In recognition of World Thrombosis Day, the Anticoagulation Achievement Awards (AAA) were presented in Houses of Parliament on 9th October 2019. Finalists and award winners of the prestigious awards represented healthcare professionals from across multiple healthcare providers.

The impact of VTE and anticoagulation therapy cannot be underestimated, and the AA Awards look to celebrate achievements by teams and individuals represented at the awards at reducing this burden by working to safe-guard and improve the lives of patients and their carers dependent on NHS anticoagulation services.

The awards included two Special Nomination categories – the VTE Hero Award and the Judges Award. Effective implementation of guidance into personalised care relies upon the dedication and commitment from individuals and teams. It is these healthcare providers who have the greatest impact on patient care, patient experience, well-being and patient outcomes. These two awards seek to recognise outstanding healthcare professionals whose work has and continues to bring far reaching benefit to many, many patients carers fortunate to have been within their care.

Best Resource Sharing Information about Anticoagulation Therapy for Patients and Carers
- presented by Nurse Consultant, Joanne Loades

Patients undertaking warfarin therapy require appropriate pre – operative management to prevent excessive bleeding during and after elective surgery. Some patients are at higher risk of developing a blood clot or stroke if their warfarin treatment is stopped for too long or not restarted after surgery.

These specific patients need reassurance and the confidence that their anticoagulation therapy will be managed effectively to protect them from unnecessary bleeding and preventing blood clots.

This year, the Award is presented to a team who in 2012 introduced a new bridging guideline in the Surgical and Orthopaedic Pre –Assessment clinics in the Princess of Wales Hospital following a number of safety incidents which highlighted there was a lack of guidance and poor communication: consequences of patient not being restarted on warfarin when surgery was cancelled and, operations being cancelled as the patient’s INR levels were not safe for surgery.

The team set out to develop a Warfarin bridging therapy service which would:

  • reduce further incidents
  • make patients feel safer and less anxious about the whole process
  • have patients admitted on the day of surgery so length of stay is reduced
  • help clinicians and nurses feel more confident in caring for these patients

The dedicated bridging service pathway was established by the Anticoagulation Advance nurse Practitioner whose patients are counselled prior to surgery with a bridging form placed in the patient's case notes for the benefit of the surgical team when preparing pre and post - operative bridging therapy for the individual patient. A patient letter was designed to give advice and information regarding the bridging therapy process.

The success of the introduction and subsequent evolution of the guidelines is impressive.

  • In 2011, only 33% of elective patients taking warfarin were admitted on the day of surgery
  • Between 2012 and 2014, 90% of elective patients requiring bridging therapy were admitted on the day of surgery
  • In 2018 – 100% of elective surgery patients were admitted on the day of surgery

Positive outcomes can be seen from every perspective.

  • Patients benefit by alleviating their fears when it comes to stopping their treatment, guiding them through the pre and post op anticoagulation management and reassurance their surgical team are fully appraised of what bridging has been provided and how they will be managed post-surgery
  • Surgeons are not frustrated with not being able to operate when patients are not within their INR ranges pre-surgery
  • Hospital beds are not being over occupied by warfarin patients awaiting surgery days before the event and GPs are confident that their patient is managed effectively and returned back to them to resume INR monitoring when safe to do so


Best Work in the Prevention of Hospital Acquired Thrombosis (HAT)
- presented by Professor Roopen Arya

The judges felt that there was an outstanding application that truly demonstrated how they had:

  • recognised the issues and challenges of their existing services
  • planned a revised VTE care pathway that embedded VTE risk assessment across daily practice
  • continually leaned from root-cause analysis
  • secured sustainable implementation


  • Across the UK there is historical challenges within hospital of poor compliance when completing VTE risk assessment, and subsequent appropriate VTE management
  • NICE Guidance sets out standards … but implementation is not always universal, and while in England there was a mandated CQUIN incentive that rewarded, or penalised practice. In Wales, Scotland and Ireland, this did not exist
  • VTE became a Tier 1 priority in Wales but change and improvement in practice relied solely upon education, recognition and acknowledgement of the need to improve and then embedding in everyday practice

