Reducing avoidable harm from Venous Thromboembolism Policy (VTE Policy)

1. Staff Summary & Introduction
2. Purpose & Effect
3. Key Definitions
4. Process Flow Charts & Supporting Information
5. Key Staff and Committees/Groups
6. Equality Analysis
7. Consultation and Review Process
8. Standards/Key Performance Indicators
9. Process for Monitoring Compliance and Effectiveness
10. Plan for Communication and Dissemination of Policy
11. References / Associated Documentation

1. Staff Summary & Introduction

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are collectively known as venous thromboembolism. Venous thromboembolism (VTE) has the potential to cause either mortality or long term morbidity. Prevention is the best strategy to minimise this.

The policy is based on NICE NG89 Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism, NICE NG158 Venous thromboembolic diseases: diagnosis, management and thrombophilia testing and the NICE Quality Standards for VTE Prevention and Treatment.

The Policy supports the requirements of the NHS Standard Operating Framework goals, NICE Quality Standards, NHS Litigation Authority Risk management standards and Commissioning for Quality and Innovations Framework standard.

The policy outlines:

• How staff can help to reduce avoidable harm from venous thromboembolism for patients managed by Leeds Teaching Hospitals (LTH).
• The risk assessment process for VTE and risk of bleeding for adult hospital in patients and day cases, using national and locally approved guidelines. Risk assessment leads to consistent VTE prevention strategies for every eligible patient, also underpinned by national and local guidelines.
• How LTH will minimise harm to patients by ensuring prompt diagnosis and treatment of VTE in line with NICE guidance. Prevention and treatment processes are summarised in flowcharts 1 and 2.
• All LTH clinical staff are required to follow this policy. Roles and responsibilities are set out in detail in this document. Prevention of VTE is part of mandatory training at LTH and all clinical staff should ensure their mandatory training is up to date.
• Staff should consult the VTE resource page on the Intranet for detailed guidance, see link

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2. Purpose & Effect

The purpose of this document is to standardise VTE prevention, diagnosis and management across LTH. The policy should ensure that all patients receive evidence based VTE care which is aligned with NICE Guidelines and Quality Standards with the aim of reducing avoidable morbidity and mortality associated with VTE.

The policy is applicable to all LTH sites. The policy applies to all LTH clinical staff and outlines the responsibilities and duties they hold related to aspects of VTE prevention, diagnosis and management.  The policy applies to the care of LTH hospitalised patients, and outpatients with suspected or confirmed VTE.

2.1 Policy specific information

VTE Prevention

• All adult inpatients (aged 16 years or over) should be risk assessed for VTE and bleeding risk using the LTH VTE risk assessment tool on PPM+ on admission or by the time of first consultant review**. This should be repeated at each consultant review and whenever the clinical situation changes.
• Appropriate thromboprophylaxis should be offered / considered in accordance with trust guidance.
• Patients at risk of VTE should be given verbal and written information during their hospital admission and on discharge. The leaflets are available in  standard printed format on all wards and admissions areas and can be viewed through the VTE resource pages on Leeds Health Pathways
• Patients whose treatment requires lower limb immobilisation in the outpatient setting will be individually assessed for the risk of VTE and bleeding using the LTH VTE risk assessment tool for outpatient lower limb immobilisation. 
• The details of speciality based guidelines should form part of a local induction package for clinical staff.  Reference can be made to the detailed documents within the clinical area or through the VTE resource pages of Leeds Health Pathways

         ** Excluding patients that are categorised as VTE low risk cohort groups.

Prophylactic Treatment Regime

• All patients should be adequately hydrated and undergo early mobilisation, or regular leg exercises for those unable to mobilise.
• If a patient requires chemical thromboprophylaxis enoxaparin is the low molecular weight heparin (LMWH) of choice and should be started within 14 hours of admission, see dosing charts below.

    Enoxaparin doses for patients with creatinine clearance (CrCl) over 30mL/min 

    Enoxaparin doses for patients with creatinine clearance (CrCl) less than 30mL/min

• If anti-embolism stockings (AES) are required they should be fitted and monitored in accordance with NICE NG 89. The AES guideline and care plan are available on the VTE pages, see link

• The use of intermittent pneumatic compression (IPC) and Geko devices is recommended in some speciality guidelines. When IPC or Geko devices are required it is essential that they are fitted and used by trained personnel and that the equipment is appropriately managed.

