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VTE in the hospitalised patient

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Summary

This on-demand teaching session will explore one of the leading causes of preventable deaths in hospital: Venous Thromboembolism (VTE). Through this interactive session, Michaela Nur, nurse and founder of Learn with Nurses, and Joanne, nurse and clinical director of Learn with Nurses, will present a whistle-stop tour of the factors associated with VTE, including risk, signs and symptoms, diagnosis and management, prevention, and potential barriers. This session also includes a quiz to test your knowledge and different statistics from the UK. Join us to understand and gain the most up-to-date information on VTE and discover simple steps to its prevention.
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Description

A collaboration between Smart Health Solutions and Learn With Nurses, supported by Viatris

Every 37 seconds somebody in the western world dies from a venous thromboembolism (VTE).

Most of these are related to a hospital admission and all healthcare professionals have an essential role to play in preventing and managing VTE.

Delivered in a 1 hour 15 minute webinar by Smart Health Solutions / Learn With Nurses Founder and Director Michaela Nuttall and Clinical Director Joanne Haws.

This on-demand teaching session for medical professionals was originally recorded live in 2022 and explores the significance of Venous Thromboembolism (VTE) in hospitalized patients. Attendees will gain insight into the risk factors of VTE, the signs and symptoms, diagnosis and management, as well as prevention.

Learning objectives

Learning Objectives: 1. Identify three categories of risk factors associated with VTE. 2. Describe the importance of preventing hospital acquired VTEs. 3. Recognize the top statistic revealing the impact of VTE in the western world. 4. Interpret data collected about prevalence of VTE in different regions in the UK. 5. Analyze the significance of different risk factors for VTEs.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

So that thing near good evening, everybody. Well, I say good evening. It's evening where I am welcome to another of the Learn with nurses sessions. My name is Michaela Nur. I'm a nurse and founder of Learn with Nurses. And I'm joined this evening by Joe, my good friend and colleague, Joe. Joe say hello, I'm sure many of them know you. Hi, everyone. I'm Joanne. Ha, I'm also a nurse and I'm the clinical director of with nurses and it's lovely to be with you this evening talking about this really important topic with me mate. Absolutely. So I put back to the slides. Now our session, remember if anybody does social media, we are hashtag learn with nurses at learn with nurses. Although this is a very special session and we're doing it in collaboration with smart health solutions and we have been supported by, by actress. So a huge big thank you to by actress to help make this happen. We have a plan for tonight and our plan is we're gonna be talking about VTE venous thromboembolism in the hospitalized patient. But I think before we start, let's have a little think about who you are and where you are. So Joe and I have loaded a couple of polls already and I'm gonna put a poll out there to say, where are you actually joining us from? So we're looking at this now in the context of which continent and anybody that has joined us. And we used to use a different platform. I used to put this out there. So hopefully you can all see and we've got Africa, Antarctica, Asia, Australia, Oceana, Europe, North America and South America. So at the moment, Europe's looking like it's in the lead and I'm gonna let that one roll for a little while because, um, I can see. Wow, 20 that, well, although we know you're in Europe, we don't know which country you are in. So please do also use that chat to be able to let us know which country you're in. Now. We may do another poll in a moment or two after we found out a little more of um, what we're gonna be after Joe's given us some quiz results. So tonight, as I said, VTE in the hospital patient and we are going to give you a whistle stop all through. Well, it's quite a lot, Joe, isn't it? Really? We've got to get through. We're gonna think about who's at risk that, how do those plots happen? What are the signs and symptoms along with? How do we get the diagnosis? How do we manage? How do we prevent challenges and barriers and simple steps, simple steps to success. But before we start, but before we start, let's have a look at that quiz. Jo, how do, how do people do? Well, you know how I love a quiz and I certainly do. You certainly do. I don't even mind winning. It has to be said, um, and well, really, we could do better. So, um, I don't know if anyone, anyone that's joining us this evening actually took part in the quiz. I'm not gonna tell you what I got the first time I did it. But suffice to say I've done quite a bit of learning um particularly around statistics in preparing for this webinar. But our average school across the 10 quiz questions that we had was 45%. So less than halfway there for us. And um shall I tell you which question people found the hardest? Well, Joe, I've just popped in there a a poll as well to say, have you done the quiz? People can be doing that one. What happened? Yeah. Anyway, the hardest question, the hardest question that people found um was question four, which was asking what percentage of medical patients accounted for the total number of hospital acquired VTE S and the answer I'm just going to click a yes here because I did take the quiz. Um The answer was 75%. So three quarters of all hospital acquired VTS happen in medical patients and as you can see from the graph up there, the majority of people vastly underestimated just how significant this is in medical patients. So I'm gonna let us know now a little bit about just exactly what is VTE and when we're talking about now when we've been putting this out on social media, I have had people coming back saying what's VT. So I have to say, well, that's what we used to call or we still call it the collective term for PE SDVTS and SVT. So pulmonary embolisms, deep thrombosis and Joe and I as cardiac nurses, SVT was something very different for us, superficial vein, thrombosis is what we think about. Now. I'm going to tell you a little bit more about those clots later. But I'm gonna ask Jo if she can just let us know, is it, is it important? Why should we worry about VTE G? Well, we're here. So, um I think we all know it's pretty important and why we're dedicating this time to talking about it. Now, you and I have been doing some a little bit of work earlier, putting together some podcasts on this very subject. And when I gave you that top statistic there that every 37 someone in the Western world dies from a VTE, you were pretty horrified and I know you've been tweeting about this. This is something that we can surely do better. So one in four people die around the world causes that are related to blood clots. And you know, you're going to tell us a bit more about how the blood clots are made later on. Now, over half of B te cases happen whilst people are either in hospital or in the period directly following hospitalization. And BT savvy is the number one cause of preventable deaths in hospital. And it's that word, preventable that we really, really could make a difference on this. So let's have a little look, I'm gonna give um a bit of a whistle stop tour of some of the figures from here in the UK before I put a challenge out to our lovely guests evening. So um in terms of the UK and if you could pop that next little graph up for me, um Michaela's driving tonight, so he knows where we're going to end up because geography is not always easily lost, I think is the question I think so. Um So you can see from here. So this is uh this graph is looking at um how the rate of risk assessment for VT has changed here in the UK. And for the past about 12 years, I think now there's been a mandatory data collection that all the hospitals everyone's participated in on um how much risk assessment we're doing in patients admitted to hospital. And as you can see, we we're doing pretty well, but there are still gaps, there are still people being missed So there is still some work to be done here. Um Now, as well as um there being, you know, slight variation there in the risk assessments