Patient safety and human factors: RCN programme - venous thromboembolism

Blood clots are the cause of the greatest number of preventable hospital deaths (Lifeblood 2010). Hospital-acquired blood clots claim an estimated 25,000 deaths each year, accounting for one in 10 deaths in hospital (Lifeblood 2010). Evidence suggests that the perception that thrombosis is a condition only affecting older people is false. The Lifeblood charity has obtained data from the Office of National Statistics which show that deaths in the under 50s have reached nearly 3,000 between 2005 and 2008 (Lifeblood 2010). Despite the impact of hospital-acquired and community-acquired thrombosis little direct funding is available to tackle blood clot prevention.

The research evidence around assessment and appropriate prophylaxis of venous thrombolembolism (VTE) has been evaluated by NICE (National Institute for Health and Clinical Excellence 2010a) which has also produced a related Quality Standard (National Institute for Health and Clinical Excellence 2010b). The Academy of Medical Royal Colleges (2010) pledged to reduce the number of avoidable deaths from VTE in England and also in the other three nations of the UK. The joint action recommended by the Department of Health, strategic health authorities and professional leads includes assessment of risk in primary care at time of referral to hospital. It also recommends setting systems to ensure VTE assessment, regular audit of patients risk-assessed for VTE, and reinforcement of the importance of VTE through educational programmes (Academy of Medical Royal Colleges 2010; Keogh 2010).

As part of National Thrombosis Week 2011, NHS Medical Director Sir Bruce Keogh has highlighted the progress made in embedding a culture of VTE prevention across the NHS as part of a national programme developed by a partnership of clinical leaders which includes the Royal College of Nursing, and through the efforts of frontline workers (Department of Health 2011).

VTE resources

The RCN's patient safety resource will provide a place for material about VTE which will be updated as the RCN's contribution to the UK wide programme progresses. The RCN has mapped learning and development UK material available on VTE and we have organised this under the following headings:

Agencies and programmes
Clinical guidelines and standards
Quality improvement
VTE risk assessment
Safety alert
Implemementation stories
Patient information
Policy and reports
Online learning
Discover more
References

Some resources are PDFs - see how to access PDF files

Agencies and programmes

HSC Safety Forum (Northern Ireland)
Prevention of venous thromboembolism (VTE) is an important part of the strategy of the HSC Safety Forum to improve patient safety in Northern Ireland. The Forum established and facilitated a regional collaborative which developed a single VTE Risk Assessment Tool for Northern Ireland. The aim is to ensure that every adult patient has a documented VTE risk assessment on admission to hospital which reflects guidance from the National Institute of Clinical Excellence (clinical guideline CG92). "It is hoped that this unified approach to VTE risk assessment will also improve and streamline the training of medical and nursing staff and reduce the need for re-training if they move their place of employment".

King’s Thrombosis Centre
The King's Thrombosis Centre forms part of the Department of Haematological Medicine, an Academic Clinical Unit providing haematology laboratory and clinical services within King's College Hospital. It was identified by the Department of Health as the first NHS VTE Exemplar Centre and hosts the information about the National VTE Programme. It brings together information about all the National VTE Exemplar Centres and materials produced by these Centres, as well as information about other resources including multimedia and e-learning resources.

Lifeblood: Thrombosis charity
Lifeblood aims to increase awareness of thrombosis among the public and health professionals and to improve the prevention and treatment of venous thromboembolic disease. The charity launched the 'Spot the clots' campaign in 2010 as a result of the many stories received about blood clots being missed by health professionals in the community and in hospital.

National VTE Exemplar Centre Network
The King’s Thrombosis Centre was identified as the first NHS VTE Exemplar Centre and now hosts information about all the Centres and materials they have produced for the prevention of VTE.

Thrombosis Adviser
This resource is for physicians and patients and includes sections on: understanding thrombosis; knowing the risk; current treatments and new approaches. The resource also has an interactive tool which shows the mechanisms leading to coagulation, a thrombosis image library, publications, glossary and free downloads.

Wales 1,000 Lives Plus: Reducing harm from hospital acquired thrombosis
The 1,000 Lives Plus programme launched in May 2010 is a five year programme to improve patient safety and reduce avoidable harm across NHS Wales building on the work of an earlier 1,000 Lives Campaign. Reducing harm from hospital acquired thrombosis was one of the programme areas in 2010. The archived programme area contains l;inks to a range of risk assessment tools and the 'How to guide' on preventing hospital acquired thrombosis.

