Statistics from Altmetric.com
It was noted that VTE prophylaxis was frequently prescribed to patients admitted to the cardiology ward and high dependency unit at The Royal Free Hospital, however the prescriptions usually did not correspond to a contemporanous VTE risk assessment. VTE prophylaxis was often prescribed before patients arrived on the ward from accident and emergency or the coronary angiography and interventional cardiology suites. Overall the completion of VTE risk assessments early in admission seemed to be poor. The completion of VTE risk assessments was frequently left to pharmacists who reviewed the drugs charts in the days following the patient's arrival on the ward. Medical reviews of patients' risks for thromboembolism were seldom undertaken at later stages in the admission.
Preventable VTE has been estimated to kill 25,000 people every year in the UK.  It is also suggested that 70% of all pulmonary embolism occurs in non-surgical patients.    Low molecular weight heparins are the mainstay of prophylaxis and treatment for VTEs, and have been shown in two meta-analyses to reduce the risk of VTE by between 38-57%.   However, studies have indicated that the prescription of VTE prophylaxis is inconsistent. The IMPROVE study assessed the provision of VTE prophylaxis across 52 hospitals in twelve countries, finding that only 60% of the patients who were eligible for VTE prophylaxis actually received it.  In the global ENDORSE study which looked at 68,000 patients, only 38.5% of eligible medical patients received appropriate VTE prophylaxis.  NICE guidelines (CG92) outline a recommended approach to assessing VTE risk and selecting appropriate prophylaxis for adults admitted to hospital (See NICE Guidelines below).  It has been noted that dissemination of information by local colleagues has been conducive for improving uptake in VTE prophylaxis.  In addition, the efficacy of educational interventions as well as nominating a designated person to take on the role of ‘champion’ for the task has been noted in several studies.     
Other measures described to improve VTE risk assessments include asking consultants to remind junior doctors, educational posters, designating nursing staff to check for VTE assessment, putting a visual reminder against the patient name on the bed board, and the use of electronic reminders. The latest report from NHS UK indicates a generally high level of risk assessment provision, with 96% of all patients receiving a risk assessment on admission. 
NICE Guidelines CG92
Assess all patients on admission to identify those who are at increased risk of VTE
Reassess patient’s risks of bleeding and VTE within 24 hours of admission and whenever the clinical situation changes, to: ensure the methods of VTE prophylaxis being used are suitable, and to ensure that VTE prophylaxis is being used correctly
A baseline audit (Cycle 1) was carried out in the cardiology ward in which drug charts for forty inpatients were checked for VTE risk assessment completion. It was seen that 40% of the patients assessed did not have a documented VTE assessment on admission and 95% did not receive a further check at 24 hours as per NICE guidelines (Table 1).
In addition, data pertaining to the prescription of LMWH on drug charts audited in Cycle 1 and Cycle 2 was collated retrospectively from electronic medical records (Table 2).
See supplementary file: ds5490.pptx - “Table 1 ”
In order to increase the number of patients who successfully received VTE risk assessments at the point of admission we undertook to provide an educational presentation, poster, email, and the appointment of a ‘VTE champion’. The VTE champion would aim to review drug charts for patients on the day of their admission to ensure an appropriate VTE risk assessment had been carried out.
The findings of the baseline audit were presented and discussed at the cardiology department education meeting. There was an educational presentation on the need for improving the provision of admission risk assessments and how creating a position of responsibility has been shown to be an effective measure for this purpose at other hospitals. A poster and update emails were produced and circulated within the cardiology department. At the end of the first cycle, a VTE champion was nominated to start work on the project. A second audit cycle (Cycle 2 in Table 1) was completed after a two week interval, and a third audit cycle (Cyle 3 in Table 1) was completed after a further two week interval in which the VTE champion monitored charts independently of the auditor.
From the baseline audit, the second and third audit cycle indicated improvements in the completion of both the initial VTE risk assessments and in the completion of the 24 hour reassessment of VTE risk. The improvement was sustained from the second to the third audit cycle.
Data collected retrospectively was limited due to incomplete availability of electronic medical records (Table 2). However, from scanned records of 32 of 40 drug charts audited in Cycle 1, it was seen that 55% of cards contained a LMWH prescription. From scanned records of 29 of 44 drug charts audited in Cycle 2, 36% contained a LMWH prescription. In Cycle 1 50% of drug charts without LMWH prescription contained an explanation for this as a documented clinical decision. This was true for 38% of drug charts without LMWH prescription from Cycle 2. It is interesting to note the discrepancy between patients who were prescribed LMWH and those who were not, despite completed risk assessments ‘triggering’ for LMWH prescription. These two measures do not directly correlate however, due to the third factor of documented contraindications to LMWH despite risk of thrombosis, and the use of alternative antiplatelet or anticoagulant agents which may have been prescribed elsewhere on the drug chart rather than in the designated section for low molecular weight heparins. Table 3 contains several examples of documented explanations for not prescribing LMWH.
See supplementary file: ds5808.pptx - “Tables 2 and 3”
Lessons and limitations
Lessons from Cycle 1: The provision of initial VTE risk assessment was shown to be poor and not concurrent with prescription of VTE prophylaxis.
Limitations: Audit being done at junior doctor changeover time may have misrepresented to some degree normal practice of provision of effective risk assessment.
Lessons from Cycle 2: There was an improvement in provision of initial VTE risk assessment and also in reassessment post 24 hours.
Limitations: The VTE Champion was not independent from the auditor at this stage.