that's happening, there's also some variation in the rates of BT that are occurring. So this all of these dates from these few graphs I'm presenting now are from the all Party parliamentary thrombosis group and this is from a survey that we did in 2019. And so if we look at the rates of hospital acquired thrombosis, um you can see there are some real variation between the regions just here in England alone. So if we look at the south of England and it's divided up into the southeast and the south west here there is a higher than the national average rate of BT. Whereas if we go to the north of the country, the rates are slightly better. So doing better in the north than in the south, um which, you know, is, is often not the case. You often think about, you know, things being healthier and healthier and wealthier in, in different areas um in the south of the UK. And if we look at who's getting these VTS and how um there's a lot of stuff piled into this graph here, but looking at the green bar at the front there, um 40% of all of the hospital acquired thrombosis that's happening in the UK is from people, patients who have not received thromboprophylaxis. So it's that preventative treatment that is also so important and the gray bar slightly further along is the bit that's telling us that most of the hospital acquired thrombosis are happening in medical patients, as we mentioned a little bit earlier on. So where's the trend going? Well, if we take pes as an example, um we're seeing more pes now um than we ever have done. And I guess you could argue whether we're better at looking for these things and assessing risk and finding out what's going on before people have um disastrous consequences. Um because although there are more pe s happening, the outcomes are better than they were say 15, 20 years ago. So, you know, it, it's a balance here in some areas, things are looking a little bit better, but there is still an awful lot of work to be done. So that's a snapshot for us here. So, um we know we're not all in the UK, we're different areas of Europe, different areas of the world. So the challenge for you is to look at what's happening in your country. Now, you can see our little world map up here from the Journal of Thrombosis and Metasis, which is just a year old now. And you can see that there are real geographical differences here in the use of thromboprophylaxis. So do have a look at your country and see how well you're doing or not as um as the case may be. So that's a little bit of a background on them. So Michaela, why don't you tell us how it all happen? Thank you, Jo. And um yeah, how does it happen? Well, they are clots. Ok, that's the first thing to say is they are clots. And I'm going to talk in a bit about how those clots actually form. But when we're thinking about BTE, we kind of lump it into the risk factors into two different categories. We have those that are inherited. So that means people are more genetically predisposed to developing those clots. And you can, you can see here on the screen what's there. But um in the context of what we're going to be talking about tonight and of course, those inherited conditions do do influence it, but we're really gonna focus as well on those that are acquired and often acquired whilst in hospital. And you can see there that there is a very short list of potentially acquired risk factors, but not all risk factors are that why I not change? And not all risk factors are the same. And this is kind of the um the thread that I'm going to go through now in the fact that not all clots are the same, not all risk factors are the same. And that leads us into where we get to the scoring system and trying to decide just how much somebody might be at risk of developing those clots. So we divide our risk factors into those that are strong and we're going to and then moderate and then weaker risk factors. And the ones we can see here, well, they're ones that you may well think about and that's that, you know, any sort of trauma, a fracture. Certainly a previous history of a VTE is a very strong risk factor. Now, we can also see on here, um, the question that lots of people got wrong on the quiz as well. For those of you that haven't done the quiz, this is an opportunity to get an answer, right? That hospitalization for heart failure or af within the previous three months is a strong risk factor. So it's really thinking, not just who is that patient now that you've got in front of you, but what is their history? What has it been all about? So that is our, they have what we call the strong risk factors. Then we've got slightly larger list of things that are moderate. And you can see these are all things that people often have when they're in hospital or they come into hospital with them also. So whether you're thinking of your autoimmune diseases, um people with heart failure, but also HRT are coming in for different investigations and having those um, venous lines in and intravenous catheters. And those leads that all of these create the potential for clots to happen. That's what we're looking at here. On that potential. So, still moderate and we've got even bigger list of moderates. We have another set here. Again, ones that people would think about, you know, the, the contraceptive pill. But would you be thinking about I BS even irritable bowel syndrome is a moderate risk factor for VTE. So, when we're doing our assessments on patients, when they're admitted, we do have a short list and I'll be showing you those. Our list is quite, is quite long. Now, these are the weaker factors that come through. And we found that in the quiz, a lot of people thought bed rest for more than three days was quite a strong risk factor when actually, it's one of the weaker risk factors when compared to some of the others. Of course, we've got things that we know as we get older, we just develop a lot more problems as well, but things like hypertension diabetes, things that we would expect to cause clots. Um, do so. Not all clots are the same, not all risk factors the same. And we use the term clots a lot. So we, we've talked about VT now when we talk to patients, we talk about clots and not all clots are the same. So we have a, you know, clots in essence, are made up of blood, they're blood and they happen for different reasons. Now, we have our circulatory system and that's the system that carries blood. And I don't know why I always feel the mood to do this motion of circulation happening Joe around the body. And when blood leaves the heart, it goes out in that arterial system. And our arteries, well, who doesn't love an artery? The artic arteries are beautiful things and arteries are very powerful creatures with special linings and they cause a certain type of clot. Now that clot is often due to some sort of trauma or damage to the inside of the artery. And that's, that's what gave us our job. So many years, that's our heart attacks and anginas and strokes. So those clots happen as a result of some sort of damage to the inside of your endothelium, that special lining, your platelets become activated and you cause a clot, you cause a clot to try and stop that leak. That is not what we're talking about when we're talking VTE. Ok. That's not that sort of clot, that's your heart attack, that's your ischemia. That is a very platelet driven clot. What we're thinking about is that venous system now, veins of very different creatures to our arteries. I always think they're the little, little floppy things that bring blood back up to the heart and they, well, I, I, yeah, I'm sure they're not as floppy as you think, but they're little floppy things with some valves in to stop the, stop the blood from going back down. And that's our venous system and it's that venous system that we get the clots that we're talking about today and those clots are really, they're fibrin rich clots. So, if you imagine if you've got a bucket of blood, now, most of us don't have a bucket of blood hanging around. But if you've got a bucket of blood or maybe a cup of blood, then rather than a bucket and you leave it on the side, it's going to form a clot and it, it clots because it's not so the way it clots is different. And so that's why when we're talking about VT, we're thinking about those venous clots and we have to be careful when we talk to patients. And it's very important that we do talk to patients about, about the formation of clots and that what we should worry about