Clinical guidelines and standards

British Committee for Standards in Haematology (BCSH) (2010) The investigation, management and prevention of venous thrombosis in children (PDF 256.45KB)
This guideline aims to provide a rational basis for the investigation and management of children age one month to16 years with VTE, including cerebral venous thrombosis (CVT). Venous thrombo-embolism (VTE) is increasingly recognised in paediatric practice and there are significant differences in epidemiology and potential differences in the mechanisms for VTE in this age group.

A number of key national resources have been produced by the National Institute for Health and Clinical Excellence (NICE):

Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing (CG144)
This NICE clinical guideline published in 2012 offers evidence-based advice on the diagnosis and management of venous thromboembolic diseases, investigations for cancer in patients with thromboembolic diseases and the role of thrombophilia testing. It advises that people who present to hospital with blood clots in the legs or lungs should be offered treatment within 4 hours and have their investigative tests including scans within 24 hours. Those aged 40 and over who develop a blood clot should also be tested to see whether they have an underlying cancer.
Venous thromboembolism - reducing the risk (CG92)
This clinical guideline published by NICE in 2010 is about the care and treatment of people who are at risk of developing deep vein thrombosis (DVT) while in hospital in the NHS in England and Wales. It covers the care and treatment that should be offered to all adults (aged 18 and over) who are admitted as inpatients including day case surgery.
NICE Guidance by topic: Thrombosis
This section of the NICE website provides information about all of the guidance published or in development on thrombosis.
Diagnosis and management of venous thromboembolic diseases (QS29) (2013). This quality standard defines clinical best practice within this topic area. It provides specific, concise quality statements, measures and audience descriptors to provide the public, health and social care professionals, commissioners and service providers with definitions of high-quality care. This quality standard covers the diagnosis and treatment of venous thromboembolic diseases in adults, excluding pregnant women. For prevention of VTE see the NICE quality standard for the prevention of VTE.
VTE prevention quality standard (QS3)(2010)
As a result of the NHS Next Stage Review report of 2008 'High quality care for all' NICE has been tasked with developing independent standards clarifying what high quality care looks like. The aim is to provide quality standards which are produced collaboratively, are derived from best available evidence and act as markers of high quality, cost effective patient care. This NICE quality standard defines a high standard of care within VTE prevention. It provides specific, concise quality statements, measures and audience descriptors to provide patients and the public, health and social care professionals, commissioners and service providers with definitions of high-quality care. View the NICE quality standards.
NICE Pathways: Venous thromboembolism overview
NICE Pathways is an online tool for health and social care professionals that brings together all related NICE guidance and associated products in a set of interactive topic-based diagrams. The venous thromboembolism pathway covers assessing and reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. Information is provided at each stage of the pathway and there are also sections which list all the relevant NICE guidance and bring together implementation information and tools.

NHS Evidence: Venous thromboembolism: reducing the risk. Evidence Update February 2012
This latest summary focuses on a summary of selected new evidence relevant to the NICE clinical guideline 92 ‘Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital’ (2010).

Scottish Intercollegiate Guidelines Network (2010) Prevention and management of venous thromboembolism (SIGN 122)
Prophylaxis and treatment of venous thromboembolism were previously considered separately in SIGN 62: Prophylaxis of venous thromboembolism (2002) and SIGN 36: Antithrombotic therapy (1999). This update brings together new evidence on prophylaxis and treatment of VTE in a single guideline. The guideline identifies adult patient groups at risk of venous thromboembolism and describes the available methods of prophylaxis, with general recommendations about efficacy, safety, and how they should be used.

SIGN has launched audit tools and a risk stratification tool (2011) for the above guideline, 'Prevention and management of venous thromboembolism'. The tools aim to measure: current practice in VTE prophylaxis, specific to general surgery, and assist in the implementation of the SIGN guideline. View the audit tools.

