Venous Thromboembolism Prevention Clinical Care Standard

Assess each patient for VTE risk to determine their need for VTE prophylaxis. Use a standardised, locally endorsed, evidence-based tool or checklist to aid the assessment, for example, the NSW Clinical Excellence Commission (CEC): Adult VTE Risk Assessment Tool51 (see Key considerations on page 14). Ensure the tool includes an assessment of patient and admission-related factors that are known to increase VTE risk (see ‘The contribution of risk factors to developing VTE’ on page 14). Use the best possible medication history (BPMH) obtained as part of the admission process to identify medicines the patient might be taking (including complementary and over-the-counter medicines) that increase the risk of clotting. At the time of the assessment, document the findings on a national standard medication chart (paper or electronic), or where applicable, the patient’s medical record, approved risk assessment form, or other place according to local hospital/unit policy. This will assist all clinicians involved in the patient’s care to be aware that the patient’s risk has been assessed and whether they require VTE prevention

Ensure a multidisciplinary VTE prevention program is in place that facilitates the assessment and documentation of a patient’s VTE risk according to evidence-based guidelines. Ensure a standardised approach to risk assessment is taken by selecting and endorsing an evidence-based tool or checklist for use within the health service organisation, which includes assessment of patient and admission-related factors that are known to increase the risk of VTE (see Key considerations on page 14). Ensure a standardised approach to obtaining a BPMH is also in place to identify any medicines the patient is taking that are associated with an increased risk of clotting. For ongoing quality improvement, ensure that monitoring of, and feedback to clinicians takes place to confirm risk assessments are being conducted in accordance with the tool.

If you are going to hospital, your doctor or another member of your clinical team (such as a nurse or midwife) will conduct a thorough assessment to see what risk you have of developing blood clots during or following your hospital stay. Your risk depends partly on the reason why you are in hospital and the treatment you need to have, and partly on other risk factors you may have. Therefore, you will be asked about the things that can increase your risk including:

• your general health and mobility
• whether you or a family member have had blood clots before
• other health conditions you might have such as cancer, an infection, heart disease (such as heart failure), history of stroke, or whether you are under or overweight
• any medicines you are taking (including over-the-counter and complementary medicines), as some medicines, like an oral contraceptive, can make blood clotting more likely. 

Once your risk of developing blood clots has been assessed, the findings will be recorded so that all the clinicians involved in your care understand what your risk is and whether you need preventive care.

For patients assessed to be at risk of VTE, develop a plan for VTE prophylaxis by balancing the risk of VTE against the risk of bleeding and its potential adverse clinical consequences. Check for other contraindications to VTE prophylaxis before offering it to the patient. Assess bleeding risk using a standardised, locally endorsed evidence-based tool or checklist (see Key considerations on page 18–19). Ensure the tool assesses the admission and patient-related factors that may influence bleeding risk, including the reason for admission, the patient’s comorbidities, bleeding history, and medication history. Use the BPMH52 obtained during the admission process to identify medicines the patient might be taking (including complementary and over-the-counter medicines) that increase the risk of bleeding. See Appendix 1 for a list of medicines that can affect bleeding risk.

Ensure systems are in place so that a patient at risk of VTE has a VTE prevention plan based on an assessment of bleeding risk, which is carefully balanced against the risk of thrombosis, the adverse consequences of bleeding, and contraindications to VTE prevention methods. Ensure a standardised approach to bleeding risk assessment is taken by selecting and endorsing an evidence-based risk assessment tool or checklist for use within the health service organisation. Ensure a standardised approach to obtaining a BPMH is in place to identify any medicines the patient might be taking that are associated with increased bleeding risk. Ensure that monitoring also takes place to identify that VTE prevention plans are developed in accordance with local hospital/unit policy.

If you are assessed to be at risk of developing blood clots, your clinician will develop a clot-prevention plan with you by weighing up your risk of clotting against your risk of bleeding, and what the consequences could be if you unexpectedly bleed. This is important as the medicines used to prevent clots can increase the risk of bleeding in some people and make it harder to stop bleeding if it starts. Your risk of bleeding depends on the reason why you are in hospital and the treatment you need to have, as well as other risk factors you might have that can make you more likely to bleed. Therefore, you will be asked about:

• whether you or a family member have a history of a bleeding disorder or a health condition that may increase your risk of bleeding such as kidney or liver disease, high blood pressure, stroke, or peptic ulcer disease
• whether you have had any recent bleeding (for example, in the last week)
• any medicines you might be taking (including over-the-counter and complementary medicines) as some medicines may increase your risk of bleeding
• whether you have any other conditions where clot-prevention might further increase your risk of bleeding.