• Extended prophylaxis with either a low molecular weight heparin, fondaparinux or an oral anticoagulant licensed for VTE prophylaxis (e.g. rivaroxoban or aspirin for total knee replacement) should be prescribed for certain high risk groups,  refer to specialty based guidelines via the VTE resource pages on Leeds Health pathways

2.3 Procedure to be followed if VTE is suspected or a diagnosis confirmed

• The management of any patient who is suspected to have a DVT or PE will follow a standard clinical diagnostic assessment involving appropriate investigations. Details are available in the Guideline for Investigation and initial management of venous thromboembolism (VTE) in Leeds Teaching hospitals (LTH) which can be found via the link.

• A standard low molecular weight heparin or unfractionated heparin based treatment regimen or direct oral anticoagulant should be initiated on suspicion of VTE, within 4 hours for a suspected DVT and immediately/within an hour  for a suspected PE, unless contra-indicated due to bleeding risk factors.

• The same day emergency care (SDEC) areas at LTH manage patients presenting acutely with suspected deep vein thrombosis and suspected pulmonary embolism who can be managed as an out-patient, according to a standard protocol.

• If a DVT or PE is confirmed the patient will require on-going anticoagulation unless contra-indicated. Details are available in the Guidelines detailed below which are available through the VTE resource pages, see links detailed below.

Guidance on the use of Treatment Dose Low Molecular Weight Heparins to treat Venous Thromboembolism in Adults

Guidance for Starting and Maintaining Adult Patients on Warfarin

Guidance for the use of direct oral anticoagulants for the treatment of VTE

Additional detailed medicinal product information is available through the standard resource of the NetFormulary

• There are also specific Guidelines for the Treatment of patients with Cancer Related Venous Thromboembolic Disease (VTE Adults), pregnancy related VTE and the use of Anti-Thrombotic Treatment in Children. All documents are available on the VTE treatment resource pages, see link detailed. 

2.4 Staff Education

• The VTE team - consultant haematologist, consultant pharmacist, and VTE prevention nurse will provide on-going staff training on VTE prevention via the trust induction & mandatory training programmes.
• The VTE prevention e-learning module and video forms part of the statutory mandatory training requirements for clinical staff and compliance rates will be monitored by the thrombosis team.  Clinical staff required to complete the refresher VTE e-learning every three years.
• Anticoagulation and VTE prevention training is part of trust induction  for new F1 doctors who join the trust. New F1 and F2 doctors are also advised to complete the Script anticoagulation training package on-line
• Records of training captured electronically and held centrally on electronic staff records.

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3. Key Definitions

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4. Process Flow Charts & Supporting Information

Flow Chart 1: VTE Prevention

# A VTE cohort can be used for any admission/procedure where VTE prophylaxis would never be required regardless of the patients own risk factors

## Appropriate prophylaxis depends on the patients VTE and bleeding risk factors and their reason for admission. Please consult the appropriate specialty VTE prevention guideline.

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5. Key Staff and Committees/Groups

5.1 Executive Lead

The Trust Chief Medical Officer is the Executive lead for VTE Prevention and has overall accountability for ensuring that there is an approved documented process for managing the risks associated with the prevention, diagnosis and management of VTE and that it is implemented and monitored.

5.2 Clinical Directors

Responsible for:

• Ensuring that specialties in their CSU are achieving the agreed VTE goals.
• Local compliance with NICE Venous thromboembolism in adults Quality standard.
• Ensuring there is a CSU approach to hospital associated thrombosis (HAT) and learning from root cause analysis (RCA)
• Ensuring that the CSU is represented at Thrombosis Steering Group
• The Clinical Director will work closely with clinical colleagues to ensure that:
  • Appropriate speciality guidelines are available through LHP
  • Local audit of speciality VTE pathways are undertaken as part of the Trust audit programme
  • Appropriate multidisciplinary review of hospital associated thrombosis (HAT) occurs and learning from root cause analysis is shared across specialities and the CSU
  • Performance monitoring criteria are agreed and reported as part of performance discussions