that we don't get them confused because not all clots are the same but not all clots are equal. Now, as Joe knows, I'm not very good with geography, but the closer the heart, the clot is to the lungs, the worse it is for you. So a clot that sort of happens down in your peripheries, down in that distal region is not going to be as bad for you as something that happens closer to the lungs more like that pe So the risk increases, the closer it gets the lungs, but the risk also increases whether it's symptomatic or not. So if you say have got a proximal DVT, that is going to be worse if you've got symptoms rather than an asymptomatic. One, of course, the worst symptom you can get is pe with death. And, um, when you listen to the, if you do listen to the podcasts, Joe, and I certainly had some thoughts and discussions about, um, those fatal Pe s and I, I have to, I'm not gonna, you know, I'm not gonna say them here. But if you, I want to entice you to listen to the podcast. But I have vivid memories of two fatal pe s that I, um I, I watched, I saw whilst I was at work. So not all clots are the same and not all clots are equal. Now, according to where those clots are, gives different symptoms. So jo my symptom queen over to you. It does indeed. And um as you described at the top, when we're talking about BTE, we are talking about DVTs, deep vein thrombosis, p pulmonary embolism and then uh superficial vein thrombosis also known as Thrombophlebitis. And so as you might imagine, depending on whereabouts in the body is being affected. That's where you are going to see your symptoms coming through. So we'll start off with the DVT and what we will be experiencing seeing then is uh swelling. So it normally be in one limb. You could be really unlucky and have two going on at the same time, but one leg, possibly one arm, it does also happen in your arm, um, swelling that is accompanied by pain or tenderness and warm to touch. So hot, swollen, painful, often you'll see some discoloration to the skin, reddish or possibly even a bluish tint to it. So, in one of your limbs and a generalized pain tenderness. Now, pe as the name might suggest is what's going on in your lungs. And that will usually be characterized by a sudden shortness of breath coming on, that may be accompanied by a sharp chest pain. Now, we know that chest pain can occur for multiple reasons. So this differential diagnosis is um, is really important at this point. Um So that real nasty sharp pain, but it will usually get worse on inspiration. So you take nice deep breaths and you'll get that sharp pain in the lungs, usually accompanied with a rapid heart rate and can be accompanied by a unexplained cough and often people will be coughing up some blood stream nastiness, um when they are coughing there. Now, the final one of the trio are thrombophlebitis or um superficial vein thrombosis. The the the main difference here because this is also going to be in a limb. Got a f, in fact, I think we might have even used the same picture. But the key here is um that this is very much more local eye. So with the DVT, though you might get the swelling and the discomfort overall in the limb here, you can, you're pretty much going to be able to point to it. So it is in a specific area, there will be pain tenderness, it might be itchy, it might be red or the skin might become hardened around the edge. And often you could see that in the pigmentation of the skin that can actually hang around. So these symptoms can develop over hours, possibly days and they can take the same sort of time to resolve and that hardness of the vein could even go on for months. So, um I think when we were again, not, not promoting our podcast in any way, shape or form, but I did this was an angry vein. It is very much an angry vein I think. Oh, I could just imagine. I would be itching it, it would be annoying. Yes. Yeah. Yeah. Irritating and angry. Oh, I won't, I'll leave that there. I won't, yeah. Don't go over there. Don't go anybody we know at all. Um, so I guess the next bit to move on is really around the prevention. That's why we're here. That's what we're most interested in. So I will hand it back over to you to talk about preventing VT and I'm just going to go in and answer Juliette's question here. Lovely. Thank you. Thank you. So, exactly. So, the best way to do it to prevent it well, to prevent AD VT or PE is to prevent it. And we have quite structured processes to do that. And Jos already mentioned that the, you know, between the medical and the surgical patients and that medical patients make up quite a significant proportion of those vte that are there. And of course, Jo and I have been chatting about this quite a lot and we were saying, but, but you really think of surgical patients when we're doing this, you have memories of, you know, well, you know, either going in having operations or patients having operations, friends and family and you think right, they surgical patients, they get assessed legs get measured all of that. And whilst we do think about it in the context of medical patients, it's not necessarily a high up in our brain, maybe what it should be or we do it because it's part of a, you know AAA pre assessment, you come into hospital, you've been admitted, it's part of that tick box. But that really understand it the impact of what we're doing when we do that. And, and that, that 11 every 37 seems that it's more important than ever that we do do this. And so we do an assessment now we have nice guidelines in this country but it be lines that are in your. So and they should either be done by a professional network for as we've got a national body or in or even from a peer-reviewed journal because we know countries are all different shapes and sizes and not everywhere has that same structure that's there and that, that has set happen as quickly as possible as soon as they've been admitted. And certainly by the time there's the first consultant with you, we have to have that decision made. Does this patient need thrombo prophylaxis? And what we're trying to do there is balancing out the risk of forming a clot versus the risk of anticoagulation. And we do that a lot, don't we, you know, throughout health care and particularly medicine, it's looking at that, getting that balance right is the intervention that we're going to be doing better and have less hazards and less harm to patients than if we don't do something. And that's exactly what we're going to be looking at here. So I'm going to talk you through a variety of different guidelines to start with. So, um the first one we're going to look at is the nice guidelines and, and many of us now this is probably going to show up very, very small. So I've split it into a couple of shit. They will, we'll take it step by step. And the first one is step one. Now, these will be produced by the Department of Health and based on nice guidelines and many different organizations of trusts have adapted these into their own local sets of policies and in your area of work, you will have it somewhere particularly if you're in the UK. It's as Joe said, it's a part of a national data set. We have to report on it. Um Those reportings will happen. Step 10, it's a twirling step one. And that's exactly what I said. We really need to assess our patients as soon as they come into have hospital. Actually, when we're thinking about their mobility. So we said that being in hospital and being in bed rest is a low risk. But actually when we come into hospital, we don't move quite as much that also influences our sort of risk, then we start going through those big tick boxes that we have deciding on. What are the risks for that patient at that point in time. So there some of the risks that I mentioned earlier on, it's not all of them, it's some of them. Now we can see here whether we're a medical or a surgical patient. But also are they, what's their age? Are they dehydrated? What's their weight? Have they got a past medical history of vte any problemss with phlebitis? And they're what we call patient related risk factors. And then we apply next to that, the admission related risk factors. So people walk in or have these conditions or have these risks to start with? And what extra is being added to their risk when they're in hospital? So is it that they're in critical care? Have they got, uh are they having surgery? Is there that hip replacement? So there's, there's a whole layers of things and that gets us prizes