Support the patient to have an active role in preventing VTE by providing information and education about: 

• VTE and ways to potentially prevent it tailored to the patient’s risk and in a format they can understand
• the importance of mobilising as soon as possible and remaining hydrated, unless mobility or fluid restrictions are in place
• the findings of their VTE risk assessment and their individual risk factors for developing VTE
• the risks and benefits of VTE prophylaxis, including how it works, correct use, monitoring requirements, available options to manage potential adverse events such as bleeding, precautions to be taken while using prophylaxis, and the potential outcomes if prophylaxis is not used correctly
• the symptoms of VTE and bleeding, how to minimise the risk of these occurring, and what to do if these occur
• any changes to the VTE prevention plan that may be required if their risk factors or clinical condition changes
• other clinicians or resources for further information about VTE and ways to prevent it (see Key facts about VTE for patients on page 22). 

This information is important so that patients can have informed discussions about their VTE prevention plan, especially where there are factors such as bleeding risk, needle-phobia, or other personal beliefs raised by the patient (for example religious beliefs) that may influence the choice of prophylaxis. Ensure the plan for prophylaxis is then discussed with the patient, particularly if there are multiple options available, or specific clinical issues to raise, and document the outcome of the discussion as part of the informed consent process. 

Ensure systems are in place for clinicians to provide patients with information and education about VTE and possible prevention methods, and to support shared decision-making. Ensure information provided to patients covers the risks and benefits of VTE prevention, its correct use, risks associated with its use or misuse, precautionary measures to be taken while using VTE prevention, the symptoms of VTE and bleeding, and what to do if the patient believes these symptoms are occurring. This will support the patient to be engaged in their care and to participate more effectively in decision-making about their VTE prevention plan, which is consistent with the Partnering with Consumers Standard in the NSQHS Standards (2nd ed.).

Your doctor or another member of your clinical team will provide you with information and education about blood clots and explain why you may be at risk. Information about the possible ways to prevent blood clots will be tailored to your risk factors and presented in a format that you understand so that you can share in decisions about your care, and participate in activities to help prevent blood clots forming. 

You will have the opportunity to ask questions and be involved in the development of your clot-prevention plan, which will be based on the results of your risk assessment. Your clinician will also consider the methods you prefer to use to reduce your clotting risk if there are different options available. Methods commonly used to prevent VTE include anti-clotting medicines and/or mechanical methods (such as compression stockings). Information about the different types of prevention methods suitable for you will therefore include:

• the risks and benefits
• correct use
• any monitoring that may be needed
• precautions you should take while using clot-prevention
• the symptoms of blood clots in the leg (such as pain, swelling, or tenderness of the leg or ankle) or lung (such as unexpected shortness of breath or chest pain), or bleeding, and what to do if these occur. 

Unless told otherwise, you will also be encouraged to get out of bed as soon as possible during your hospital stay and to remain hydrated regardless of whether you need anti-clotting medicines or mechanical methods to prevent blood clots. This is because not moving for long periods of time and dehydration can increase your risk of developing blood clots. See Key facts about VTE for patients on page 22 for more information about blood clots and ways to prevent them, including the actions you can take while in hospital.

Once you have discussed the plan for VTE prophylaxis with the patient, document the prevention plan with the results of the risk assessment on a national standard medication chart (paper or electronic), or where applicable, the patient’s medical record, approved risk assessment form, or other place according to local hospital/unit policy. Ensure other clinicians involved in the patient’s care are aware that a prevention plan has been documented so it can be actioned.

Ensure that systems are in place that specify where to document decisions about VTE prevention, and how clinicians will be advised that documentation has occurred. This might include the patient’s medical record, a national standard medication chart (paper or electronic), approved risk assessment form, or other place according to local policy. Monitor documentation procedures to ensure they occur according to local hospital/unit policy.

When your clot-prevention plan has been discussed with you and decided upon, your clinician will document your plan so that all the clinicians involved in your care know what methods of clot-prevention you need.

If medicines and/or mechanical methods are required as part of a patient’s VTE prevention plan, make sure they are used according to a current, locally endorsed, evidence-based guideline, taking into consideration the patient’s clinical condition and the methods of prevention they prefer to use. Provide information and education about the recommended prophylaxis at the time it is initiated to reduce the likelihood of harm associated with its use. This should include the risks and benefits of prophylaxis, how to use it, how long to use it for, possible side effects and how they should be managed, and any associated precautions. Invite the patient to ask questions, and use methods such as teach-back to confirm the patient understands how to use their clot prevention correctly

If medicine is prescribed, document the fact that information and education about the medicine has been provided on a national standard medication chart (paper or electronic), or, if applicable, the patient’s medical record, or other place according to local policy.

