined. There is a gap in research in the incidence of DVT depending on the ethic group (White et al 2009). When the BDVT is compared with the Harrogate DVT (HDVT) pathway, both the pathways have similar recommendations in terms of using two- points well score and d-dimer test for predicting purpose. Both pathways are recommended for high probability DVT patients to commence rivaroxaban 15mg twice a day until the diagnosis is confirmed. Apixaban is recommended by Rotherham Clinical commissioning group. In order to understand the reasons behind the choice of the rivaroxaban or apixaban within the pathways, it is essential to critical analyse the evidences that are presented regarding all direct oral anticoagulants’ drugs.

According to the recommendations of NICE (2012) rivaroxaban can be treated as an option for the treatment of DVT and for the prevention of recurrent DVT whereas as all the direct oral anticoagulants (DOACs) namely edoxaban, apixaban, warfarin , and dabigatran are considered as the alternative options (BNF, 2019).In randomised controlled trials, the effectiveness of all DOACs was found to be equivalent for the treatment of thromboembolic events(Nunnelee, 2011).

Rivaroxaban and apixaban are superior in nature in comparison to dabigatran and edoxaban as rivaroxaban and apixaban can be commenced independently without the need of starting the low molecular weight heparin (LMWH) (Schaefer et al, 2015). This is the main reason for including rivaroxaban and apixaban in several pathways including the Bradford and Harrogate. LMWHs are very expensive and need special counselling to educate the patients before the subcutaneous administration. It is long acting and it becomes very complicated to reverse the effect in the event of overdose. Perhaps as a result of this, several region of CCG are not using dabigatran and edoxban within the pathway.

Both BDVT and HDVT have not included warfarin within the pathway due to the requirement of regular clinical INR monitoring, dietary restrictions and board drug interactions despite having equivalent clinical efficacy as rivaroxaban and apixaban (Weitz et al ,2017).Cost effectiveness and efficacy in reducing the workload are the major reasons for including pathways. Warfarin do not show these proprieties when compared with rivaroxaban or apixaban. However, approximately 60% of the rivaroxaban is excreted via the renal pathways and this leads to a high bleeding risk among the patients along with renal impairment (SIGN, 2013). Several clinical trials recommended the use warfarin over DOACs in case ofchronic Kidney disease (where the creatine clearance rate is 30) among the patients.

As an advance practitioner, I feel it is important to compare and contrast the available licensed drugs for prophylaxis or for treating DVT. Critical analysing the available anticoagulant drugs in terms of the cost-effectiveness, therapeutic effectiveness and profile of adverse effect will prevent from simply following the pathways. Having clinical knowledge about the drugs will promote the autonomous practitioner to provide options to the available treatment. For example, I came across one patient who needs to be referred to ultrasound scanning. The patient was confirmed with allergy against macrogol. Rivaroxaban has macrogol ingredients, but it was the only available drug included in the BDVT. Apixaban has no difference in the aspect of clinical effectiveness with rivaroxaban (McBane and Wysokinski, 2015). The doctor and I prescribed apixaban which does not contain macrogol and this will prevent the anaphylaxis reaction although this medicine was not in the DVT pathway protocol. Therefore, the rationale for not following BDVT was documented.

One of the differences between Harrogate and Bradford pathways is the presence of the checklist. HDVT has included the checklist which can be considered by the clinicians while the consultation process (Refer appendix 1.3). Having checklist provides benefit to the practitioners regarding the discussion of the essential relevant points and therefore it prevents the missing of vital information during the consultation. Flicker et al (2014) also explained the advantages that the checklist offers to the clinicians regarding a standardised process which will provide reminders to the clinicians for the patient centred consultation. The approach helps to develop the consistency and augments the quality of care offered to the patient. Arriaga et al (2013) stated that by improving the specific clinical procedures following the adherence can effectively reduce medical errors. Therefore, according to my belief, having checklist concerning the pathway which will provide simple easy to follow steps and structures will help to build strong performance during the process of consultation. Apart from this the checklist can also limit the potentiality of consultation by limiting the ability to structure according to the individualised needs of the patient..

Moreover, there are several positive outcomes of using the pathways which includes the elimination of potential medical errors and supports in the process of decision making within a short period of time by evaluating the recent updated evidences for the improvement of the patient care service. Pathways should be updated on a regular time basis to keep pace with the current medical recommendations and the guidelines. As mentioned previously the cost saving aspect of NHS is considered to be a significant primary parameter other than the patient experience. The procedure of getting the robust feedback for each of the pathways will eventually promote better level of understanding and therefore it will act as a great tool for further improvements in the future. This shows the gap in the existing literature which can be explored during further research.

As explained earlier that the BDVT pathway was formulated to identify the patients having high probability to get referred to the secondary care setting for further updated investigation and these are the patients who are less likely to be treated at the primary care setting. The NHS procurement departments and the organisations are the leading targets and it results in a short term NHS cost reduction. It would be appropriate and also necessary to incorporate the further transformation within the care pathway so that a more effective quality services can be achieved within the community. To achieve the above mentioned targets according to my belief, adaptive leadership should be encouraged which will result in innovation across the work boundaries and also facilitates the employment of the advanced practitioners who will assist the doctors regarding few cases with the full responsibility of the DVT pathways management. There are varied evidences that depict the value of specialised advanced practitioners such as the nurses and the pharmacists playing the role in the specific clinical areas in order to improve the experience of the patient and reduce the admission to the hospital. Therefore, this practice demands further research in order to elaborate to the commissioners and the policy makers regarding the positive contribution, the advanced practitioners can deliver in terms of cost effectiveness, acceptability, appropriateness of the quality DVT and the other services of the community.

References

Arriaga, A.F., Bader, A.M., Wong, J.M., Lipsitz, S.R., Berry, W.R., Ziewacz, J.E., Hepner, D.L., Boorman, D.J., Pozner, C.N., Smink, D.S. and Gawande, A.A. (2013). Simulation-Based Trial of Surgical-Crisis Checklists. New England Journal of Medicine, 368(3), pp.246–253.

Schrijvers, G., van Hoorn, A., & Huiskes, N. (2012). The care pathway: concepts and theories: an introduction. International journal of integrated care, 12(Special Edition Integrated Care Pathways).

Dr. Worsfold, J. (2019). DVT pathway. Assist/pathways module /haematology. Available at: NHS Systmone [Accessed 5 Jan. 2020].

Nunnelee, J.D. (2011). Review of an article: Oral rivaroxaban for symptomatic venous thromboembolism. The EINSTEIN Investigators et al. N Engl J Med 2010; 363(26):2499-2510. Journal of Vascular Nursing, 29(2), p.89.

Schrijver’s, G., Hoorn, A. van and Huises, N. (2012). The Care Pathway Concept: concepts and theories: an introduction. International Journal of Integrated Care, [online] 12(6). Available at: Schrijver’s, G., Hoorn, A. van and Huiskes, N. (2012). The Care Pathway Concept: concepts and theories: an introduction. International Journal of Integrated Care, 12(6). [Accessed 4 Jan. 2020].