Standard operating procedure

VTE Risk Assessment & Prophylaxis Procedure

How [Organisation Name] assesses every eligible patient for venous thromboembolism and bleeding risk, decides on and prescribes appropriate thromboprophylaxis, informs patients of the risk and warning signs, reassesses after the procedure, and audits completion in line with NICE guideline NG89

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What's inside

This standard operating procedure is fully drafted and structured, ready to brand and complete for your service. It covers:

  • 1. Purpose
  • 2. Scope
  • 3. Definitions and abbreviations
  • 4. Responsibilities
  • 5. Procedure
  • 6. Reassessment
  • 7. Documentation and records
  • 8. Audit of venous thromboembolism risk assessment
  • 9. Related documents
  • 10. Review and version control
  • 11. Disclaimer

Legislation & standards it maps to

  • National Institute for Health and Care Excellence, Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism, NICE guideline NG89 (2018, updated 2019)
  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - Regulation 12 (Safe care and treatment)
  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - Regulation 17 (Good governance)
  • National Institute for Health and Care Excellence, Quality standard for venous thromboembolism in adults: reducing the risk in hospital, NICE quality standard QS3 (2010, updated 2021)
  • The Human Medicines Regulations 2012 (SI 2012/1916, as amended) - prescribing and administration of prescription-only medicines
  • Mental Capacity Act 2005
  • Data Protection Act 2018
  • UK General Data Protection Regulation

Who it applies to

All operators, surgeons, proceduralists, anaesthetists and sedationists, prescribers, registered nurses and operating department practitioners, pre-assessment and ward staff, healthcare assistants, and the registered manager or [Insert Job Title] at [Organisation Name] who admit, assess, prescribe for or care for patients undergoing a procedure or a period of care that carries a risk of venous thromboembolism

Glossary

Plain-English explanations of the technical terms and legislation used in this document.