and the prizes is getting close towards needing anticoagulation. Now, anticoagulation is not without its own bleeding risk and we can see this here. That's again, that's another, that's another scoring system. So it does feel that we're for to boxes. However, what we're trying to do to approach to making sure that we don't miss people and we are missing people because one every seven seconds means we're missing it. We saw on some of the stuff from the All Party parliamentary group that we are missing that opportunity. I'll talk a bit more about the challenges that we have in a moment as we come through. But again, that bleeding risk, we have the patients related. So what have they got, but also the admission related. So we know that they're actively bleeding and that's a really big, really big risk, acute stroke or hypertension and what have they come in for if they come in for spinal surgery, eye surgery, those highly vascular areas. And now depending on what the that risk is and depending on whether we move forward. So there are two risk tools that we use. That's our risk tool that we use in England. But of course, we're joined by people from all over and I saw we've got people, I'm from Lithuania, Egypt and Joe. I get very excited when we see people putting in the chat where you're from. So keep throwing it in. I can't see the chat at the moment, but I'll have a look in a moment. But there are other risk tools out there. Now, the two that I'm going to talk about briefly as well, the premi one and the Differences Society of Cardiology, the American Society of Hematology or even the CDC, they are all over the place, but risk assessment tools don't want to leave them in a cupboard on a folder on your computer. You have to make them kind, you have to turn them into more than just I'm gonna tick a box. You understand the implications of what you're actually doing and act upon them. So we do a risk score and this one is for medical patients and you can see in here, then it is the same sort of risks that are there. So whether it's previous vte uh reduced mobility, whether their, what their age is, heart failure, heart attacks. And then this one, if you score five or four or more, then that's counted as a high risk and you would move forwards towards anticoagulation and we'll have a look my payment, what that might mean. Um And the pre me now this is for surgical patients and this, well, this has got more risk factors on here and they are, you know, I I think when it comes to these risk assessment tools, you, we, we don't expect anyone to remember every risk and what every point is worth it really is knowing where to go and get yours. Now, for this one, for the capri one, we can categorize people to low, moderate or high according where they are and some points, you know, a risk factor can get you five points. And that's whether it's to do with multiple trauma or a stroke. It doesn't take a lot for a patient who's in hospital to actually start clocking up the points. So I think we can see that most patients, I would suggest that probably or many patients will probably benefit from some form of thromboprophylaxis treatment. The risk score range for capri, then depending what we do, depends on what their score is. So as I mentioned briefly there, we've talked about the low, high risk score, but you can have even higher risk scores when it comes to the caproni one. And really what we're trying to see and then what we can see here is that early ambulation and that's really important. So as well as givings getting our patient moving, and I think that's something Joe I touch is absolutely essential in so many ways. Now, I'm just going to show you one more and you're probably thinking how many risk scores can you have? But I do like a, I love a schooling system because to me what that means is it's reliable. We're not just waiting on patient people's judgment or you look like you might be able to risk, but that we've got at that system, last one I'm going to mention is called the improved bleeding score that's actually available on online and you can go in and you start filling it in and here and that will give you your percent. And what you can see if it's less, less than six, they don't have an increased risk. And if six, I can't, even if it's less than seven, the risk is not increased. But if it's greater than seven, the risk is increased. And you can see the same scoring system that happens there. So we've got a variety of different tools. We know that what we want to do is as soon as patients are admitted, whatever they're admitted for, we should be using an appropriate risk assessment tool and recording it and acting upon it. But what are we gonna do? Ge how are we going to stop these clots? Well, like everything that we look at um preventing is always better than having to find a treatment. Of course, um this is across the board in cardiovascular disease as well as in multiple other conditions. And the key here is around that prophylaxis. And if we are going to use pharmacological VT prophylaxis for medical patients, it's so important that it started as soon as is practically possible. And absolutely, within 14 hours of that admission, unless there is uh some kind of population specific recommendations for the patient and the group that they are in. So for example, patients that are having an acute cardiac event, an acute stroke or other forms of acute illness, there may be slightly different rules on what is appropriate for them. Um Thinking about people that are admitted to critical care, people that may have renal impairment, a malignancy, psychiatric illness or patients who are receiving palliative care. So when you look across at the guidelines and having spent quite a quite a bit of time looking across at the nice guidelines, there are very many different groups of people where there are slightly different variations on the recommendation. So it's important that you are much like your risk score, selecting the right page for the patient that you're dealing with and you know, is quite a complex matter. So again, like your risk scores, there are multiple sets of guidelines um depending on where you are. We have nice here in the UK. Um I was just looking back at our poll where people are from and I think we do have some guests from North America, we have some from Africa as well. Um So here is an example, we have the American Society of Hematology 2018 guidelines for the management of VT. And this is specifically looking at prophylaxis for hospitalized and non hospitalized medical patients. And if we were to look at this in more depth, um there's a total of 19 recommendations um available within this guideline, but it's recommendations 12 and three that we are particularly looking at for um patients who are acutely unwell uh in the hospital. And it takes you through again, weighing up pros and cons balances what is going to be the best option. So from using a parental anticoagulant agent, um or not using low molecular weight heparin versus unfractionated heparin, looking at fondaparinux versus low molecular weight heparin or um against unfractionated hera as well. So, looking at all the different choices of agents that we have and weighing up the pros and cons according to which particular patient group that you're looking at. So a lot of guidelines out there again, you know, this is same recommendations for everyone. Look at your patient group, look at where you are and follow the appropriate guideline for you. But of course, it's not all about the medicine, it's not all about anticoagulation. There are other um prevention that we also use on a regular basis and could probably use more of. So most commonly, we have those lovely anti embolic stockings that I'm sure most of us have wrestled with or another and, you know, routinely seem to get, you know, packet tossed at everyone as they come through a hospital door. But um it's not quite like that. Um But we need to be cautious um because even the non pharmacological interventions can have complications and issues as well. So we need to make sure we're using the right thing on the right patient. So for example, if patients have some form of occlusive arterial disease, they've had previous um bypass surgery involving the lower limbs. If they have any sort of sensation problems, peripheral neuropathy or some other form of sensory impairment, there, local skin problems, any allergies to the the materials that these are