Scottish Intercollegiate Guidelines Network (2012) Antithrombotics: indications and management (SIGN 129)
This guideline provides recommendations based on current evidence for best practice in the management of adult patients on antithrombotic therapy. It includes antiplatelet therapy, parenteral and oral anticoagulant therapy and thrombolytic therapy for prophylaxis and treatment in a range of clinical conditions such as atrial fibrillation, peripheral arterial disease and cerebrovascular disease. Antithrombotic therapy during pregnancy and for patients with intravascular devices is also covered. The guideline needs to be used alongside a range of other current SIGN guidelines which are highlighted in this document.

Quality improvement tools and techniques

1000 plus (2010) How to guide: Preventing hospital acquired thrombosis (PDF 2.5MB)
This guidance was developed as part of the programme for reducing harm from hospital acquired thrombosis, one of the programme areas of the 1000 Plus quality and safety improvement initiative in Wales. Key interventions are described and top tips are given for each of the three drivers: assessment of risk; prophylactic treatment; patient involvement.

King's Thrombosis Centre, VTE Exemplar Centres and Lifeblood (2010) Venous thromboembolism prevention. A Guide for delivering the CQUIN goal
This guide has been created in partnership between King's Thrombosis Centre, VTE Exemplar Centres and Lifeblood and forms the output of the National Workshop hosted on 26 April 2010 at BMA House in London. A financial incentive for organisations to focus on VTE prevention has been introduced through the Commissioning for Quality and Innovation Payment Framework (CQUIN) for 2010-11. This workshop brings together the key challenges, suggested solutions and shared best practice to help ensure trusts are able to meet the VTE CQUIN goal.

National Institute for Health and Clinical Excellence: NICE pathways
NICE Pathways is an online tool for health and social care professionals that bring together all related NICE guidance and associated products in a set of interactive topic-based diagrams. Information is provided at each stage of the pathway and there are also sections which list all the relevant NICE guidance and bring together implementation information and tools.

National Institute for Health and Clinical Excellence (2010) Venous thromboembolism: reducing the risk. Audit support
This audit support document can be used to measure current practice in reducing the risk of VTE. It accompanies the NICE guideline and provides audit criteria and standards based on the guideline's recommendations.

VTE Exemplar Centres
The Exemplar Centre network is a key component of the National VTE Prevention Programme in England. The centres are demonstration sites selected on the basis of their existing track record of excellent VTE prevention and care. Information about each of the centres and their work is available.

Venous Thromboembolism (VTE) leadership summit
Videos from the summit held in March 2011 which include: Lynda Bonner talking about the role of nurses in VTE prevention; Dr Roopen Arya talking about the Thrombosis Exemplar Network; Beverley Hunt Medical Director of Lifeblood; Andrew Gwynne MP talking about his experience of having a blood clot. Sir Bruce Keogh, DH Medical Director as part of National Thrombosis week has also highlighted the progress made in VTE prevention – see NHS leading the world in blood clot prevention.

VTE risk assessment

1000 Lives Plus: Programme maintenance area: Reducing harm from hospital acquired thrombosis
This page within the 1000 Lives Plus website in Wales provides information about one of the 1000 Lives Plus initiative earlier work programme areas which was on reducing harm from hospital acquired thrombosis. It includes risk assessments produced by the All-Wales Thrombosis Group, for medical risk, elective and acute surgery, elective and acute orthopaedic risk. A video available on the website 'Reducing hospital acquired thrombosis' describes the use of the All Wales VTE risk assessment form. The video can be accessed from the report of a 1000 Lives Plus national conference.

Department of Health (2010) Guidance notes to accompany VTE risk assessment data collection
The data collection was made mandatory from June 2010, and data has been published on the DH website quarterly from the first full quarters data (July-September 2010).
Latest figures are for January to March 2012 which is the seventh set of quarterly statistics - see VTE risk assessment data January to March 2010.

Department of Health (2010) Venous thromboembolism (VTE risk assessment)
One of the main recommendations of the Chief Medical Officer's Expert Working Group Report, in April 2007, was that all hospital patients should receive a VTE risk assessment upon admission to hospital. The risk assessment was first published in September 2008, and revised in March 2010.

