FOI Request
- Disclosure ID
- FOI/03418
- Request Date
- November 18, 2019
- Subject
- VTE Risk Assessment
- Description
I would like to request some information from your Trust under the FOI act relating to VTE risk assessment.
1). Each month your trust reports VTE risk assessment compliance, please could you specify the time frame from admission that this applies e.g. VTE risk assessment completion within 12 hours of admission.
2). Please provide a breakdown of VTE risk assessment compliance for the last 12 months. Where compliance is is <95% please provide information relating to the factors affecting performance and mitigations in place to recover the position.
3). Does your Trust have a Thrombosis Committee or similar whereby VTE risk assessment is monitored alongside hospital acquired thrombosis. If you do please could you provide a copy of the meetings terms of reference and the minutes of the last meeting.
- Response
1). A primary Venous Thrombo-Embolism (VTE) Risk Assessment must be completed within 4 hours of admission.
All patients must receive a re-assessment at least 4 hours after primary assessment and within 24 hours of admission (or within 24 hours of admission if primary assessment completed in pre-op assessment).
2). Compliance information is available at the following link:
https://improvement.nhs.uk/resources/vte-risk-assessment-q1-201920/
We do not have an electronic patient record or a fully assured electronic system to collect VTE assessment data. We are therefore continuing to undertake manual data collection. This comprises a combination of real time audit of all eligible patients and a retrospective case note audit of any patients who have not been captured via the real time audit. This assures that all eligible patients are captured and thus reports an accurate picture of the current compliance with undertaking VTE assessment in line with NICE guidance. The Trust recognise that this is demonstrating a compliance which does not meet the required standard. As such VTE assessment and subsequent care has been identified as a priority to be addressed and an action plan to drive improvement is in place and overseen by the VTE committee which is led by a lead clinician. Progress is monitored via the Clinical Effectiveness Committee.
3). Yes the Trust does have a VTE Committee which meets bi-monthly.
The TOR have been reviewed to reflect changes to the Trust Committee reporting structure and are expected to be approved at the January meeting.
Please see accompanying documents