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Theme: CLAHRC - Healthy People, Healthy Environments
Status: Complete


Venous thromboembolism continues to be a major and often unrecognised cause of morbidity and mortality in hospitalised patients. Over one-third of hospital in-patients are at risk of developing venous thrombo-embolism (VTE). A National Institute for Health and Clinical Excellence (NICE) guideline was issued in February 2010. Its key priorities were to assess patients for risk of VTE on admission to hospital and to evaluate the risks and benefits for prescribing VTE prophylaxis.


A PenCLAHRC study assessed what models for implementing VTE risk assessment and VTE prevention were applied in four hospitals in the NHS South of England region. We examined how each hospital compared in terms of design, assumptions and conditions for implementation. A before and after observational design study was used to evaluate the implementation of the NICE guideline and investigate changes in VTE risk assessment and the prescribing of appropriate thromboprophylaxis. Two specialities were covered in the study; one with a relatively high proportion of elective patients (Orthopaedics) and one with a high proportion of emergency admissions (General  Medicine).


Results showed that differing Implementation strategies such as audit, education and training were used. The combined statistics for all for four hospitals showed that the percentage of patients for whom a VTE risk assessment was documented increased from 51.5% (210/408) in 2009 to 79.2% (323/408) in 2010; difference 27.7% (95% CI: 21.4% to 33.9%; p<0.001). There was little evidence of change in the percentage who were prescribed prophylaxis amongst patients without a risk assessment (71.7% (142/198) in 2009 and 68.2% (58/85) in 2010; difference -3.5%% (95% CI: -15.2% to 8.2%; p =0.56) nor the percentage who were prescribed low molecular weight heparin amongst patients with a contraindication (14% (4/28) in 2009 and 15% (6/41) in 2010; RD = 0.3% (95% CI: -16.5% to 17.2%; p =0.97).

Interview analysis suggested that:

  • The perception of the VTE prevention policy and practice sometimes differs between Consultants.
  • Policy can become fragmented between (and even within) different wards or settings. In effect meaning there could be several policies operating in one hospital.
  • Pharmaceutical preventions are generally preferred to mechanical interventions such as compression stockings.
  • Drug / prescribing sheets are an important means of communication.
  • Clear VTE protocols do not prevent ‘hard’ clinical decisions which may override protocol.
  • Internal audits of VTE risk assessment are becoming more frequent.


We were able to conclude that the documentation of risk assessment improved following the implementation of NICE guidance; however it is questionable whether this led to improved patient safety when prescribing prophylaxis.


Journal articles

2013 Child S, Sheaff R, Boiko O et al. (2013) Has incentive payment improved venous thrombo-embolism risk assessment and treatment of hospital in-patients? [v1; ref status: indexed,] F1000Research 2013, 2:41 (doi: 10.3410/f1000research.2-41.v1).

2011 Child, S; Boiko, O; Sheaff, R; Nokes, T; Copplestone, A. Implementing models of care to prevent venous-thromboembolism in hospital in-patients: which is the best method? British Journal of Haematology, 153, (Suppl.1), 1-88

Conference papers

2012 Bateman, A; Sheaff, R; Child, S; Boiko, O; Ukoumunne, O; Gericke, CA. The Implementation of NICE guidance on venous thromboembolism risk assessment and prescribing of prophylaxis: The impact on patient safety across four hospital sites in England. Value in Health 15 (7) A535 Paper presented as a poster at the 15th Annual European Congress of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Berlin, Germany, November 2012.

2011 Gericke, CA; Boiko, O; Child, S; Nokes, T; Copplestone, A; Sheaff, R. Implementation of evidence-based national guidance on venous thromboembolism prophylaxis for hospital in-patients in England. Paper presented as a poster at the 14th Annual European Congress of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Madrid, Spain 5-8/11/2011.

Three further papers are currently in the course of peer review and will appear here once accepted for publication.




Others Involved

Dr Sue Child, Dr Olga Boiko, Dr Alice Bateman, Dr Obioha Ukoumunne


This project is being carried out in collaboration with various hospitals in the South West