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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

on admission.





2) Driver Diagram & PDSA Cycles

3) Results

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

medical team.

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.


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