Ensure that systems are in place to provide clinicians with access to a current evidence-based guideline about the quality use of medicines for VTE prevention and appropriate use of mechanical prophylaxis, and that usage patterns can be monitored against the guideline for feedback to clinicians and ongoing quality improvement. Ensure that systems support clinicians to provide individualised information and education to patients about their clot-prevention, and that patients have access to ongoing advice when needed. Ensure medicines used to prevent VTE, particularly anticoagulants, are identified within the organisation as high-risk medicines. Oversee their storage, prescribing, dispensing and use according to local high-risk medicines policies, and consider the implementation of stewardship activities, such as audit and feedback, to optimise their safe prescribing and use.

Your clot-prevention plan will be based on current guidelines for VTE prevention. The clot-prevention method that is best for you depends on several factors, including your other health conditions, other medicines you are taking (including all prescribed, over-the counter and complementary medicines), and the methods of prevention you prefer to use. 

Your clinician will provide you with information and education about the specific clot-prevention methods you are using, including their risks and benefits, how they should be used, how long they should be used for, possible side effects and how to manage these, and any precautions you should take while using clot-prevention. You will have the opportunity to discuss your clot-prevention plan with your clinicians, and to ask questions to make sure you understand how to use the prevention methods correctly. Your clinician may also ask you questions to confirm that you understand the information you have been given.

During a patient’s hospitalisation, reassess and document the risk of VTE and bleeding at intervals no longer than every seven days, whenever there is a change in the patient’s clinical condition or goals of care, and on discharge from hospital. Ensure that reassessments also include a review of any VTE-related complications that may have occurred (such as a clot or bleed) and of any medicine-related problems related to the use of medicines to prevent VTE, such as erroneous concomitant prescribing. If VTE risk or bleeding risk changes during the admission, review VTE prophylaxis and adjust in line with a current, locally endorsed, evidence-based guideline and the patient’s preference.

Ensure there are systems in place to support regular reassessment of VTE risk during a patient’s hospitalisation, with intervals no longer than every seven days, whenever there is a change in the patient’s clinical condition or goals of care, and on discharge from hospital. Ensure systems are in place to support monitoring and documentation of complications such as bleeding or thrombosis, or medicine-related problems associated with the use of medicines to prevent VTE.

Your risk of developing blood clots, bleeding, or other problems relating to clot-prevention will be regularly reassessed throughout your hospital stay to make sure you continue to get the care you need. 

If there are any changes to your risk or if you have had any problems because of your clot-prevention (for example a clot or bleed), your doctor or other member of your clinical team will discuss this with you. There may be a need to adjust your clot-prevention plan or to review whether you might be at further risk of clotting or bleeding.

Before a patient leaves hospital, reassess their risk of VTE and bleeding to determine the need for prophylaxis after discharge. Develop a written discharge plan or care plan with the patient and provide them with information about the ongoing care required to prevent VTE. Ensure the plan summarises the reason for the patient’s admission, their risk factors for VTE, any VTE prophylaxis used while in hospital and any ongoing prophylaxis needed on discharge. If the patient needs medicines to prevent VTE following discharge, ensure they are not already taking an anticoagulant for another  

Ensure systems are in place so that clinicians can develop a written discharge plan or care plan prior to a patient’s discharge, and can provide patients with individualised information about the ongoing care that they need before they leave hospital. This should include information about the safe use and disposal of medicines, if they form part of the discharge plan. 

Ensure a multidisciplinary approach to discharge planning is taken, involving a range of clinicians appropriate to the patient’s needs. Ensure there are systems to support communication of the discharge plan or care plan to the patient’s general practitioner or other ongoing clinical provider within 48 hours of discharge, so that there is continuity of care to prevent VTE, and that care can be provided and completed by the ongoing care provider in accordance with the plan to reduce the likelihood of VTE-related complications following hospital discharge.

Before you leave hospital, your doctor or another member of your clinical team will provide you with a written discharge plan or care plan, as well as information and education about the ongoing care you need to help prevent blood clots after you leave hospital.

You will be involved in the development of your plan, which may need to be updated as your condition changes. The plan will summarise the reason why you came to hospital, any clot-prevention methods you received, whether you require clot-prevention blood tests or follow-up appointments after you leave hospital, and a list of any medicines you need to keep taking. You will also be provided with information to ensure you know how to use any medicines safely. 

