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Venous Thrombo-Embolism

 

Our vision:

To develop an all-Wales approach to the prevention and reduction of harm associated with venous thromboembolism, aiming to improve the patient experience and outcomes.To develop an all-Wales approach to the prevention and reduction of harm associated with venous thromboembolism, aiming to improve the patient experience and outcomes.

 

The term venous thromboembolism (VTE) includes deep vein thrombosis (DVT) and pulmonary embolism (PE). A DVT occurs when a blood clot forms in a deep vein in the lower leg, thigh, or pelvis. If a blood clot breaks up it can travel through the bloodstream to the lungs causing a PE.

VTE is the leading cause of preventable death in hospitals with 55-60% cases occurring during or following hospitalisation (Thrombosis UK, 2024). Many such deaths are preventable if patients receive a VTE risk assessment on admission to hospital and are offered appropriate thromboprophylaxis. The latest available data from the Office of National Statistics shows 369 deaths in Wales related to VTE during 2020. VTE also remains the leading direct cause of maternal death (MBRRACE, 2023). A VTE diagnosis can also have a significant long-term impact on the health of an individual, in many cases resulting in lifelong dependency on anticoagulant medication.

In NHS Wales in 2023, 11 claims related to VTE were submitted for reimbursement totalling £6,789,090.61, of which £4,797,728.33 was related to hospital acquired thrombosis (HAT). Delayed or missed diagnosis was the most featured contributory factor, highlighting the importance of a thorough risk assessment, as soon as possible after admission to hospital or by the time of the first consultant review (NICE, 2019). Failure to escalate and medicines management also featured.

Cases presented to the Welsh Risk Pool Committee include matters where there is a failure to recognise the symptoms of a PE or DVT and where there is a failure to complete a thorough risk assessment of a patient on admission. In 2021, having observed an increase in the numbers of redress and clinical negligence cases relating to VTE, the Welsh Risk Pool Committee requested that a review of compliance with the all-Wales VTE Policy was undertaken by the WRP Safety and Learning team. The review identified variation in practice across NHS Wales and issued five recommendations to all Health Bodies to reduce avoidable harm associated with VTE.

 

The VTE Recommendations

  1. All health bodies within NHS Wales adopt the All-Wales Thromboprophylaxis Policy.
  2. All clinical staff undertake All-Wales training, both in relation to the recognition of patients presenting with symptoms of VTE and in the prevention of Hospital Acquired Thrombosis (HAT).
  3. All patients receive a documented VTE risk assessment, using a Department of Health Risk Assessment Tool (or similar) on admission, as part of the initial patient clerking.
  4. An All-Wales check list for the investigation of a HAT is developed in order to maintain a uniform investigative approach across NHS Wales.
  5. VTE risk assessment compliance data and HAT data is shared at appropriate health body governance meetings.

 

Having also identified a lack of a standardised approach to staff training in VTE detection, prevention and management, the WRP led on the development of 2 e-Learning modules, and these have been available on ESR since 2022 and are scheduled for review by the WRP in 2024.

To establish the current position across NHS Wales in relation to the VTE recommendations, the WRP have recruited a specialist nurse to help coordinate a programme of work - commencing with a scoping review of practice relating to VTE in all organisations. The scoping exercise will review:

  • What VTE risk assessment tools are used
  • What VTE Patient information leaflets are used
  • What system is used to identify potential HATs
  • Process for Root Cause Analysis relating to potential Hospital Acquired Thrombosis
  • Reporting process for HAT data locally
  • Whether thromboprophylaxis features on the theatre safety check list
  • Arrangements for Local education and promotion
  • Compliance with the VTE e-Learning modules
  • Any best practice and quality improvement projects

The findings from the scoping review will inform the programme of work scheduled for 2024, aiming to address any variation identified and work towards an all-Wales approach, whilst remaining cognisant of the bespoke requirements of the different specialities.

The WRP recognises that there is some excellent practice existing in NHS Wales in relation to the prevention, recognition and management of HATs. Direct oversight of the VTE Wales programme will be via a WRP VTE Board - reporting to the Welsh Risk Pool Committee. The WRP VTE Board will have wide representation, including leading clinicians from different specialties and other key stakeholders – aiming to drive improvement in the area. 

 

Timeline for VTE Wales

The VTE Wales programme has developed from an initial review commissioned by the Welsh Risk Pool Committee in 2021 into a Safety and Learning Programme. Fig.13 outlines the timescales and plans for the programme.

Fig 13: Timescales and Plans for VTE Wales