publishing

Insert hospital logo & name



Insert title of the manual where this policy resides (if applicable):





>>>

e.g. Venous Thromboembolism Prophylaxis Policy for Adult Inpatients (Non-obstetric)





1. STAFF THIS POLICY APPLIES TO



List staff with various disciplines and positions and state any specific exclusion(s) here.



Example:



All medical, surgical, nursing, physiotherapy and pharmacy staff treating acute adult inpatients.



2. PURPOSE OF POLICY AND PROCEDURE



State the purpose of the policy here. This should include what is known about VTE risk in

hospitalised patients, why hospitals need a policy on this issue and the consequences if patients

don’t receive adequate VTE prophylaxis. You may wish to support some of the statements with

evidence from literature and list these under “References”.



Example:



In Australia each year over 30,000 people are hospitalised with primary or secondary blood clots in

their legs or lungs referred to as venous thromboembolism (VTE).(1) Most of the VTE cases that

are treated in hospital settings are related to prior hospitalisation for either surgery or acute illness.

VTE results in an estimated 5,000 deaths annually (2) and many survivors develop long term and

costly complications. Most of these deaths are preventable with appropriate use of cost-effective

pharmacological and mechanical prophylaxis measures.(3)

The prevention of VTE in acute care hospitals has been recognised nationally and internationally

as a priority patient safety issue because of the strong evidence base for preventive measures and

high potential for improvements in patient outcomes. Despite good evidence, VTE prophylaxis

measures continue to be under-utilised or used sub-optimally.(4,5)



This policy outlines the procedure for the assessment of VTE risk and for thromboprophylaxis in

the adult, non-obstetric, inpatient consistent with state policy and the 2009 Clinical Practice

Guideline for the Prevention of Venous Thromboembolism in Patients Admitted to Australian

Hospitals.(6)



3. POLICY AIM



This section should contain a brief statement that summaries the aim of the policy in measurable

terms. When formulating your aim keep in mind the S.M.A.R.T rule, an acronym that stands for:

specific, measurable, attainable, realistic and timely.



Example:



All adult patients admitted to > will be assessed for risk of VTE within

> by a member of the medical staff and receive appropriate

prophylaxis based on this risk assessment.









VTE Prophylaxis Policy Template June 2011 1

4. PROCESS



This section could be written as text, or table, or by inserting your risk assessment tool/form or

other relevant documents in the Appendix. It should include:



I. VTE risk assessment

 Which patients should have their risk for VTE assessed (with explanations for exclusions)

 When patients need to be risk assessed

 What factors are used in the categorisation of risk in medical and surgical patients

 Whether risk assessment tools exist and where they can be found

 When patients need to have their risk re-assessed.



II. Pharmacological and mechanical VTE prophylaxis

 What contraindications to pharmacological and mechanical prophylaxis apply

 What recommended pharmacological and mechanical prophylaxis options apply to each

clinical category (surgical and medical patients) including time of administration, dosage

and duration of pharmacological prophylaxis

 What dose adjustments are recommended for pharmacological prophylaxis in the elderly,

patients with renal impairment, and those with low body weight

 Any unit specific protocols that exist with additional considerations (for example obstetric,

orthopaedic, spinal injury patients). These may be provided as electronic links or in

Appendices.

 Any additional considerations such as:

 drug interactions that may increase risk of bleeding

 guidelines for the reversal of anti-clotting medications in the event of bleeding

 advice regarding co-morbidities such as hepatic or renal failure

 Timing of pharmacological prophylaxis in patients receiving neuralaxial block anaesthesia.



For further information refer to National Health and Medical Research Council (NHMRC).

Prevention of venous thromboembolism in patients admitted to Australian hospitals: Guideline

Summary. Melbourne: NHMRC; December 2010.(7)



III. Documentation of VTE risk assessment and prophylaxis

 Documenting the VTE risk assessment in the patient’s medical record

 Documenting mechanical prophylaxis orders

 Ordering VTE pharmacological prophylaxis on the medication chart (when indicated).



IV. Communication with patient/carer

 Discussing outcome of VTE risk assessment and prophylaxis measures to be undertaken

with patient/carer to ensure support for and adherence to prophylaxis measure

 Providing written information to patient/carer highlighting the risk of developing a blood clot

during hospitalisation. The patient information brochure “Blood Clots - Reducing Your Risk”

developed by NHMRC is available at

http://www.nhmrc.gov.au/_files_nhmrc/file/nics/programs/vtp/NHMRC_VTE_prevention_gui

deline_information_for_patients.pdf



V. Roles and responsibilities

The policy should clearly state who is responsible for:

 Undertaking and documenting risk assessments

 Providing education to patient/carer on VTE prophylaxis

 Selecting, prescribing and administering pharmacological prophylaxis

 Selecting, prescribing and administering mechanical prophylaxis



The hospital may consider complementary clinical practice guideline specific for nursing staff.