made of swelling or anything that's going to mean it's, it's difficult or NIH and impossible to get a correct fit. So we do have to use our caution, clinical judgment, um particularly if people have got some form of wound there too, but as I say, it's not just about throwing the packet at someone and leaving them to get on with it. We do need to make sure that we're measuring patients legs and using the correct size garments for them. And so they should always be fitted and patients shown how to use them properly by staff who are trained in their use. Now, I know you're going to talk a bit more about training and the like a little bit later on, but it's really important that we're checking for any swelling. Um, patients have had um any surgery and if there are any changes in dimensions that we remeasure and refit those antibotic stockings and uh you know, we need to also monitor them once people are wearing them and encourage them to keep on wearing them until they don't need to anymore. So otherwise, when they are much more um active up and about and they do need to come off for um, washes showers, et cetera as well. But um particularly so that we can have a look at the skin condition underneath them. So thinking um particularly about frail, older people, if there's problems with mobility problems with skin integrity or any sensation, then you know, they might need to come off several times in a day just to check that there's, there's no injury soreness or nastiness lurking underneath them. Um, checking people are wearing them properly. Now, we've all seen them rolled up, rolled down all manner of situation to um, in the vein attempt to make them slightly more attractive and comfortable than they actually are. But um, we, we do need to make sure that people are, are, are wearing them as instructed and we also need to be able to stop them if there's any problems with the skin or pain and discomfort that happens. Um, if suitable, there are other options. Now, Michaella, I know when we were talking about this, you were, um, when I mentioned alarmingly. So I think by Jo and um I'm, I'm, I'm kind of expecting inflatable boots. Um, at the Christmas party, it has to be said, um, so by inflatable boots, we are talking about intermittent pneumatic compression, which is a AAA newer depending on how long you've been in this game or out of it. Um, er, er, probably a, a newer set than, um, the stockings. And this essentially is an inflatable garment, usually boots that you can put on. And we have uh, it's connected to an air pump and there will be a cycle of inflation and deflation. So a bit like the, the mattress is, you know, when the air mattress first came out with the different cells would inflate and deflate. And so there will be this within the boots. And so that's going to stimulate the normal pumping movement. We would get in our leg muscles from moving around. So getting that blood moving, stopping it from just pooling around being static and um obviously increasing the risk of of clots being forming. Now, um like with everything, there are always some slight practical issues around comfort and having the right kit and all the rest of it, um critical care, particularly good to using them. But um you know, often patients are perhaps not as awake in there to, to be able to have some of the problems that we've reported there, but they do need to be prescribed. But you know, there, there are, there are lots of things um available there for, for prevention, shall we say? But of course, things don't always work out the way we would like them to do. They, this is where I jump back in, I think Joe, isn't it? So, and even if we have done everything we're supposed to, we could still suspect that BTE, so we need to always be aware of it. But we know that actually if people aren't appropriately treated, then that really does increase the risk. And we saw that, that to people who one of your earlier jo that the people who actually to have it are those that are not or not receiving thromboprophylaxis. So let's start with as soon as a VT is suspected. Now let's just start with, let's start with the worst first. And that's your pe and we've already had of those symptoms. Although one of the first, one of the, another symptom of um of pe is death and, and so some people can die very quickly. It can be very, you know, from nowhere, it almost feels like that, that pe appears and boom, they've gone. So, um but let's assume that that that hasn't happened and that it's not a fatal pe at the moment. But what we want to be able to do is assess how likely is it that they have a pe got those symptoms. Now, you know, the pain and the cough thing might be something else, but we want to be suspicious of it. And we use, uh this is again based on, on the, on our, our guidance, a nice guide for England. And that is the, well here, it's another scoring system and, and we do have a lot of scoring system, it needs to be said and four is the magic number. So we get three points for signs and symptoms. We get three points at an alternative diagnosis is less likely than A P. And then we start to go down depending on the heart rate, mobilization. Previous history of DVT malignancy hemoptysis. So they really, you know, it doesn't take a lot to get those four points if you've got this pain that's going on. So what do we do? Well, we use it another flow chart in real life. This happens a little bit smoother than us having to, you know, you're not flicking through pages and pages. There's often logic built into software to really help us make that decision. We use the well score. Now, almost whether we score four more and four is the magic number for this. We need to think about starting somebody on interim therapeutic anticoagulation whilst we're waiting, if they haven't, if they're not already on it, we need to think about starting it. So let's imagine they've scored four or more. Then what we want to be able to do is jump straight in with a CT pulmonary angiogram and that's really getting us to get that definitive done. It's a pa but we don't wait until then for patients, we start, start that thromboprophylaxis, we start anticoagulation if of course, that uh that angio, that pulmonary angiogram is positive. Well, you've already started your anticoagulation, you've started dissolving that clot early. So that's good. Now, if it's negative and you're worried there might be a, then what you want to do is move towards the ultrasound and you've already got your, hopefully your anticoagulation on board. Now, if your score is four or less, well, that says your pa is unlikely, but it doesn't mean that it's not there. So at that point, we might still think about um anticoagulation. Of course, this is done on a clinical decision if it's all. But then we're starting to look at that d-dimer test. If the d-dimer is negative, then we can stop the anticoagulation. So, a negative ddimer means we can see, but if that ddimer was positive, then really, we want to go and start looking at that. Is there any other clots anywhere else sitting there? We've maybe seen the one on the leg, but is it back in the lungs? And what are we thinking of? So, so that's if we suspect a pe now, if we suspect AD VT and that's looking at that, um looking at the patient as Joe said, they might have a very sore swollen. So we're going to do more. Just um look at the limb though, we assess the whole patient that's there. So we might see that sore swollen, like we might be, it might be tender and staff. It might be if I to take measure out, it is a bit bigger. Again, what is, who is the rest of that patient? Have they been in plaster? Have they been, have they been immobilized for a while? Cancer? Um Have they had, and this is one that I think, uh again, always comes out a bit of, hm, have they had major side within 12 weeks? So you, were you thinking not just that the person there and then, but what is their history in the last few months that might be influencing their body's ability to make that clot if the score again is, and we can see on our, on our, it's another scoring system, we have another scoring system. So if again, if the wells is greater than two, then we will be able to do an ultrasound scan on that leg. And we want to do that along with the d-dimer. And then if it's less than one, we do with that and if your ddimer ends up as negative, you can stop everything. But if the scan is positive or you have a d-dimer that is positive, you will