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Quality improvements for venous thromboembolism prevention

Pharmacists from the Royal National Orthopaedic Hospital in London describe what the trust has been doing to meet national VTE requirements and the central role of pharmacists in these initiatives

Hospital-acquired thrombosis is associated with increased morbidity, mortality and length of hospital stay.1,2 Its prevention is a key patient safety priority for hospitals.3

Hospital gurney (Spotmatik/Dreamstime)

The introduction of mandatory venous thromboembolism (VTE) risk assessment has been shown to reduce the incidence of hospital-acquired thrombosis.4 VTE risk assessments on admission to hospital have been implemented by the Department of Health (England) to aid recognition of the need for prophylactic measures.5 Hospital inpatients should also be reassessed for VTE risk and bleeding risk within 24 hours of admission.6

At the Royal National Orthopaedic Hospital (RNOH) — a tertiary specialist centre for orthopaedic and neuromusculoskeletal services — the quality improvement strategy for VTE prophylaxis and management  is led by a multidisciplinary group. Pharmacy input into the group has intensified over time with the increasing involvement of the haemostasis and thrombosis specialist pharmacist and deputy chief pharmacist (clinical services).

Together they have taken a leading role in three key quality improvement processes. They are:

  •  Real-time continuous audit of VTE prophylaxis
  •  Delivery of VTE prophylaxis training to medical and nursing staff
  •  Pharmacist input to 24-hour VTE risk reassessment

Real-time auditing

On admission to the RNOH, all patients undergo a VTE risk assessment. These are completed by the admitting medical or surgical team. The risk assessments are embedded into a paper-based decision-making tool that guides doctors to consider patents’ risk of VTE against their bleeding risk and document a plan for VTE prevention for the duration of inpatient stay.

Real-time auditing allows for early detection of problems. Pharmacists at the RNOH collect audit data on all aspects of VTE prevention during inpatient stay for a representative proportion of patients when they are discharged from hospital. Information on initial risk assessment, 24-hour reassessment, prescribing and administration is collected and entered into a purpose-built electronic audit program.

A score is generated each month for the percentage of patients treated in the hospital whose VTE prevention, including assessment, prescribing and administration, was in line with national guidance. This score can be used to measure success in implementation of prevention strategies.

Results are disseminated across the trust at regular intervals — raising interest and awareness of VTE prevention.

Education and training

Pharmacists deliver training to doctors and nurses on the trust policy and processes for VTE prevention. For doctors, this is delivered as part of the trust induction process and for nurses it is delivered through regular seminars delivered by the specialist pharmacist and the completion of an e-learning package. Discussions with pharmacists on wards also provide ongoing training opportunities for both groups.

Structured training encompasses information about the background to VTE risk assessments and clinical information on VTE prevention. Some training on the initial management of suspected VTE is also included. Folders containing all relevant VTE training information are available on each ward. Specific sessions on VTE prevention have been planned for future trainee intakes.

24-hour reassessments

Most patients are admitted to the RNOH for elective surgery and therefore in most cases 24-hour risk reassessments should be conducted post-operatively to identify any changes that may be necessary to the VTE prevention plan.

In 2012, audits of VTE risk assessment demonstrated that, although initial assessments were completed in over 95% of admissions, documented reassessment after 24 hours or postoperatively was rare.

The VTE group designed a template for 24-hour reassessment and ward pharmacists assumed responsibility for carrying out the assessment during the working week — a novel idea for the trust and, we believe, nationwide. Responsibility for 24-hour reassessments that need to be completed outside normal working hours continues to sit with the surgical teams.

Implementation of this plan was led by the haemostasis and thrombosis specialist pharmacist. There was a three-month pilot of the initial template, one-to-one training of ward pharmacists, ward visits and subsequent improvement in design and clarity (using small scale “Plan-Do-Study-Act cycles”). This new initiative was rolled out to the rest of the trust in May 2013.

Patients who require 24-hour reassessment are identified by the ward pharmacist and the assessments are carried out as part of daily ward duties. The template designed by the VTE group is a guide that facilitates identification of new risks (see Box).