Lessons from Cycle 3: The provision of initial VTE risk assessment was improved from Cycle 1 but not from Cycle 2. The VTE Champion was independent from the auditor.
Limitations: The sample size remained too small to be able to indicate a statistically significant improvement in provision of initial VTE risk assessment.
This audit has shown an improvement in the admission VTE assessment being carried out for patients admitted to the cardiology ward, however not at a statistically significant level. There remains room for improvement in the provision of admission VTE risk assessments by admitting doctors. This audit has shown a sustained and statistically significant improvement in the 24 hour VTE risk reassessment of patients.
In order to ensure long term sustainability in the provision of admission VTE risk assessments it will be necessary to continue to deliver further teaching and training in this regard as there are frequently new members joining the team as well as a change in junior doctors every four months. The role of the VTE champion has contributed greatly to the improvement noted, and it would be advisable to allocate this responsibility to a junior doctor who can review the risk assessments and prescriptions for VTE prophylaxis for their patients.
It is relevant to consider how the culture of ‘championing’ VTE risk assessment documentation can be sustained and whether the frequent changeover of staff will impact upon this and the need for constant reminders. The advent of electronic prescribing will facilitate the documentation of VTE risk, as this will entail a compulsory risk assessment, which may link to a prompt for appropriate prescription. Electronic recording of risk assessment and prescriptions will be complemented by an understanding of the value of risk assessment and the motivating factors for ‘compliant’ prescriber documentation. Junior doctor led teaching, electronic learning modules and multidisciplinary discussion should serve to emphasize the risk assessment as a reminder that patient specific VTE risk changes with an evolving clinical picture and its use therefore as a tool for risk re-evaluation, more so than as a ‘tick box’ exercise or hospital audit device.
In order to meet national standards in which both an admission assessment and a reassessment 24 hours post admission are completed it will be necessary to institute a system for medical and pharmacy staff reviews of drug charts. It is also recommended that revised drug charts incorporate VTE prophylaxis prescription with the risk assessment tool.
These findings are applicable to other centres where patients are received by on call doctors and then handed over to ward based medical staff.
1 House of Commons Health Committee (2005). The prevention of venous thromboembolism in hospitalised patients. London: The Stationery Office.
2 Sandler DA, Martin JF. Autopsy proven pulmonary embolism in hospital patients: are we detecting enough deep vein thrombosis? J R Soc Med. 1989;82:203–205.
3 Lindblad B, Sternby NH, Bergqvist D. Incidence of venous thromboembolism verified by necropsy over 30 years. BMJ. 1991;302:709–711.
4 Baglin TP, White K, Charles A. Fatal pulmonary embolism in hospitalised medical patients. J Clin Pathol. 1997;50:609–610.
5 Dentali F, Douketis JD, Gianni M, Lim W, Crowther MA. Meta-analysis: anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalized medical patients. Ann Intern Med. 2007;146:278–288
6 Wein L, Wein S, Haas SJ, Shaw J, Krum H. Pharmacological venous thromboembolism prophylaxis in hospitalized medical patients: a meta-analysis of randomized controlled trials. Arch Intern Med. 2007;167:1476–1486.
7 Tapson VF, Decousus H, Pini M, Chong BH, Froehlich JB, Monreal M. et al. Venous thromboembolism prophylaxis in acutely ill hospitalized medical patients: findings from the International Medical Prevention Registry on Venous Thromboembolism. Chest. 2007;132:936–945.
8 Bergmann JF, Cohen AT, Tapson VF, Goldhaber SZ, Kakkar AK, Deslandes B. et al. Venous thromboembolism risk and prophylaxis in hospitalised medically ill patients. The ENDORSE Global Survey. Thromb Haemost. 2010;103:736–748.
9 Rashid ST, Thursz MR, Razvi NA et al. (2005) Venous thromboprophylaxis in UK medical inpatients. Journal of the Royal Society of Medicine 98 (11): 507-12
10 NICE. CG92 Venous Thromboembolism-reducing the
risk:full guideline. 2011.
11 Kakkar, A K Davidson, B L Haas, S K. Compliance with recommended prophylaxis for venous thromboembolism: improving the use and rate of uptake of clinical practice
guidelines. Journal of thrombosis and haemostasis 2004;2(2):221.
12 Gaston S, White S. International Journal of Nursing Practice 2013; 19: 60–64 Venous thromboembolism (VTE) risk assessment: Rural nurses' knowledge and use in a rural acute care hospital, 19:5, 60–64
13 Brumfield, Elisha J. "Venous Thromboembolism." (2007).
14 Smith, Karen. "Preventing venous thromboembolism: Karen Smith describes the range of initiatives developed at NHS East of England in line with national and regional guidance on assessing and managing patients." Nursing Management 18.3 (2011): 12-17.
15 Improving adherence to guidelines for extended venous thromboembolism prophylaxis in patients with colorectal cancer BMJ Quality Improvement Reports 2013
16 Watts L and Grant D. Venous thromboembolism (VTE) risk assessment and prophylaxis in acute orthopaedic admissions: improving compliance with national guidelines.BMJ Qual Improv Report. 2013
17 NHS UK - Venous Thromboembolism (VTE) Risk Assessment data collection Quarter 1 2014/15 (April to June 2014)
Declaration of interests
Dr Mahmood Ahmad. Pulmonary Hypertension Registrar; Royal Free Hospital.
This project was exempt from ethical approval because as a designated improvement study local policy indicated that ethical approval was not required.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.