almost keep scanning until you find the negative. So it's really hard, we don't stop that anticoagulation until we get a double negative on both. So that is what we do in or what we should be doing. I will say doing in England, there are other guidelines for other countries and this is where we're going to look a little guideline heavy for a moment. But I think it's really important to understand the evidence that underpins what is um what is being recommended. So the European guidelines is something that many people use. Um many people use across different countries. And again, you can see here they're talking that that initiation of anticoagulation without delay, that the risk of that pain whilst trying to decide, do they have the P, is there a VTE going on? Now deciding what to use again is based on local prescribing areas. So let's delve a little further into the guide guidelines on what they're actually talking about. So these guidelines are phased to look at, starting with the patients who are most at risk, those at the higher risk. What do we go for? So we can see the best evidence to here for our patients who are more at risk and that is looking at anticoagulation. We're really trying to clot and it's only if we or if thrombo thrombosis is contra indicated or it hasn't worked. Do we then move on to think about something surgical like an embolectomy? There is other evidence for different ways to try and get into sorting out that clot. But this is again in our high risk for you patients. The evidence isn't as strong as that anticoagulation that's there. Now, when we move into our patients that are more into or lower risk of pa it's still the strongest evidence for anticoagulation. Whatever that version is, you use your local guidelines, whether that's your trust, your organization, your hospital, wherever you're working, follow your guidelines. And it's about getting patients on the right appropriate medication as soon as possible. Here. Now again, in these uh intermediate and los patients, there are other things we can use. The evidence again, is not quite as strong. And I'm going to take you through to some of these ones looking at this reperfusion treatment. And we might be thinking about really assessing that patient. Who are they, what is wrong with them? What is their level of hydration? Like are they already on anticoagulation? What sort of surgery they have had? And we are starting to think about different. Um Yeah, quite a hol for patients. It's interesting, but I would say is actually quite essential in knowing that. And we'll come on to this one in a moment into coming on to a whole system approach because it's not, not one person's responsibility and um I'll be picking that one up in a moment, but remembering your risk of pe and DV, once you the hospital, it continues on it. And so there is also a role for um community primary care also being aware and patients being aware for what that risk is and it continues on and some patients might need to be discharged on appropriate therapies. So this is a very busy slide that is our prescribing guidance in uh for anticoagulation for DVT or suggest for you is find out what is yours for your country out. So it Joe and I have tried to do is take you on a journey on why and how and how we can do it in different elements. I think now what I want us to think about is that multiple disciplinary team who is with Ger Well, I've just been having a nice chat with Roseanne on the chat about putting your stockings on. I'm going to have a little look at the chat then. So we need to maybe have a video demo of something like this because I think the, I think the wrestling analogy with them is, is resonating quite nicely with them people, so we can have a little chat about that at the end. But as you rightly say, it's, it's everybody's job. So whether you are, you know, in charge of the show, you are the chief medical director of the hospital. Um you know, you need to make sure that there's a policy in place that that's implemented and much like you said, with your scoring system, having something in the cupboard and not referred to is, you know, you can have the best policy in the world, but if it's not implemented, then it isn't gonna make a difference to patients. So as we kind of go down the ranks, it were, then it's everybody's job to make sure that these policies are there that implemented, that they're adhered to in all of the areas that they are monitored, um and appropriate. I know you're going to talk about audit in a minute. But the appropriate data is um directed down to the individual level of of the clinical staff who are looking after patients to make sure that they are using the correct risk scoring system to make sure that they are recorded things in the right way. So for most of us nowadays, that will be um a digital record, an electronic patient record of some description. And this is something that certainly in this country, the regulators will um look at and assess when inspections are being done to make sure that these things are actually happening. Um So yeah, through to um the prescribers, pharmacists to make sure those prescription charts are there, treatment plans are in place. So it really is a huge team effort to make sure that we have everything in place and that it's being followed. So looking specifically the practicalities of what we could do. Well, I think we've learnt from you that, that assessment and that continuous reassessment process of patients, so we can keep um our eye on their risk level and their situation and make sure that we are in a position to be able to treat um both in terms of prophylaxis, but also looking out for any symptoms. And as I think you said, leaping on them when they occur. Um but in terms of prevention, you know, it's, it's, it's not just for our lovely physios to be encouraging patients to move and mobilize and do passive movements if they can't get up, you know, this, this is for all of us to encourage people to mobilize and to encourage them to stay hydrated as well. And we all know how busy everywhere is these days. And, um, you know, we, we've, we hear stories about patients, you know, not being able to stay hydrated when they're in hospital. You know, access to fluids, um having help to be able to mobilize to the bathroom to get washed and all these kind of things and you know, everywhere is busier than ever. So, you know, we can't underestimate some of the challenges and I I know you're, you're gonna come on to um some of the challenges that we face and um educating ourselves, educating our colleagues and educating, of course, our patients because there's an awful lot that patients can do to help themselves or relatives can do to support patients. And this is, as you've rightly said, not only for that period of hospitalization, but also thinking about when people go home as well. So looking out for symptoms and that's this is where our education comes into, for people to know what to look out for. Because if you just say you want to be looking out for any blood clots, um I'm not sure many of us would actually know where to start. So being specific that what we are actually looking out for so that patients and relatives can keep an eye out for that. You know, it's very hard to see somebody's hot, swollen leg when it's buried under a duvet. For example, for people to understand why it's so important that they are as mobile as they possibly can be and that they stay hydrated and to make sure that they let us know of any problems that they're having again, we're all so busy. Everyone's rushing around, call, bells flying off everywhere, telephone calls going off everywhere. It could be very easy to sit. Everything I can't give them another problem to think about. But we do need to know, we, of course, need to know of any more problems, er, that people are experiencing so that we can take the right action. Now. I've probably touched on quite a few of the, um, challenges and barriers that we face there. But, um, well, I could think of a few more, don't you? W don't you worry? Exactly. So, you know, it's implementation is what Joe and I love and I have made reference to, you know, protocols are, are no good if they sit on the shelf and all too often. We've seen that Joe, haven't we in action that well or not in action as it goes? And you always want to have that balance because you don't want to spend forever having to tick boxes and fill this in and fill this in