Anaesthetist
A doctor who specialises in giving anaesthesia and managing a patient's care before, during and after a procedure.
Anti-embolism (graduated compression) stockings
Specially fitted stockings that gently squeeze the legs to keep blood moving and reduce the risk of a clot.
Anticoagulant
A medicine that reduces the blood's ability to clot, often called a blood thinner.
Antiplatelet
A medicine that makes the blood less likely to form clots by stopping tiny blood cells called platelets from sticking together.
Bleeding risk
The chance that giving a clot-preventing medicine could cause or worsen bleeding, which has to be weighed against the risk of a clot.
Blood-thinning medicine
A common name for an anticoagulant, a medicine that reduces the blood's ability to clot.
Body mass index (BMI)
A measure of whether a person's weight is healthy for their height.
Care Quality Commission (CQC)
The independent regulator of health and social care services in England.
Contemporaneous record
A record written at the time of, or as soon as possible after, the event it describes.
Contraindicated
A situation where a particular treatment or device should not be used because it could cause harm.
Data Protection Act 2018
The UK law that governs how organisations collect, store and use people's personal information.
Deep vein thrombosis (DVT)
A blood clot that forms in a deep vein, most often in a leg, which may cause pain, swelling, warmth or redness.
Department of Health and Social Care
The UK government department responsible for health and social care policy in England.
Direct oral anticoagulant
A type of blood-thinning medicine taken by mouth that helps prevent or treat blood clots.
Duty of candour
The legal duty to be open and honest with a person and their family when something goes wrong with their care.
Epidural
An injection of pain-relieving medicine into the space around the spinal cord, often used during surgery or childbirth.
Fondaparinux
An injectable medicine that helps prevent blood clots.
Fundamental standards
The minimum standards of safety and quality below which care must never fall.
General anaesthetic
Medicine that puts a patient fully to sleep so they feel nothing during a procedure.
General practitioner (GP)
A family doctor who provides everyday medical care in the community.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The regulations setting out the fundamental standards that providers of regulated health and social care must meet.
Hormone replacement therapy (HRT)
Treatment using hormones, often given around the menopause, that can slightly increase the risk of blood clots.
Hospital-acquired
A condition that develops as a result of being admitted to hospital or having a procedure, rather than being present beforehand.
Human Medicines Regulations 2012
The UK law governing how medicines are licensed, prescribed, supplied and administered.
Intermittent pneumatic compression
Inflatable sleeves placed around the legs that squeeze gently in cycles to keep blood moving and prevent clots.
Low molecular weight heparin (LMWH)
A type of injectable blood-thinning medicine commonly used to prevent blood clots.
Lumbar puncture
A procedure in which a needle is inserted into the lower back to take a sample of the fluid around the spinal cord.
Mechanical prophylaxis
Physical devices, such as compression stockings or inflatable sleeves, used to keep blood moving and reduce the risk of a clot.
Mental Capacity Act 2005
The law that protects and supports people who may be unable to make particular decisions for themselves.
Mobilisation
Getting a patient up and moving as soon as it is safe after a procedure to help blood flow and recovery.
National Institute for Health and Care Excellence (NICE)
The national body that produces evidence-based guidance on treatments and care in England.
Near miss
An event that could have caused harm but did not, by chance or because it was caught in time.
Neuraxial anaesthesia
Pain relief or anaesthesia given near the spinal cord, such as a spinal or epidural injection.
NG89
The National Institute for Health and Care Excellence guideline that sets out how to reduce the risk of hospital-acquired blood clots in people aged 16 and over.
Oedema
Swelling caused by a build-up of fluid in the body's tissues, often in the legs or ankles.
Oestrogen-containing contraception
Forms of contraception, such as the combined pill, that contain the hormone oestrogen and can slightly increase the risk of blood clots.
Operating department practitioner
A registered healthcare professional who helps care for patients before, during and after surgery.
Peripheral arterial disease
A narrowing of the arteries that reduces blood flow to the limbs, usually the legs.
Pharmacological prophylaxis
Medicines given to reduce blood clotting and so prevent blood clots.
Platelet
A tiny blood cell that helps the blood to clot and stop bleeding.
Prophylaxis
Treatment or measures given to prevent a condition rather than to treat one that has already occurred.
Pulmonary embolism (PE)
A blood clot, usually coming from a deep vein thrombosis, that travels to and blocks an artery in the lung; a life-threatening emergency.
Registered Manager
The person registered with the regulator as responsible for the day-to-day running of a service.
Regulated activity
A type of care or treatment the law requires a provider to register with the regulator to deliver.
Renal function
How well the kidneys are working, which affects how some medicines are dosed and cleared from the body.
Risk assessment
A structured check identifying what could cause harm and what is being done to prevent it.
Risk-assessment tool
A recognised, structured form used to assess a patient's risk of a blood clot and their risk of bleeding.
Single assessment framework
The structure the regulator uses to judge a service, built around quality statements and five key questions (safe, effective, caring, responsive, well-led).
Spinal (anaesthesia)
An injection of anaesthetic into the fluid around the spinal cord to numb the lower part of the body for a procedure.
Standard Operating Procedure (SOP)
A written, step-by-step instruction setting out how a particular task is to be carried out consistently and safely.
Summary of Product Characteristics (SmPC)
The official document that tells healthcare staff how a particular medicine should be used, including its doses, cautions and side effects.
Thrombocytopenia
A lower than normal number of platelets in the blood, which can increase the risk of bleeding.
Thrombophilia
An inherited or acquired tendency for the blood to clot more easily than normal.
Thromboprophylaxis
Measures, whether devices or medicines, taken specifically to prevent blood clots forming in the veins.
Thrombus
A blood clot that forms inside a blood vessel.
UK General Data Protection Regulation (UK GDPR)
The UK's main data-protection law governing how personal information is collected and used.
Venous stasis
A slowing of blood flow in the veins, which makes a clot more likely to form.
Venous thromboembolism (VTE)
A blood clot that forms in a vein, covering both deep vein thrombosis and pulmonary embolism.

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