C o m m ittee, 2 0 05). The enquiry identified significant inconsistencies in th e application of
existing VTE guidelines, particularly th e adm inistration o f throm boprophylaxis. The Health
Select C o m m ittee enquiry also concluded th a t th e re was lack o f awareness o f VTE as a
clinical problem across th e NHS.
5.2 Overview of VTE Management in the NHS
Following th e House of Commons rep o rt (H ealth Select C om m ittee, 2 0 05), collaborative
w o rk com m enced involving th e new ly fo rm ed A ll-Party P arliam entary Throm bosis Group,
th e D e p a rtm e n t o f Health, th e National Institute fo r Health and Care Excellence (NICE)
and th e Royal M edical Colleges. They sought to develop a system atic approach to VTE
m an ag em en t across th e NHS. Their aim was to educate and spread awareness o f VTE as a
clinical problem and to highlight th e effectiveness o f throm boprophylaxis. F urtherm ore,
all NHS Trusts w e re tasked w ith developing m ultidisciplinary Thrombosis C om m ittees and
specialist throm bosis team s to cham pion VTE and to im p lem en t protocols locally using
th e existing clinical governance fram ew orks and audit systems. Following th e Health
Select C o m m ittee enquiry, th e D ep artm en t o f Health commissioned NICE to develop VTE
guidelines fo r surgical patients. In addition, th e Health Select C o m m ittee also suggested
th a t national guidelines should be developed fo r adult surgical in-patients, covering risk
assessment, effective throm boprophylaxis and p atien t counselling. They reco m m en d ed
th a t VTE dem onstration sites should be set up to showcase NHS Trusts th a t had a proven
track record fo r excellent VTE m anagem ent, including education, audit and q uality control
systems. M o reo ver, th e Healthcare Commission was tasked w ith inspecting VTE
and th a t guidelines w e re being fo llow ed. Around th e sam e tim e , th e D e p a rtm e n t of
H ealth's Chief M edical O fficer w ro te to all NHS England M edical Directors announcing th e
a p p o in tm e n t o f a m ulti-stakeh o ld er independent exp ert w orking group to develop and
im p le m e n t a national VTE tre a tm e n t and prevention strategy. He also recom m ended th a t
all NHS Trusts should im p le m e n t existing guidance fro m collegiate groups w hile th e NICE
guidelines w e re being developed.
5.2.1 Guidelines for prevention and treatment of VTE
This section outlines in detail th e VTE England Program m e T im elin e fo r rolling o u t national
VTE m an ag em en t program m e (VTE England, 2 0 1 2 ), and th e im plications of national
events fo r NHS Trusts. The first NICE guidelines fo r th e prevention and tre a tm e n t o f VTE
w e re published in April 20 0 7 . These guidelines covered in -p atien ts undergoing surgery
and w e re prim arily based on existing evidence fro m random ised controlled trials. NICE
recom m ended effective risk assessment and use of both mechanical and pharm acological
throm boprophylaxis w h ere indicated. The NICE VTE G uideline D evelo p m en t G roup also
proposed high quality m onitoring o f VTE-related adverse events and em phasised th e need
to ensure effective translation o f research into practice in o rd e r to curtail th e various
uncertainties and inconsistencies th a t had been highlighted in th e House o f Com m ons
Health Select C om m ittee report. The ind ep en d en t exp ert w orking group also published
its rep o rt in April 2007. It recom m ended m an d ato ry VTE risk assessment fo r all
hospitalised patients. In a le tte r sent to all NHS England M edical Directors, th e Chief
M edical O fficer supported th e independent expert w orking group's recom m endations
and announced plans to im p lem en t a national, systems-based VTE prevention strategy
across NHS Trusts in England. This strategy becam e known as th e VTE Prevention England
program m e. It was headed by NHS England's D irector o f Patient Safety, w orking closely
w ith th e A ll-Party P arliam entary Thrombosis Group, th e D e p a rtm e n t o f H ealth, the
national VTE Board, NHS commissioners and M edical Directors fro m all NHS England
Trusts.
In January 20 1 0 , NICE published revised VTE guidelines and q uality standards aim ed at
system atically im proving th e structure, processes and outcom es o f NHS Trusts' VTE
m an ag em en t efforts. Unlike th e 2007 guidelines, which only focused on surgical patients,
th e n ew NICE VTE guidelines required th a t all adult hospital in-patients should be risk
assessed on admission, and w h e n e v e r th e ir condition changed during th e ir stay in hospital
and on discharge as specified in th e revised D ep a rtm e n t o f H ealth's VTE risk assessment
te m p la te . In April 2 0 1 0 , th e A cadem y o f M edical Royal Colleges issued a s ta te m e n t in
support o f ongoing g o vern m en t initiatives fo r VTE prevention, th e updated NICE
guidelines fo r VTE and q uality standards, th e national VTE risk assessment te m p la te and
th e th en new ly proposed Commissioning fo r Q uality and Innovation fra m e w o rk . The
academ y re ite ra te d to its m em bers and fellow s th e im portance o f effective VTE risk
assessment in prim ary and secondary care, as w ell as ap p ro p riate do cu m en tatio n ,
prescription and adm inistration of throm boprophylaxis w h e re indicated. The A cadem y
m em bers w e re tasked w ith auditing th e ir local systems in line w ith th e Commissioning fo r
Q uality and Innovation goals. Additionally, healthcare professionals w e re encouraged to
ensure th a t VTE prevention becam e an integral com p o n en t o f und erg rad u ate and
postgraduate m edical teaching, and w id e r dissem ination through e-learning m odules and
o th e r prom otional m aterials.
In February 2 0 1 2 , th e updated Am erican College o f Chest Physicians guidelines w e re
released. They focussed on im proving risk stratification m ethods fo r medical patients and
a n ti-th ro m b o tic treatm en ts. The D ep artm en t o f Health issued fu rth e r detailed VTE
guidelines in M arch 2013. The n ew guidance stressed th a t VTE com pliance data should
include all patients ad m itted to hospital w ho had been risk assessed using th e specified
criteria. Around th e same tim e , th e NICE pathways fo r VTE w e re published. The pathways
brought to g e th e r existing NICE VTE guidelines, quality standards and all published
m aterials used to support th e national VTE prevention program m e. In line w ith previous
A ll-Party Parliam entary Thrombosis Group recom m endations, th e national VTE Board
issued a commissioning to o lkit to help commissioners m ake ap p ro p riate decisions locally
to support effective VTE prevention using th e NICE Q uality Standards and O utcom es
Fram ew ork. Further guidelines w e re issued by NHS England through a 'fre q u e n tly asked
questions' press release fo r commissioners and th e NICE Q uality Standards fo r VTE
prevention aim ed at im proving and speeding decision making processes and audit
systems a t local level. VTE risk assessment and root cause analysis data collection and
reporting w e re now a central fe a tu re on NHS Trusts' quality agendas. Figure 5 .1. shows
th e D e p a rtm e n t of Health's national paper based VTE risk assessment to o l.