In April 2007, the CMO published the expert working group report on the prevention of VTE in hospitalised patients and NICE issued guidance on reducing the risk of VTE in inpatients undergoing surgery. Both reports contained an explicit recommendation that all hospitalised patients are assessed for their risk of thrombosis and that risk assessment was firmly embedded in Trust or other Institutional risk management frameworks, with core standards set by the Department of Health.
In September 2008 the Chief Medical Officer released the national VTE risk assessment template. Authored by the VTE Implementation Working Group in consultation with the main stakeholders in VTE, this risk assessment template was a useful evidence-based tool to raise awareness and guide the risk assessment process.
In January 2010, NICE published guidance setting out how patients should be risk-assessed for VTE. The recommendations take into account the potential risks of the various options for prophylaxis and patient preferences. This guideline updates NICE clinical guideline 46 on VTE prevention after surgery and replaces it.
A revised Department of Health (DH) national VTE risk assessment tool was published in March 2010; this forms a key component of the implementation phase of the National VTE Prevention Programme. This is the tool that is referenced in the CQUIN document and sets out the criteria for VTE risk assessment that the DH expects all Trusts to employ.
The next phase of the Programme will amplify the importance of VTE prevention and continue the development of resources to support the NHS.
VTE prevention is one of two nationally mandated goals in the Commissioning for Quality and Innovation Payment Framework (CQUIN) for 2010-11. A proportion of acute CQUIN payments will be conditional on providers enabling NHS Trusts (in England) to earn a percentage of money set aside for work that meets quality and innovation standards if they meet a minimum target of risk assessing at least 90% of hospitalised patients.
From 1 April 2010, trusts will be reporting the data they collect on risk assessments that have been carried out. As well as ensuring uptake of risk assessment procedures, this will also support the National VTE Prevention Programme by providing a national picture so that any work can be appropriately targeted.
These commissioning arrangements for VTE prevention are enhanced in the national contracting process in 2010/11. Acute hospital Trusts will be required to report to the lead commissioner through monthly audits of the percentage of patients receiving appropriate prophylaxis after risk assessment using the national tool.
A root cause analysis of all confirmed cases of hospital-acquired of VTE will be required from every acute hospital -an approach proven to be of particular importance in the reduction in rates of hospital-acquired infection.
These measures will be accompanied by challenging work on the improvement of the utility of measures of outcome, such as discharge coding of VTE and development of the health economic rationale for VTE prevention.