VTE Prophylaxis Policy Template June 2011 2

VI. Continuity of care

 Developing a VTE prophylaxis plan for patient requiring continuation of prophylaxis upon

discharge either into the community or transfer to another care facility. This should include

duration of pharmacological prophylaxis considering patient’s mobility status.

 Communicating the plan to patient’s general practitioner in a timely manner

 Ensuring patient has continuous supply of ongoing treatment until follow-up appointment

with patient’s general practitioner

 Educating patient/carer on administration of ongoing prophylaxis where necessary.



5. OUTCOMES



5a. Expected outcomes



This section should include a brief statement that summarises the expected outcomes of the policy



Example:



ALL patients admitted to > are systematically assessed for VTE risk

within > and the overall risk assessment is documented in the

patient notes.



Patients at high risk of VTE will receive appropriate VTE prophylaxis and measures to be

undertaken are documented in the patient notes.



5b. Monitoring and Clinical Audit



This section should include information on the process for monitoring adherence to policy and

patient outcomes. This may include:

 Monitoring Indicators for Quality Use of Medicines in Australian Hospitals (QUM Indicators)

for venous thromboembolism (8). The QUM Indicators relevant to this area are:

QUM Indicator 1.1 - % of admitted adult patients that are assessed for risk of venous

thromboembolism

QUM Indicator 1.2 - % of patients at high risk of venous thromboembolism that receive

appropriate prophylaxis

 Case review of patients developing VTE or bleeding or other complications from

pharmacological prophylaxis

 Participating in National Inpatient Medication Chart Audit – VTE prophylaxis (Section 5).(9)





6. RESPONSIBILITY



This section should include information about who endorsed the policy and who has ongoing

responsibility for the policy. It may also include suggested timing for review of the policy if not listed

elsewhere on the policy document.



Example:



This policy has been endorsed by the Hospital Executive and will be implemented by the Drug and

Therapeutics Committee. It was developed in October 2011 and will be due for review in October

2013.



7. ACKNOWLEDGEMENT/S



List any other individuals, Committees/groups or organisations that have assisted in the

development of this policy.







VTE Prophylaxis Policy Template June 2011 3

8. DEFINITIONS



List definitions and abbreviations used in this document. Refer to glossary of terms in the 2009

NHMRC Guideline available at http://www.nhmrc.gov.au/nics/programs/vtp/prevention.htm



9. REFERENCES



1. Austrian Institute for Health and Welfare (AIHW) 2010. National Hospital Morbidity Data, 1999-

2009. Canberra: AIHW.

2. Access Economics. The burden of venous thromboembolism in Australia, Report for The Australia

and New Zealand Working Party on the Management and Prevention of Venous

Thromboembolism. Access Economics; 2008.

3. National Institute of Clinical Studies (NICS). Preventing venous thromboembolism in hospitalised

patients. Evidence-practice gaps report, Volume 1. Melbourne: NICS; 2003.

4. Gibbs H, Fletcher J, and Blombery P et al. Venous thromboembolism prophylaxis guideline

implementation is improved by nurse directed feedback and audit. Thrombosis Journal 2011, 9:7.

Available at http://www.thrombosisjournal.com/content/9/1/7

5. Gallagher M, Oliver K, Hurwitz M: Improving the use of venous thromboembolism prophylaxis in an

Australian teaching hospital. Qual Saf Health Care 2009, 18:408-412.

6. National Health and Medical Research Council (NHMRC). Clinical practice guideline for the

prevention of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in

patients admitted to Australian hospitals. Melbourne: NHMRC; 2009. Available at:

http://www.nhmrc.gov.au/nics/programs/vtp/prevention.htm

7. NHMRC. Prevention of venous thromboembolism in patients admitted to Australian Hospitals:

Guideline Summary. Melbourne: NHMRC; December 2010.

8. Indicators for Quality Use of Medicines in Australian Hospitals: NSW Therapeutic Advisory Group,

2007.

9. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Inpatient

Medication Chart Audit Form; 2010. Available at

http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/NIMC_2010-

NationalAudit



10. APPENDIX



Link or append any related policies, procedures or guidelines.



Example:

- VTE risk assessment guide (local hospital or NHMRC Guideline Summary)

- NHMRC Prevention of venous thromboembolism in patients admitted to Australian hospitals:

Guideline Summary, December 2010

- Unit specific guidelines/protocols

- NHMRC Summary of availability of evidence for use of thrombo-prophylactic agents by clinical

category, 2009

- Reversal of anticoagulation therapy in the event of bleeding

- Education resources for staff

- Education resources for patient/carer





Date issued:

Developed by:

Approved by:

Review date:

Reviewed by:

Disclaimer:









VTE Prophylaxis Policy Template June 2011 4