At this particular centre, in

  • September 2017, an audit showed there was only 34% compliance with competing VTE risk assessment. Practice had to change
  • So, the team set their goal – to increase compliance for VTE risk assessment on admission by 2018 and set a second goal to reduce the hospital’s preventable HAT rate by 50% within this timeframe
  • Understanding the risk assessment is just the first step in preventing events and reducing risk, they then introduced a ‘thromboprophylaxis walk around’ which checked documentation and prescribing. The intention being to increase compliance and accuracy in appropriate prescribing
  • Embedding – well the ‘Walk Around’ developed involved a multi-discipline team approach. As well as seeking to improve compliance and accuracy, this also became an effective avenue for sharing best practice, supporting education and helping to establish a sustainable practice
  • Furthermore, all staff are encouraged and have opportunity to raise questions, learn from what went well and identify areas for improvement which has led to timely identification and improvement of practice and increased patient
  • They introduced monthly thromboprophylaxis and VTE training sessions for all staff
  • and include both consultants and junior doctors root cause analysis in the audits
  • As a result, data now shows a significant improvement – by year end 2018, there was a 100% compliant rate for carrying out VTE risk assessments and 100% compliant rate for appropriate subsequent prescribing
  • Undoubtedly this has brought very clear benefit to patients and a reduction in physical and psychological impact of HAT and prevention of avoidable deaths


Best Comprehensive Thrombosis Management Centre
- presented by Mike Fealey PH Wales

Guys and St Thomas’ Hospital is a large London teaching hospital with a well-established VTE prevention programme and a tertiary centre for complex thrombotic problems. It benefits from multiple specialities and a multi disciple approach to the management of patients entering their service, and as a result has implemented:

  • Fast access to investigation, diagnosis and counselling for all suspected VTE patients and support for each patient to ensure informed and appropriate management
  • All patients are provided with hot-line telephone or email details for ongoing support from the team
  • Newly diagnosed VTE patients have access to a walk-in service which offers a VKA clinic service led by a pharmacist and nurse for dosing, bridging and patient self – testing
  • For those patients with significant complications, there is access to thrombolysis by the Vascular or Interventional Radiology teams on a 24/7 basis
  • Patients who have cancer-associated thrombosis are seen for ongoing management in a dedicated clinic
  • Those who are identified as at risk or diagnosed with a VTE and pregnant are reviewed in a specialised pregnancy VTE clinic
  • The multi-discipline team work closely with joint clinics, vascular and respiratory teams and collaboratively work to provide expertise in monitoring and managing long term complex issues, such as post thrombotic syndrome or pulmonary hypertension
  • The centre is also very active in research, participating in clinical trials as well as with its own active research programme
  • There is an established Rapid Access Atrial Fibrillation clinic for new diagnoses of AF developed from study evidence that demonstrated reduced cardiovascular hospitalisations and mortality when utilising a nurse–led model versus standard of care
  • Patient resources are reviewed and in collaboration with patients, the team has produced award winning patient information videos for anticoagulation in AF
  • Having been awarded VTE Exemplar status, Guy’s and St Thomas’s provides advisory and consultative services for the trust, other teaching and district hospitals including anticoagulation control, management of high- risk cases (pregnancy) and bleeding disorders
  • And with the growth in district nursing for VKA testing, the team have been central in redesigning a care pathway to implement effective, reliable, safe and efficient management of these services
  • Within patient care pathways there is review to identify patients eligible to switch to a direct oral anticoagulant or for those requiring Vit K antagonist, to be introduced to point of care testing to reduce venous samples being taken and to improve patient experience and access to immediate dosing advise

The judging panel commented that this was a mature, multi-disciplined, highly reflective and responsive service.


Best Comprehensive Thrombosis Management Centre
- presented by Mike Fealey PH Wales

Within this relatively small district hospital an ambulatory emergency care department was opened in 2014 with the aim of providing acute medical and surgical care on an outpatient basis.

Now seeing more than 600 patients each month, the department is staffed by a multi- disciplinary team which includes Emergency Care Practitioners (ECP), Assistant Practitioners and Associate Specialists.

Since opening, the department has developed and implemented deep vein thrombosis, pulmonary embolism and atrial fibrillation care pathways that enable the emergency care practitioners team to manage appropriate patients independently.

Seeking to review and improve the service, a wide ranging quality improvement work programme was initiated in 2018 covering PE, DVT and AF.

After introducing a three month follow up clinic for all patients diagnosed with a PE or DVT the team decided to standardise documentation and improve the safety of anticoagulant prescribing by designing PE, DVT and AF proforma’s. Containing an anticoagulation checklist.

Reviewing this change, there has been significantly improvement in the quality of documentation and guarantee the quality of information provided to every patient that enters their care.

The QI (Quality Improvement) programme also identified benefit in

  • (i) Making provision for ‘Alert Anticoagulated’ bracelets to be given to all anticoagulated patients
  • (ii) A current lack of cardiac monitor, which resulted in hampering the ability to treat patients with atrial fibrillation

Funding was acquired for each of these areas, an as an outcome, not only were patients able to access the Alert Bracelets, but with the cardiac monitor in situ, the hospital was able to join the Southwest Academic Health Science Network audit on atrial fibrillation screening.