and, you know, without actually being near your patient. But equally, we do need some sort of structure and rigor to, to be able to make sure that what we're doing is in a consistent way and that it is auditable. So, um I love a good audit and I think I made somebody blush once when I said it that way. But I do, I love a good audit. Um It allows me and I think that's the public health side of me as well that allows us to really see and not just where we're going wrong, but also allow us to see our successes too because, you know, it's not all doom and gloom. There is a lot of fantastic work going on out there in trying to prevent BT ES and it's really finding out more of that. And I certainly, when I was doing some work looking for this NHS digital has got some really great case studies of what's happening. So you've already touched on that time and, you know, we've had the pandemic, we've got that next wave coming through now. There's never been so many, you know, the whole world is short staffed. It feels like in the health service. So the pressures are greater than ever. But let's just think very practically that. And I, and I have to say because it's been a while since I've been in a hospital, I didn't, I don't think I've ever had training on how to put a VTE on. Not in a system? Oh, to put, how to put, have you worn one lately? Have you? Yes. No, how to put on those stockings. I, I don't think I've ever been taught how to do that. So, um, so whether you're a nursing staff or medical staff, then we need to have, make sure during your induction and every two years that you should be updated on VTE on the prevention, identification and management. And there is, um, a Department of Health. So for us in England there's an e-learning module. Hopefully you've got something relevant in your area and for anybody who wrestles on with those stockings should have training to wrestle on with those stockings. And I was about to put in the chat to Annemarie that, er, I, I put them on, um, I put them on my daughter from time to time and I use, um, I use a carrier bag now, I don't know if a carrier bag is allowed, but I'll use a carrier, that conversation going on. Was that ok? A carrier bag over the foot, you shovel it all on and then you pull a carrier bag out the bottom. But, um, the toes that would be awful. You can't get your carrier bag out. Well, then you've got to have devices that help and stuff, don't you? So they should be training and regular training. And I think, you know, you and I have discussed VTE a lot recently jo and both of us haven't really thought about it in the way that we probably should have thought about it. Um either as healthcare professionals, but also as relatives and friends and visitors and from patients, you know, being a patient from time to time is having more awareness and I am still flawed by that one, every 37 seconds. Somebody in the Western world I it still floors me and particularly as so much of it is preventable. So, audit training that good baseline that's there. And if you don't have appropriate tools in your country, go and have a look at the nice guidelines, it has got perfect audit standards you can use, they've got operational, they've got clinical so you can think about, you know, what does my trust, what does my organization do? How, what should we have as well as each individual person being responsible as well? Um, just don't use plastic bags for non, absolutely. They won't work at all. I'm looking at the chat and trying to talk at the same time. So I'm probably gonna just think about those tips now. So for, for people and I can't believe we've had people staying with us the whole hour. We've been doing this Joan now and I think, you know, the tips are we all have a role to play. We all. So whether they're in hospital, outside of the hospitals, in the community education and training, we all have a role to play not just for us, but also we've all, we've all got family and friends who are going in and I think there is something out there to make patients more aware, to look for those clots. I think we need to be careful of our language and when we talk about clots, but asking them, let us know if your leg starts getting a bit sore, all of those signs and symptoms that JO has mentioned moving and drinking. Well, it's important for everything really. And as you were talking about it, J I was having happy memories of dragging my cardiothoracic surgery patients, my bypass patients out of bed and getting them out of bed, sitting them up, pushing them down to the showers, giving them a hose down all of that sort of stuff. What probably was very early on in the post surgery time. But the best thing for them was to get up, um, be aware of the signs and symptoms. They're not really going to change, you know, they're not gonna, a pe is not gonna look dramatically different in the 10 years time. Those symptoms are still going to be there. So keep yourself updated. Keep yourself going on that training and that early intervention, many of us will go ok. There's a lot of questions to ask tick, tick, tick, tick tick. We've gotta tick all of those questions, da da da da da. Without actually thinking some of those questions we're asking is more important than others. And that's why good record keeping data, data, data is absolutely essential. Oh, I think we're getting close to running out of Steve Jo. Do you want, do you want to summarize for us? We are. Yeah. So, um let's wrap it up then and then we'll, we'll get on to the chat and any other questions that people um may have. So, um, we know the hospital aqui VT accounts for thousands of deaths annually here in the US. Absolutely millions. If we look worldwide and I'm sure none of us will forget that every 37 seconds, someone in the Western world diess from a VTE and those fatal peas remain a leading cause of people dying in hospital. And ultimately, this doesn't need to happen. We can't prevent everything, but certainly we can prevent a lot. Um We've shown you lots of different guidelines and tools and things that are available for that. It's really find what's right for your country or within your organization, there will be a policy there, there'll be a guideline there, find it, have a look at it, see what you need to be doing because together we can take up that challenge. And so the biggest challenge, the first challenge is one to prevent. But if we cannot prevent, then we need to detect, we need to diagnose and we need to treat because at risk of sounding like a politician together, we actually can really save lives. I think we should, er, and look at the questions now we should do in. I did, I did, I thought, let's have a look at who's here. So we worked out which countries people are from and predominantly we're from Europe, but we're from all over Europe. Lithuania, Malta. And we've got, we've got some people from Africa and North America so we tend not to have Asia in it this time of night because it is in the wee hours. But they're usually very good at a bit of a catch up in the, in the wee morning. And then, so what I've done now is said, what is your role? And we have some people are from the, from the A HP side of the world. We've got some doctors, we've got a lot of nurses and we've got a lot of something exciting because we, we, we just thought, well, we can't have this huge long pole. So who's popping is gonna pop it in the chat? What is that? Um, something exciting. So, Roseanne says, drink is important for better circulation, right? Well, I want to say it depends what you're drinking really. But I think what we mean is staying hydrated is what you're thinking about there. Roseanne, isn't it, Je? And does it matter what fluids we drink? Well, um, you know, water's always gonna be the handiest thing to drink and probably something that's not going to be have too much of a diuretic effect. But, yeah, keeping that volume up in your circulation is certainly going to be helpful. Keep that circulation going around and not have any little, little nooks and crannies where those little clots can form. So, yeah. And I think as well when we're in hospital, people don't drink quite as much as what maybe they could do at home just simply because that old jug of tepid water, despite it being changed regularly, the tea round doesn't happen as, maybe as often as people would like to have cups of tea. So it really is, um, it really is important now. We've got, er, another 10, there's a lot