Your general practitioner or other ongoing clinical provider will also receive a copy of your plan within two days of you leaving hospital so that they can ensure the care you need to prevent blood clots is completed in line with your plan.

• Ensure systems and processes support people to self-report their Aboriginal and Torres Strait Islander status and to record self-identification.
• Ensure all staff engage regularly in cultural safety training.
• Implement the six actions for Aboriginal and Torres Strait Islander Health from the NSQHS Standards.

• Provide flexible service delivery to optimise attendance and help develop trust with individual Aboriginal and Torres Strait Islander people and communities.
• Establish robust communication channels and referral pathways with primary healthcare providers (including Aboriginal Community Controlled Health Organisations [ACCHOs]).
• Where possible, provide outreach services close to home, on Country or in collaboration with ACCHOs or other community healthcare providers.

• Take a collaborative approach to ensure that interventions are suitably tailored to the individual’s personal needs and preferences for care.
• Encourage the inclusion of support people, family and kin or the person’s trusted healthcare provider (such as their ACCHO) in all aspects of care, including decision making and planning treatment and management.
• Engage culturally appropriate interpreter services and cultural translators when this will assist the patient.
• Involve Aboriginal and Torres Strait Islander Health Workers or Aboriginal and Torres Strait Islander Health Practitioners as part of a patient’s multidisciplinary team and involve Aboriginal and Torres Strait Islander Liaison Officers in hospital settings.
• Use culturally and linguistically appropriate materials to aid in communication and discussion, accounting for varying levels of health literacy.

Despite current efforts, evidence suggests that a large proportion of hospitalised patients are at risk of VTE, however many patients do not receive appropriate VTE prophylaxis.^6,7 VTE prevention strategies have been shown to significantly reduce the incidence of VTE by about 70%.

While the incidence of VTE among hospitalised patients is 100 times greater than in the community⁸, the risk of developing VTE also continues after discharge from hospital. Hospitalisation is a major risk factor for VTE, with about 74% of VTE cases occurring up to three months after hospital discharge.⁹

The key clinical guideline in Australia for VTE prevention in hospitalised patients was rescinded in 2016.⁵ The development of the Venous Thromboembolism Prevention Clinical Care Standard was proposed by states and territory health departments as a way of improving the uptake of appropriate VTE prophylaxis strategies.

Read more about the scope and goal of this Standard or see further background in the Venous Thromboembolism Prevention Clinical Care Standard. 

The Standard applies to the following healthcare settings:

• all hospital settings where patients are at risk of developing VTE, including public and private hospitals, day procedure services, and sub-acute facilities such as rehabilitation, palliative care, and mental health units
• general practice and other community settings where ongoing monitoring and reassessment of VTE risk are required to prevent VTE following hospitalisation.

Not all quality statements in this Standard will be applicable to every healthcare service or clinical unit. Healthcare services should consider their individual circumstances in determining how to apply each statement. 

When implementing this Standard, healthcare services should consider:

• the context in which care is provided
• local variation
• quality improvement priorities of the individual healthcare service. 

In rural and remote settings, different strategies may be needed to implement the standard. For example, the use of:

• hub‑and‑spoke models integrating larger and smaller health services and ACCHOs
• telehealth consultations
• multidisciplinary teams including allied health involvement where clinically appropriate.
   

National Safety and Quality Health Service Standards

Monitoring the implementation of Clinical Care Standards helps healthcare services to meet some of the requirements of the:

• National Safety and Quality Health Service Standards (NSQHS Standards) for acute services
• National Safety and Quality Primary and Community Healthcare Standards (Primary and Community Healthcare Standards) for services that deliver health care in a primary and/or community setting.

Find out more about how healthcare services are expected to implement the national standards in How to use the Clinical Care Standards.

The Commission is committed to supporting healthcare services to provide culturally safe and equitable healthcare to all Australians. 

Person-centred care recognises and respects differences in individual needs, beliefs, and culture. The Commission: 

• is committed to supporting healthcare services to provide culturally safe and equitable healthcare to all Australians
• acknowledges that discrimination and inequity are significant barriers to achieving high‑quality health outcomes for some patients from culturally and linguistically diverse communities

Culturally safe service provision and environments are those where the places, people, policies and practices foster mutual respect, shared decision making, and an understanding of cultural, linguistic and spiritual perspectives and differences. Cultural safety is supported by organisations and individuals that recognise cultural power imbalances and actively address them by: 

• ensuring access to and use of interpreter services or cultural translators when this will assist the patient and aligns with their wishes
• providing visual or written information in a language that the patient, their family and carers will understand
• providing cultural competency training for all staff
• encouraging clinicians to review their own beliefs and attitudes when treating and communicating with patients
• identifying variation in healthcare provision or outcomes for specific patient populations, including those based on ethnicity, and responding accordingly.