Links have been established with arrhythmia specialist nurses and timely review of newly diagnosed AF patients are now routine.

This really is an example of patients, and patient safety at the heart of a service.

The pathways developed allow patients diagnosed with AF or a VTE to be seen independently by the advanced care practitioners within a multidisciplinary team.

While the anticoagulation guidance bundle ensures the provision of thorough counselling to patients for VTE and AF, resulting in all patients receiving personalised information around their medication and management.

Furthermore, the quality improvement and implementation this team have deceived include:

  • A Junior Doctors handbook ‘Anticoagulation Choice Guide’
  • Routine three month follow up for VTE patients
  • Screening for patients suspected of having AF
  • Anticoagulated patients receive an anticoagulation alert bracelet

Whilst the benefit of effective outpatient care for PE patients has reduced impatient bed days from between five-seven days to zero, freeing up beds for other patients and cost savings to the hospital.

Not only have patients commented that they are impressed with the same day access to scans and investigations, previously would have required admission to facilitate them.

As the judges noted: this centre is clearly patient centred and excellent team work is demonstrated with good use of clinical resources making the service sustainable


Centre Best Able to Demonstrate Adherence to NICE Quality Standards for Atrial Fibrillation (AF)
- presented by Dr David Collas

In 2015/2016, the Academic Health Science Networks(AHSN) identified AF stroke prevention as the first national collaborative programme and since then have been working to disseminate best practice in AF detection and management with core aims to:

  • Detect: increase the detection of AF
  • Protect: increase the uptake of anticoagulation therapy in patients with AF at risk of stroke
  • Perfect: Optimise the use of anticoagulants and the anticoagulation pathway
  • The national programme worked with commissioners to support investment through the provision of smart data, business case models and infographics whilst engaging with stakeholders along the patient pathway for AF, crossing organisational boundaries, improving communication and collaboration to optimise patient care
  • Increased the opportunity to detect AF by distributing more than 6,000 mobile electrocardiogram(ECG) devices to community settings across the UK, enabling a broad range of staff to more quickly detect and treat patients with AF
  • Worked with commissioners to embed pulse checks for those over 65 and supported local care providers to host pulse screening events to raise AF awareness
  • Developed guidelines and a host of resources to be integrated into GP IT systems along with upskilling programmes for frontline staff
  • Patient resources were created to educate patients about AF and the importance of their anticoagulation therapy
  • The AF Virtual Clinic model rollout now incorporates training for GP practice based pharmacists on Shared Decision Making to ensure patients are supported when making decisions about their anticoagulation therapy
  • A framework for implementation of patient self – testing to ensure appropriate, governance, education, training and support is available for those who are self- monitoring their INR

To date, the AHSN Network have worked with the system to identify a further 130,000 people with AF and ensured 149,000 more people with risk of AF stroke are receiving anticoagulation therapy (QOF 2017/18). SSNAP indicates that stroke rate peaked in 2015/16 has fallen year on year since then.

Their 2020, our ambition is for 85% of people with AF have been diagnosed and CCGs will be anticoagulating more than 84% to reduce stroke risk, working towards the national ambition of 90%

Our interventions will prevent over 4,000 strokes, save over 1,000 lives and provide substantial cost savings to the NHS and Social Care

The consensus from the Judging Panel was that this programme has made significant improvements for the AF population taking a whole systems approach to identifying barriers, improving patient outcomes and acknowledges the scope of collaboration required across all NHS settings for implementation of an ambitious national roll out.


Centre Best Able to Demonstrate Adherence to NICE Quality Standards for Atrial Fibrillation (AF)
- presented by Dr David Collas

In 2017, the CCG identified a ‘case for change’ involving the management of AF in primary care as indicated by the NHS Right Care Data

The CCG chose to work closely with key partners, Health Innovation Manchester, NHS Rightcare, Greater Manchester Stroke Operational Delivery Network(ODN) and Interface Clinical Services Ltd to mobilise a collaborative approach to AF management.