going on COVID. Jo, what do we think about COVID contributing to BT S COVID? Made you clotty, didn't I, we, we learnt that, that people were having, um, a lot more clots when they had, um, COVID. And again, there was lots of really interesting, I say, interesting, pretty devastating things that, um, came out of COVID, um, when people actually had COVID and we also, I think Roseanne is now, um, talking about the clotting risk of um, vaccines now. Yeah, it's a whole different explore. But, um, you know, but I think I shall still be having my vaccines. But I think as well, we, we certainly saw that, um, that, that COVID made you clot. I think that was the big, but also COVID and the pandemic also interfered with you getting your anticoagulation. So there had to be a big sea change, didn't there in how people were being managed with their anticoagulation? Just simply because they couldn't come in to have their blood tested if they were say, taking warfarin. And there was a definite shift that had to happen really very fast at that point in time. That's there. Yeah. Well, and also, you know, it within the hospital, um you know, record numbers of patients struggling with staff, we had staff moved around from different areas, people working in areas they weren't used to, perhaps people coming from areas where they weren't used to doing, um, VT assessments. They used to dealing with the prophylaxis. So, you know, it would be really interesting to see some statistics or perhaps quite scary to see some statistics of, you know, the difference that it, that it did make, but I suspect that not only, um, is COVID making you more clotty, um, you know, maybe, maybe the looking for it and the prophylaxis and the assessments, but also suffering because there was just so much going on at that. Yeah, cartage, cartage everywhere. Well, I'm just going back through the chat now and una said I'm stopping at her. So, and I'm reading it out cos not everybody, particularly when people, if they're watching this on catch up, they won't see the chat in the same way. And there's a lot of discussion about getting those stockings on and it said stocking, applicators are fab and she's seen a patient on the district use an old painting that they took the bottom of as an applicator. So, whatever devices are available. Absolutely. But I think, I think, um, I think, I think what I'd really love to hear is people's experiences of doing those risk assessments. So we know we've got lots of nurses and doctors in so if we could have it in the chat. So um yeah, so, so Gwen's come in as healthcare professionals, our practice is based on evidence rather than Rs. Yeah. So and I think that's the bit Rosanne. We don't, we don't not have our boosters just yet. I think there needs to be the benefits of that, that booster for COVID is there um that we know that we're having. So um I think Naomi asked a question, way, way, way, way back up here uh evening, Naomi um talking about the oral contraceptive. Yes. Um More of a community question really and saying how the nice guidelines are. Um we know that they're applicable to over sixteens, but of course, we know the increased risk of the um oral contraceptive pills. And, you know, we do have a lot of um girls that are not yet 16 who are pills certainly in this country. Um And I'm sure worldwide as well. So there could be a bit missing there. Now, I'm, I'm not aware of any specific guidelines for under sixteens, you always have this slightly different area, don't you? Huge amount of evidence as you know, Naomi, when we've, um, being asked to put guidance together around hypertension with things in the past, certainly with, um, younger people, there's often a great lack of evidence for these things. But yeah, it would be certainly useful to have, um, some more advice on that, I think. Well, I'm just going back to the chat and Fiona macpherson left a lovely message saying she's in Scotland but worked in NHS England and Scotland. And so far this has been one of her favorite webinars, but there's not enough info and training on the subject when first starting on the wards, all paperwork. No training in the hospitals that she's worked in. And I think that's what happens, isn't it? You, you end up with a raft of paperwork or it's all computer driven now, isn't it that you have to work your way through without really seeing the reasons why and therefore the benefits of why we're doing? You know, why these things are being asked rather than it's just another set of boxes. We've got to tick and get through as quickly as we can. So I think, I think, um, I think we're getting close to, to wrapping up Je, we've got a couple of minutes left before I tell people about the exciting next steps. Have you, have you anything? Well, I've learned lots through, um, talking about this. Um, and hopefully others have too. Naomi's just popped something else. Um, and I think this is about vaccinations. She knows their vaccines, aren't I? Anyway, she, she's the vaccine queen. Um, yeah, and Rosanna is saying that they started giving the flu vaccine as well as um COVID. Yeah, people are, are doing that here too. Um, at the moment. But, um, but yeah, as I say, I, I, I've learned lots. I hope um, others have too. And, um, yeah, we, we've got quite a bit of work to do, haven't we? But um, there's gotta be some, some light there at the end of the tunnel, I'm sure. Absolutely. Well, I just, I'm gonna wrap up with a big thank you to everybody. So I just, er, now like to say thank you to you Joy for joining me on this session. Um, we might occasionally do a longer one like this again. We often do our webinars so low, don't we? So I'd like to say a big thank you to my actress who without their support, we wouldn't be able to have done this and they're doing this together with smart health solutions. Um, but also I'd like to say thank you to everyone who is joining us today. Um, because uh hopefully you've learnt a little more and Geraldine is just saying it was really interesting, although scary. Yeah, it is scary and it, and yet there's a lot we can do So if you are thinking about what else you'd like to do, share this with your friends and your colleagues because this is available on catchup. I sound, I sound like I'm on the TV, on catch up. Um It's already available on Medal and they get to people just have to reg, well, I don't even think you have to register. You can just go and look at it so very soon over the next few days, what will come out is um from, from the amazing A is we have a dedicated webpage all about B TV. Um including how to access this, this webinar and to access the slides and of course, to access the two podcasts that Joe and I have been mentioning. Yeah, podcast. I, there's two podcasts coming up so it's Joe and I um having a bit of a chat pretty much about what we've just talked about tonight, but they're slightly more rela well, more relaxed than we are now. Fashion that's there. So, yeah, and that's the sort of one that, er, it's just audio. So you don't have to look at any slides. We describe it in a way that you don't need slides for it. And um yeah, so huge. Thank you to everybody because I, I'm, I'm, you know, my nurses. Well, we do it because we love it and there's lots of people there and I'm loving hearing the messages from here that people are enjoying it. And loving it too. Thank you, Fiona for those ones there. So as always, I am going to er pop the feedback here. You follow your feedback, do your evaluation and that allows you to get your certificate. And also I've already uploaded a copy of the slides for you as well. So you get the full set of slides too. Jo Thank you very much to you too, honey, for this. I think we can. So the on your intra I missed that. What did you say, Joe? I said thanks for having me and infiltrating your webinars. OK. And Stephanie has already announced if you make sure that you um tick to say yes, you're happy to be followed up. The podcast will come out and lo and Fairness. It is called VT in the Hospitalized Patient and it's from LA of nurses. Um It'll be short and snappy that way, easy to find, but we've just got to wrap it all up as a bundle now and it'll all go out in the next few days. Well, I think that's so done, Jo, so I'm going to pop my camera and my audio off now. Um And uh but we'll, I'm going to keep the chat open for a couple of minutes just in case there is anything. Thank you very much. Everybody take care. Good night, good night.