HSC Safety Forum (2011) Risk assessment for venous thromboembolism (VTE) (Word 382.5KB)
This tool was developed by the Northern Ireland VTE Advisory Group, a regional collaborative set up by the HSC Safety Forum. The tool is designed to be used by all HSC Trusts in Northern Ireland. The aim is to ensure that every adult patient has a documented VTE risk assessment on admission to hospital which reflects guidance from the National Institute of Clinical Excellence (clinical guideline CG92). "It is hoped that this unified approach to VTE risk assessment will also improve and streamline the training of medical and nursing staff and reduce the need for re-training if they move their place of employment". For further information see Prevention of venous thromboembolism: a key patient safety priority.

Institute for Health Improvement: Hospital-acquired venous thromboembolism (VTE) incidence calculator
The calculator tool can be used to estimate the number of hospital-acquired VTEs in a hospital, and the proportion that are potentially preventable. The tool was developed by the Society of Hospital medicine and can be downloaded with full instructions.

Map of Medicine: Venous thromboembolism (VTE) risk assessment (all patients)
Map of Medicine Healthguides show the ideal, evidence-based patient journey for common and important conditions. This provides pathways on risk assessment and prophylaxis under the headings of: medical patients; surgical patients; pregnant patients; trauma patients. The healthguides are made available on the NHS Choices website.

National Patient Safety Agency (2011) How to guide to venous thromboembolism risk assessment
This guide will support NHS organisations in the implementation of venous thromboembolism risk assessment for all patients admitted to hospital. The guide builds on the existing and extensive resources already available and can be used to support the implementation of the National Institute for Health and Clinical Excellence (NICE) Quality Standards Programme, CQUIN requirements and NICE Guideline 92.

National VTE Exemplar Centre Network: Risk assessment
This section within the National VTE Exemplar Centre Network provides examples of risk assessment forms and protocols from the exemplar centres.

QThrombosis
This tool predicts the risk of venous thromboembolism. A prospective cohort study used data routinely collected from 564 general practices in England and Wales to develop a new clinical risk prediction algorithm to estimate individual patients' risk of VTE.

Safety alert

National Patient Safety Agency Alert (2010) Reducing treatment dose errors with low molecular weight heparin
Prescribed doses of low molecular weight heparins (LMWHs) for the treatment of a thromboembolic event are dependent on the weight of the patient and renal function. Underdosing has an increased risk of a further thromboembolic event, while overdosing can increase the risk of bleeding. The NPSA has recommended that all NHS organisations comply with a series of actions to reduce these risks. The accompanying Rapid Response Report provides supporting information and details the evidence and rationale for these actions.

Implementation stories (patient and practitioner)

BMC Health Services Research (2011) Clinicians adopting evidence based guidelines: a case study with thromboprophylaxis
This Australian study explored clinicians' attitudes and the clinical environment in which they work to understand their reluctance to adopt VTE prophylaxis guidelines. It found that patient outcomes can be enhanced using a coordinated programme that addresses individual, cultural and organisational constraints.

Colchester General Hospital, Essex (2010) Implementing strategies for effective VTE Prophylaxis (PDF 137KB)
Colchester General Hospital has developed a number of measures to protect patients from potentially fatal hospital acquired blood clots. They use an online risk assessment tool to identify patients at risk of venous thromboembolism (VTE). The assessment consists of a checklist that a doctor, nurse or pharmacist can run through with a patient, covering factors such as their age, medical history and previous hospital operations. The assessment tool also offers guidance on the most appropriate steps to minimise the risk (prophylaxis). All adult inpatients are risk assessed.

NHS Institute for Innovation and Improvement: Dr Ahmad, Queen's VTE Prevention Project Team, Burton Hospitals NHS Foundation Trust
A multi-disciplinary team at Burton Hospitals NHS Foundation Trust, led by haematologist, Dr Hume Ahmad, is working to reduce the risk of patients developing potentially fatal blood clots. The VTE prevention project team has set up an electronic system that ensures all patients entering hospitals in Burton are assessed for their risk of VTE and the results are recorded in their patient data.

NHS Institute for Innovation and Improvement (2009) High Impact Actions for Nursing and Midwifery
In 2009, nurses and midwives from across the UK were invited to identify examples of good practice that have had the most impact on patient care, quality and efficiency. As a result of the submissions, eight key action themes emerged. High Impact Actions for Nursing and Midwifery is a joint initiative by the NHS Institute for Innovation and Improvement, the Royal College of Nursing, the Department of Health, the Royal College of Midwives and the Nursing and Midwifery Council and is led by the strategic health authorities.