24-hour venous thromoboembolism reassessment

A 24-hour venous thromboembolism (VTE) reassessment grid is printed on the reverse of the VTE assessment chart. This is completed by ward pharmacists on weekdays and by the surgical team at weekends.

To reassess VTE risk, pharmacists will check if there is any new:

  • Acute severe illness
  • Cardiac or respiratory failure
  • Myocardial infarction or ischaemic stroke
  • Indwelling central venous pressure line or Hickman line
  • Delay in mobilisation
  • Severe leg swelling or infection

To reassess bleeding risk, pharmacists assess whether there is any new:

  • Active bleeding
  • Recent massive blood loss
  • Platelet count less than 100´109/L
  • Coagulopathy
  • Cranial bleed/cerebrovascular accident
  • Hypertension (systolic blood pressure >200mmHg, diastolic blood pressure >120mmHg)
  • Epidural catheter in place
  • Severe renal impairment (creatinine clearance <30ml/min)

The results of the assessment are discussed with a doctor from the admitting team or the responsible on-call doctor, and continuing prophylaxis is planned. This information and the initial assessment are used to determine whether prescribed prophylaxis is in line with national guidance.

The risk review should be repeated after surgery, if there is any change in clinical situation or on admission to a high dependency unit or intensive care.

A new action plan — which may involve starting, stopping or amending prophylaxis — is then formalised, working closely with surgical teams at all times.


With the introduction of the pharmacy-led quality improvement processes, we saw a rapid increase in the trust’s adherence to National Institute for Health and Care Excellence guidance on 24-hour risk reassessment, as we had expected, and also in the score for overall adherence to national guidance for VTE prevention (see Figure).

 Discharge graph
Percentage of patients discharged between May and November 2013 who had a 2-hour VTE reassessment completed and percentage of patients for whom all VTE prevention guidance was followed

VTE risk reassessment relies on there being a comprehensive and accurate initial assessment and appropriate planning of prophylactic measures. Improving the process of 24-hour reassessment at the RNOH prompted discussions with surgical teams about VTE prevention and raised the quality of initial assessments, by surgical teams — thus driving quality of the whole process.

Our real-time approach to auditing has allowed us to demonstrate the success of the initiative and the process has shown how the knowledge and skills of pharmacists can be used in an innovative way.


Ward pharmacists are busy; they have multiple tasks and perform many medicines-related quality checks. In the early stages of implementation, we were unsure about the sustainability of pharmacists taking on additional responsibilities. However, we have found that this process has created opportunities for more in-depth discussion with medical and surgical teams that has led to greater interdisciplinary teamwork and raised pharmacists’ profile in the hospital.

The future

Through the implementation of the above plans, pharmacists have proved that they can play a more active role in driving quality and improving patient care. Future work may involve independent pharmacist prescribers completing VTE assessments on admission and prescribing VTE prophylaxis in collaboration with surgical teams. This would further facilitate the process for VTE prevention.

Through their direct involvement in the VTE assessment process, pharmacists have had to collaborate with medical, surgical and nursing teams further than they might have done in their traditional roles. There is opportunity for future research including a review of opinions of the changing roles of pharmacists.

We believe it is crucial that the success of VTE risk assessments in reducing the incidence of hospital-acquired thrombosis is maintained now that the “commissioning for quality and innovation” (CQUIN) incentive related to VTE is no longer available. Our experience at the RNOH demonstrates that ward pharmacists are in a strong position to maintain standards and add value to VTE-related quality improvement.

ACKNOWLEDGEMENT Thanks to Ashik Shah, chief pharmacist, and Sarah Stilwell, clinical audit lead, both at the Royal National Orthopaedic Hospital  

Elizabeth Hardy is specialist pharmacist for haemostasis and thrombosis, Kandarp Thakkar is deputy chief pharmacist (clinical services) and Roxaneh Zarnegar is consultant anaesthetist, all at the Royal National Orthopaedic Hospital in London.


Citation: Clinical Pharmacist DOI: 10.1211/CP.2014.11136630

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