The programme provided additional clinical pharmacist resources to practices and aimed to:

  • Support early diagnosis of AF patients
  • Reduce the number of AF related strokes through the effective identification and management of risk
  • Improve the time in therapeutic range for warfarin patients
  • Improve the management of ‘known but not treated’ patients
  • Provide patients with educational and lifestyle advice relating stroke prevention in AF to support adherence
  • The clinical system was interrogated to identify patients with CHAD2S2–VASc score of 1 or more not currently anticoagulated, patients with TTR of less the 65% INR or labile INR levels, and patients requiring optimisation of a DOAC
  • To help engage patients with AF, educational material was provided with all the invitations and additional clinical capacity was set up by Interface in the form of NCAT accredited pharmacists with experience of running anticoagulation clinics and point of care INR testing
  • Multidisciplinary approach – gains to all those involved in sharing expertise and knowledge
  • Significant benefits to patients and the NHS showing a decrease in projected 12 month stroke incident from 76.82 to 66.96
  • External stroke admissions data showed a 22% reduction of stroke admissions immediately prior and following intervention. If reduction continues, a total of 114 strokes could be prevented each year
  • Cost benefit to the NHS, stroke prevented within the CCG could account for an in year saving of upwards of £1.5 million

The judging panel commented that this was a locally implemented project with clearly identified reasons for embarking on the need for change programme with good evidence of education, support and improving anticoagulation for the population.


Best Work in the Prevention of Cancer Associated Thrombosis (CAT)
- presented by Professor Annie Young

In 2008, following an retrospective audit (2006 - 2008) of cancer patients diagnosed with incidental pulmonary embolism (IPE) identified an admission rate of 33% with a mean hospital stay of 5-7 days and non - uniform management with only 58% patients treated as per international guidelines.

  • Poor communication, a lack of standardised care and lack of relevant documentation were attributed to the findings
  • In 2010 a nurse – led service was introduced to streamline diagnosis , assessment and standardise management of IPE in accordance with MRC guidance
  • Patients are seen in the dedicated Cancer Assessment Unit(CAU) which offers a 7 day service since 2018 and, provided with verbal and written information, emergency contact no and offered 1:1 training on injecting LMWH
  • A MDT meets weekly to assess management of patients, pathway integrity and safety. The service is evolving as new evidence and data is collected
  • The service has addressed the challenges of managing IPE by addressing the limitations in radiological reporting within everyday practice
  • A Comprehensive training programme is in place for the Clinical nurse specialists (CNS), nurse practitioners and a Radiographers training manual (created partly funded by AAA 2107) is now in implantation along with a auditable logbook of 100 cancer patients CT scans to be completed and checked by a consultant radiologist and CT manager
  • Has provided support to change in Trust guidelines which provided patients with access to DOAC - rivaroxaban
  • HUTH will be part of the API-CAT study which aims to assess the effects of long term anticoagulation (Apixaban ) treatment in patients with VTE
  • Recently awarded a RDS Patient and Involvement funds grant (2019) with patients expressing significant interest in being involved in developing IPE Trials
  • An excellent example of continuous development and improvement in the field of diagnosis and management of CAT


Best Work in the Prevention of Cancer Associated Thrombosis (CAT)
- presented by Professor Annie Young

In 2017, The Swansea Bay University Health Board, a review of the data from the established VTE clinic identified that 23% of the patients were Cancer associated thrombosis patients. The organisation undertook an audit which identified a variation in practice for the management of CAT across the Health Board – 30% of patients not being adequately monitored, 20% not having doses of low molecular heparin adjusted to reflect changes in body weight and most concerning, not completing six months of anticoagulation therapy.

To address these issues, the organisation took the following steps:

  • Worked with oncology colleagues to introduce a dedicated service pathway into the existing pharmacist – led VTE clinic, providing a single point of referral for all CAT diagnoses regardless of where the patient was diagnosed
  • Patients were seen in clinic for face to face reviews on three occasions within the first month and thereafter referred to a virtual clinic where they were monitored and supplied with anticoagulation therapy and a dedicated helpline is available in working hours
  • To support the service, a CAT Pharmacy Technician was upskilled to support this service and funding was obtained for a pharmacist to be available in a weekly outpatient clinic to review all patients who had completed six months of treatment
  • Patients benefit from a range of interactive CAT resources to support patient understanding and empowerment
  • Introduction of the service has resulted in significant increase in appropriate weight adjusted dosing of LMWH and adequate monitoring of bloods throughout treatment
  • The number of patients receiving the minimum evidence based intended duration of treatment has risen from 60% to 97%
  • A re- audit of this work is to be undertaken every two years and having evaluated the service by evaluating the patients anxiety and understanding of the condition and treatment, patient anxiety levels have decreased when seen in a dedicated CAT clinic compared to previous methods of managing results from 5.2/10 to 1.8/10


- presented by Jo Jerrome

This is an award that is nominated by the public, patients, providers, clinicians or anyone with an interest and experience in VTE.