NHS Institute for Innovation and Improvement: High Impact Actions for Nursing and Midwifery submissions: VTE prophylaxis nurses taking the lead
This submission looks at nurses taking the lead in VTE prophylaxis care. Over a 10 year period South Tyneside Foundation Trust has developed and embedded a systematic way of assessing surgical patients (across all specialties) who are at risk of developing VTE. Interventions are evidence-based and include the use of sequential compression devices in theatre and post operatively, until the patient is mobilised.

NHS Institute for Innovation and Improvement: High Impact Actions for Nursing and Midwifery submissions: Developing care bundles reduces mortality rates in acute hospitals
The North West London Hospitals NHS Trust has developed care bundles as part of the saving lives campaign. Ten care bundles have been implemented, including one for VTE.

NHS local: Herefordshire nurse’s ‘exceptional’ work to prevent killer condition
A Hereford nurse, Maggie Jennings, has been awarded an ‘ambassador certificate’ from the thrombosis charity ‘Lifeblood’ because of the measures she has introduced to try and raise awareness about the risk of developing blood clots in hospital. She has “promoted its importance to staff, supported national thrombosis week within the hospital, helped to produce a leaflet explaining blood clot prevention to patients and set up a forum for professional staff to raise awareness of thrombosis in the local community”.

Patient information

Ashford and St. Peter's Hospitals NHS Trust (2010) Hospital Acquired Thrombosis (blood clot) (PDF 204KB)
An example of an NHS Trusts patient information leaflet on hospital acquired thrombosis.

Lifeblood: About thrombosis
This section of the charity's website provides a range of information aimed at the public including information about thrombosis and treatment, publications available from Lifeblood, and government policy. There is also a section of personal accounts from individuals who have experienced thrombotic events.

NHS (2011) Preventing hospital-associated blood clots (PDF 95.27KB)
Leaflets designed for patients which explains what hospital-associated blood clots are and what can be done to reduce the risk of developing clots.

NHS Choices: Deep vein thrombosis
Patient information section on deep vein thrombosis, providing an introduction to deep vein thrombosis, its symptoms, causes, diagnosis, treatment, complications and prevention.

Patient UK: Deep vein thrombosis
UK sources of information and support for deep vein thrombosis.

Policy and reports

The policy and reports are listed in date order. The most recent publications appear at the top of the list.

Department of Health, Social Services and Public Safety (2011) Development of a regional VTE risk assessment tool (PDF 207.8KB)
Letter from Northern Ireland's Chief Medical Officer Dr Michael McBride recommending the use of the VTE risk assessment tool.

Department of Health (2009) Venous thromboembolism prevention: a patient safety priority
This VTE prevention document was issued at the Leadership Summit: Venous Thromboembolism in the NHS, convened by the Chief Medical Officer and the All-Party Parliamentary Thrombosis Group. It provides a useful snapshot of the progress being made to engage the NHS and others in VTE prevention.
The priority to be given to VTE prevention was underlined in the NHS Operating Framework for 2010/2011 which stated that all patients should receive a risk assessment for venous thromboembolism (VTE) on admission to hospital. And this was to be facilitated by the risk assessment template, NICE guidance and quality standard.

NHS Confederation (2009) Reducing deaths from blood clots in hospitals
This briefing summarises the issue, sets out the policy context and clinical practice, and provides suggestions for how NHS boards can provide leadership and challenge to reduce mortality and improve efficiency.

The All-Party Parliamentary Thrombosis Group (2009) Thrombosis: Awareness, assessment and management and prevention. Second annual audit of acute NHS hospital trusts
The results of the All-Party Parliamentary Thrombosis Group's third annual survey into the progress made by English hospital Trusts in risk assessing all inpatients for their risk of hospital acquired VTE.

Online learning

RCN Learning Zone: NICE care: Venous thromboembolism prophylaxis (VTE)
This resource has been developed to support health care assistants, students and registered nurses to implement the VTE NICE guideline. It focuses primarily on understanding and preventing VTE, identifying patients at risk and includes an in-depth look at VTE risk assessments.
This is made available as part of the CPD online learning.

For details of other patient safety learning areas visit: Learning with the RCN.

e-VTE
An e-learning resource for Venous Thromboembolism developed by the Chief Medical Officer's VTE Implementation Working Group.