Increasing VTE Risk Assessment Compliance on a Surgical Ward
Catriona Tweed, Fionnuala Daly, Catherine Diver ENT/Head and Neck Cancer Unit
Venous Thromboembolism (VTE) is the number one cause of preventable death in hospitals, with 60% of all cases occurring during
or after hospitalisation. It has been well recognised for a number of years that the formation of thrombi is associated with
inactivity and surgical procedures - the risk increasing with the duration of the operation and the period of immobility.
Being a surgical unit, we should have a heightened awareness of completing VTE Risk Assessments for our patients to keep them
safe throughout the duration of their stay.
To increase VTE Risk Assessment Compliance to 95% on a surgical inpatient ward by November 2020.
1) Baseline Data
In 2019 our numbers of VTE Risk Assessments
completed had dropped to 65% as per the Belfast Trust
Audit. We started to complete our own audits to analyse
the data and quickly found out the reason for this result.
It was clear that the pre-assessed short stay surgical
patients did not have a VTE Risk Assessment completed
2) Driver Diagram & PDSA Cycles
PDSA Cycle 1 Awareness Sessions helped increase VTE
compliance but the turning point in the project was PSDA Cycle
2 Clarifying Roles and Responsibilities of the medical team and
identifying who is responsible for completing the VTE Risk
Assessment for the short stay pre-assessed patients.
Our change ideas all stemmed from an awareness of our
baseline VTE audit results and discussion on what process
needed to change.
4) Learning and Next Steps
Historically changing a culture is the hardest to implement in
Quality Improvement and the challenge of questioning current
practise can be difficult to address with an established team.
We had this challenge but having senior medical staff invested
in the project helped when introducing changes among the
We plan to maintain a high level of compliance in the future
and instrumental to that would be focusing on providing
awareness for the doctors changeover twice a year.