It is intended to recognise an ‘unsung hero’, someone who goes over and beyond their job role and description to make an outstanding difference to their colleagues, the patients that come into their care and the service that is provided as a result of their passion and dedication.

The judges received nominations for Rosemary by a patient and also from colleagues, their comments for nominating included:

Patient letter:

During March 2019, I experienced excellent care from this person. A VTE Sister in Belfast City Hospital. I was referred to her with a suspected clot in my right leg and attended her clinic on several occasions. She acted with professionalism at all times, ensuring all appropriate tests were completed in a timely manner. She explained the reason for the scans and blood tests and answered my questions fully, which was very reassuring at the time. I suffered a serious injury to my leg as a teenager. Many other healthcare professionals have looked at my scars with disdain and said some hurtful things to me but this person listened intently to my story, asking appropriate questions. I also had cellulitis at the time and have previously had a PE but she ensured my care was planned in recognition of these individual needs. Her communication skills are excellent, and she really made me feel at ease and comfortable to ask questions. She maintained contact with me by telephone and text message between clinic visits, ensuring I was kept up to date with results and my plan of care. Her recommendations were linked to NICE guidelines which gave me confidence that I was receiving the best treatment and as a nurse myself, reassurance that she maintains the highest standards in her practice. (For me) this was quite a concerning experience but this nurse made me feel very safe in her care.

Thankfully, I did not have a clot confirmed but the nurse still ensured I receive the appropriate aftercare. She identified that I was at high risk of a clot due to my past medical history. As a result, she has provided me with made to measure compression hosiery and referred me on to a lymphodema specialist physiotherapist. I feel she went beyond her duty in providing me with this additional support.

The nurse was undoubtedly highly skilled…. I feel privileged to be a recipient of her excellent support and would be delighted for her to be recognised for the contribution she makes to providing outstanding person-centred care.


Judges Award
- presented by Professor Simon Noble

Effective implementation of guidance into personalised care relies upon the dedication and commitment from individuals and teams. It is these healthcare providers who have the greatest impact on patient care, patient experience, well-being and patient outcomes. This award seeks to recognise outstanding healthcare professionals whose work has and continues to bring far reaching benefit to many, many patients carers fortunate to have been within their care.

Mike has worked in the NHS since 1981 and following qualification as a Registered Nurse spent the majority of his professional career working in Operating Theatres. He worked at various hospitals in South Wales taking up post of Theatre Manager at East Glamorgan Hospital in 1995.

He moved into Service Improvement in 2003, first with the Innovations in Care team, based at the Welsh Assembly Government, managing the National Theatre Improvement and Day Surgery programmes. Since then he has worked in the National Leadership and Innovation Agency for Healthcare (NLIAH) and the Delivery & Support Unit.

In 2004 he received a MBA from the University of Glamorgan and shortly afterwards was appointed as Head of Patient Safety for 1000 Lives Improvement Service of Public Health Wales.

He led the ‘Transforming Theatres’ programme for Wales and was appointee to lead the work around reducing Hospital Acquired Thrombosis not long after the One Day Enquiry into Hospital Acquired Thrombosis held by the Welsh Government Health and Social Care Committee. Until that time, HAT had been treated rather like a nettle, no-one had grasped. Even when HAT prevention was paired with sepsis, the successes of the programme were only reflected in sepsis management and not HAT.

Mikes appointment to HAT prevention couldn’t have come at a more opportune time and he optimised the political momentum and scrutiny on 1000 Lives which the Enquiry had generated.

His calm methodical process compliant approach facilitated a meaningful dialogue with Welsh Government whilst his experience within 1000 Lives ensured we threw every tool the organisation possessed at the problem. He particular interest in ‘Human Factors’ in healthcare came to the fore whenever there were sticking points.

Mike also brought with his role a large degree of strategic wisdom; when to deal with a problem there and then/ head on or when to wait and allow things to pan out.

The successes we have seen in Welsh HAT prevention are ongoing but to date, considerable. Each Health Board has in place a system to identify and report on every HAT that occurs. Furthermore it is a requirement that each HAT is scrutinised (preferably by the responsible consultant) to ensure learning occurs. Avoidable HATs are identified and reported separately. We can now proudly boast three Exemplar centres in Wales and have several finalists in the awards tonight.

These achievements are clearly a reflection of the work of respective teams, sometimes within increasingly challenging environments. However, it is without doubt, that Mike has been the glue that has held us all together and maintained and supported the environment which has allowed us succeed.