The Venous Thromboembolism Prevention Clinical Care Standard has been endorsed by 12 key professional organisations and colleges including the Thrombosis & Haemostasis Society of Australia and New Zealand (THANZ), the Royal Australasian College of Surgeons (RACS), the Australian Orthopaedic Association (AOA), and the Australian College for Emergency Medicine (ACEM).

The Standard was presented to and noted by the Australian Health Ministers’ Advisory Council members in June 2018. 

• Arthroplasty Society of Australia
• Australian Collected for Emergency Medicine
• Australian College of Nursing
• Australian College of Rural and Remote Medicine
• Australian Orthopaedic Association
• Australian Physiotherapy Association
• Consumers Health Forum of Australia
• NPS MedicineWise
• The Royal Australasian College of Physicians
• The Royal Australasian College of Surgeons
• The Royal College of Pathologists of Australasia
• The Society of Hospital Pharmacists of Australia
• Thrombosis and Haemostasis Society of Australia and New Zealand.

The Commission develops Clinical Care Standards taking into account:

• advice from multidisciplinary topic working groups which include clinicians, consumers, and researchers
• consultation with key stakeholders including consumer bodies, professional organisations, and state and territory health departments. 

The Venous Thromboembolism Prevention Clinical Care Standard Topic Working Group provided expert advice in the development of the Standard. In addition, a public consultation process was conducted with key stakeholders.

Venous Thromboembolism Prevention Clinical Care Standard - Topic Working Group

The main roles of the Topic Working Group were to:

• advise on the continued scope and key components of care within the Standard
• advise on the key sources of evidence to inform the review.
• advise on revisions to quality statements and supporting indicators
• recommend strategies to support the implementation of the updated Standard
• actively support raising awareness of the updated Standard.

All members are required to disclose financial, personal and professional interests that could, or could be perceived to, influence a decision made, or advice given to the Commission. Disclosures are updated prior to each meeting and managed in line with the Commission’s Policy on Disclosure of Interests.

The quality statements in the Standard are based on the best available evidence and guideline recommendations at the time of development. 

Further information is available on the evidence sources underpinning the Standard.

Venous Thromboembolism Prevention Clinical Care Standard - Evidence Sources

The burden of venous thromboembolism in Australia

The references below are not a complete list of references for the Standard. A full reference list is published in the Venous Thromboembolism Prevention Clinical Care Standard which can be downloaded here.

1. Access Economics Pty Ltd for the Australia and New Zealand working party on the management and prevention of venous thromboembolism. The burden of venous thromboembolism in Australia, 1 May 2008. Access Economics Pty Ltd; 2008.
2. Cohen AT, Tapson VF, Bergmann J-F,Goldhaber SZ, Kakkar AK, Deslandes B, et al.Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet. 2008;371(9610):387–94.
3. Kahn SR, Panju A, Geerts W, Pineo GF, Desjardins L, Turpie AG, et al. Multicenter evaluation of the use of venous thromboembolism prophylaxis in acutely ill medical patients in Canada. Thromb Res. 2007;119(2):145–55.
4. Tapson VF, Decousus H, Pini M, Chong BH, Froehlich JB, Monreal M, et al. Venous thromboembolism prophylaxis in acutely ill hospitalized medical patients: findings from the International Medical Prevention Registry on Venous Thromboembolism. Chest. 2007;132(3):936–45.
5. National Health and Medical Research Council. Clinical practice guidelines for the prevention of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to Australian hospitals (rescinded 2016). Melbourne: NHMRC; 2009.
6. Assareh H, Chen J, Ou L, Hillman K, Flabouris A. Incidences and variations of hospital acquired venous thromboembolism in Australian hospitals: a population-based study. BMC Health Services Research. 2016;16:511.
7. Cohen A, Tapson V, Bergmann J-F, Goldhaber S et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. The Lancet. 2008; 371:387-394.
8. Heit JA, Melton LJ, III, Lohse CM, Petterson TM, Silverstein MD, Mohr DN, et al. Incidence of venous thromboembolism in hospitalized patients vs community residents. Mayo Clinic Proceedings. 2001.76(11):1102-10.
9. Spencer FA, Lessard D, Emery C, Reed G, Goldberg RJ. Venous thromboembolism in the outpatient setting. Archives of Internal Medicine. 2007;167(14):1471-5.