5.3 Lead Clinicians

Responsible for:

• Ensuring that all medical staff & advanced clinical practitioners comply with the content of this policy.
• Ensuring that the clinical team are up to date with VTE training. 
• Ensuring that all medical staff follow related policies and guidelines to enable appropriate assessment of VTE/bleeding risks in all patients who are admitted to LTH.
• Ensuring that all medical staff follow guidelines for investigation and initial management of VTE.
• Monitoring specialty compliance with the agreed VTE goals and leading improvement plans as required.
• Sharing learning from RCA investigations of HATs.
• Leading the development and maintenance of prophylactic guidelines.
• Ensuring the local implementation of guidelines for investigation and treatment of VTE.
• Ensuring that relevant prevention/treatment audits occur within the specialty and results are acted upon to support improvement 

5.2 Thrombosis Steering Group Chair

Responsible for:

• Providing professional expertise and ensuring that the LTHT VTE policy and related guidance is appropriately aligned with NICE guidance.
• Providing leadership within the trust for; VTE prevention, the diagnosis, treatment and aftercare of VTE.
• Leading the trust in achieving trust VTE targets as required by governing bodies and/or commissioners.
• Chairing Thrombosis Steering group meetings.

5.4 Heads of Nursing

Responsible for:

Ensuring that nursing staff are aware of their responsibilities relating to this policy and have received appropriate training.

5.5 Matrons

Responsible for:

• Monitoring local performance and ensuring clinical areas have systems in place which support adherence to all aspects of this policy and associated patient safety and quality standards.
• Supporting the Lead Clinician in sharing learning derived from RCA investigations of HATs.

5.6 Clinical Director of Medicines Management and Pharmacy

Responsible for:

• Overseeing all medicines management aspects of VTE prevention and treatment standards
• Ensuring that pharmacy staff are appropriately trained and follow policy and associated guidelines.

5.7 Consultants

Responsible for:

• Ensuring that patients are assessed for their risk of VTE and bleeding using the LTH risk assessment tool on admission.
• Ensuring that patients’ VTE and bleeding risks are reassessed whenever their clinical condition changes.
• Ensuring that patients are prescribed appropriate thromboprophylaxis in accordance with LTH guidance. Guidance can be found on the intranet  resource pages at link
• Clearly documenting any deviation from the guidance in the patient’s clinical notes.
• Informing patients about the risk of VTE and preventative measures.
• Following the diagnostic pathway and management plan for DVT/PE if either condition is suspected / confirmed.
• Complete HAT RCA if requested.
• Participate in RCA investigations when patients under their care have developed a HAT.

Ward and Clinical Area Managers

Responsible for:

• Implementing a process within their clinical area to ensure that all patients have a VTE risk assessment documented on PPM+ on admission. 
• Ensuring that appropriate thromboprophylaxis is administered as prescribed.
• Participating in RCA investigations of HATs.

Registered Nurses/Midwives

Responsible for:

• Ensuring they are up to date with VTE training.
• Working as part of the multidisciplinary team to ensure that all adult patients in their care have been assessed for their risk of VTE and bleeding on admission.
• Monitoring patients throughout their inpatient stay and ensuring they are reassessed if their clinical condition changes.
• Administering mechanical and chemical thromboprophylaxis as prescribed in accordance with an up to date VTE/bleeding risk assessment.
• Ensuring that mechanical compression devices are fitted and monitored in accordance with NICE guidelines and manufacturer's recommendations. 
• Providing written and verbal information on VTE on admission and discharge.  
• Are aware of the diagnosis and management of patients with suspected/confirmed VTE.

Pharmacists

Responsible for:

• Working as part of the multidisciplinary team to ensure that patients are appropriately risk assessed.
• Ensuring that patients have been prescribed appropriate chemical thromboprophylaxis (dose, frequency, route, duration) in accordance with trust guidance.
• Highlighting to the responsible clinician if reassessment or dose reduction / increase is required.
• Supporting speciality leads in the development of guidelines, audit tools and medicines management improvement strategies as required.
• Ensuring that pharmacological treatment for suspected or confirmed VTE is prescribed appropriately (dose, frequency, route, duration).

5.5 VTE Prevention Team

Responsible for:

• Promoting practice aligned with the LTHT VTE policy.
• Acting as a point of contact for multi-disciplinary advice on VTE prevention.
• Attendance and involvement at Thrombosis Steering group meetings.
• Identifying cases of HAT, coordinating the completion of RCAs, reviewing outcomes and disseminating the learning.
• Ensuring that specialty VTE prevention guidelines are aligned with NICE Guidelines and Quality Standards.
• Monitor compliance of VTE prevention measures throughout the trust by leading/supporting clinical audits and action plans where necessary.
• Provide training and education for clinical staff.
• Work with link nurses to provide education and resources.
• Facilitate regular VTE link nurse meetings.

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6. Equality Analysis

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7. Consultation and Review Process

NICE guideline 89; Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism was published in March 2018 (updated August 2019).  The Trust Thrombosis Steering Group has put guidelines and processes in place to action best practice recommendations. There has been extensive consultation, awareness raising events and communication about these initiatives.

NICE NG158 Venous thromboembolic diseases: diagnosis, management and thrombophilia testing was published in March 2020. LTH Guidelines on Initial Investigation and Management of VTE were developed after consultation with stakeholders. This Policy reflects the approaches already agreed.

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8. Standards/Key Performance Indicators

• 95% of patients 16 years and over are risk assessed on admission
• A root cause analysis investigation is completed for 100% of patients that have a hospital associated VTE.
• Patients aged 16 and over who are in hospital and assessed as needing pharmacological venous thromboembolism (VTE) prophylaxis start it as soon as possible and within 14 hours of hospital admission.
• People aged 16 and over who are discharged with lower limb immobilisation are assessed to identify their risk of VTE.
• People aged 18 and over with a deep vein thrombosis (DVT) Wells score of 2 points or more have a proximal leg vein ultrasound scan within 4 hours of it being requested.
• People aged 18 and over taking anticoagulation treatment after a VTE have a review at 3 months.
• People aged 18 and over having outpatient treatment for suspected or confirmed low-risk pulmonary embolism (PE) have an agreed plan for monitoring and follow‑up.

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9. Process for Monitoring Compliance and Effectiveness

This section, using the template below, must include details of how compliance and effectiveness of implementation of the policy will be monitored.  This will include monitoring for any adverse impact on different groups.  This should include the role of the Policy Lead and overseeing governance group in reviewing assurance. 

Where an audit is required in order to measure compliance or effectiveness, the audit should be considered for inclusion in the Trust Annual Clinical Audit Programme.

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10. Plan for Communication and Dissemination of Policy

The policy will be placed on the Leeds Health Pathways making it accessible to all LTH staff. It will be circulated to all clinical directors, heads of nursing, chief pharmacist and other relevant stakeholders including all members of the TSG. An article will be placed in the operational bulletin informing all LTH staff that the policy has been updated and approved.

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11. References/ Associated Documentation

• Scottish Intercollegiate Guidelines Network (SIGN), Prevention and management of venous thromboembolism in patients with COVID-19 December 2021
• Health Committee Report Prevention of VTE in hospitalised patients March 2005
• Report of the independent expert working group on the prevention of venous thromboembolism in hospitalised patients. Department of Health, A report to Sir Liam Donaldson, Chief Medical Officer. 2007
• All-party parliamentary thrombosis group Thrombosis: Awareness, Management and Prevention November 2007 and APPTG Annual Audit reports 2008 & 2009.
• Safer Anticoagulant Therapy Alert 18 National Patient Safety Agency March 2007
• Revised National Risk Assessment Tool Guidance 2010
• Reducing treatment dose errors with LMWH: National Patient Safety Agency RRR10/004
• The NHS Standard Operating Framework 2011/12
• NICE Guideline NG158: Venous thromboembolic diseases: diagnosis, management and thrombophilia testing, March 2020
• NICE guideline NG89: Venous thromboembolism in over 16s: reducing the risk of hospital-acquired    deep vein thrombosis or pulmonary embolism: March 2018
• NICE Quality standard: Venous thromboembolism in adults, August 2021

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