Shared learning database

Type and Title of Submission


Implementation of Department of Health Guidance relating to thromboprophylaxis and anticoagulation


A trust-wide piece of work to implement the guidance published in 2007 from NICE, the NPSA and the DoH commons health select committee to improve the management of thromboprophylaxis and anticoagulation.



Does the submission relate to the general implementation of all NICE guidance?


Does the submission relate to the implementation of a specific piece of NICE guidance?


Full title of NICE guidance:

CG46 - Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery

Category(s) that most closely reflects the nature of the submission:

Implementation policy
Terms of reference for implementation team
Audit tool

Is the submission industry-sponsored in any way?


Description of submission


The aim was to review the guidance, agree recommendations and implement across the trust the three pieces of national guidance published in March and April 2007, relating to anticoagulation and thromboprophylaxis: 1. NICE clinical guideline 46 2. National Patient Safety Agency, patient safety alert no.18, 'Actions that can make anticoagulant therapy safer' 3. Department of Health 'report of the independent expert working group on the prevention of venous thromboembolism in hospitalised patients'.


1. Review the three pieces of guidance 2. Review and agree the resources required to implement the guidance 3. Decide how to implement and audit compliance with the guidance


There was no trust wide policy for thromboprophylaxis and patients were not being risk-assessed. Although policies and guidance were provided for anticoagulation staff had little awareness of them. There was no support for the anticoagulant clinic which was consultant led. A number of patient complaints, clinical incidents and serious untoward incidents had involved poor anticoagulation or the lack of thromboprophylaxis. The consultant haematologists had in the past tried to address these issues without success. Some audit had been carried out but had led to little change.


1.1 An Anticoagulant Working Group was convened with a wide membership from medical, nursing, laboratory, pharmacy, audit, I.T., education and clinical governance staff. 1.2 The Group was chaired by the medical director and reported to the Clinical Governance Committee. 1.3 There were 3 subgroups - one for each piece of guidance. The subgroups reviewed the guidance and reported back to the main group which formulated the overall actions required. 2.1 The guidelines on anticoagulation were reviewed and updated and guidance on thromboprophylaxis was produced. 2.2 Patient information was provided - leaflets on thromboprophylaxis and signs of VTE, the NPSA anticoagulation patient information packs, video on warfarin shown in the ancticoagulant clinic. 2.3 Reviewed the anticoagulant clinic procedures - new referral form, patient change of circumstance form 2.4 Standardised anticoagulant drugs - heparin and LMWH 2.5 Promoted safe prescribing practices - new prescription chart with specific sections for thromboprophylaxis and anticoagulation. 2.6 Audit plan developed 2.7 Reviewed resources required - computerised dosing software support, staff training and competency assessment, audit support, anticoagulant practitioner 3.1 Circulated the new guidelines 3.2 Desk top alert for thromboprophylaxis on all PCs in Trust 3.3 Training programme for junior doctors 3.4 Posters on thromboprophylaxis on all the wards 3.5 Risk assessment tool for surgical pre-assessment 3.6 Funding for RaidPro anticoagulant dosing software and 0.5WTE anticoagulant practitioner.

Results and evaluation

1. Regular updates on progress against action plan for implementation of NICE clinical guideline no.46 and NPSA patient safety alert no.18 2. Written reports on progress for the Clinical Governance Committee from the Anticoagulant Working Group 3. Audit programme developed for anticoagulant clinic documentation patients with INRs >5.0 complications in patients on anticoagulants LMWH thromboprophylaxis patients on anticoagulants undergoing surgery 4. Trust Thrombosis Committee (part 2 of Trust Hospital Transfusion Committee) to oversee ongoing implementation and audit 5. Risk assessment on how trust is doing carried out and sent to Clinical Risk Management Committee for inclusion in trust risk register

Key learning points

1. Sense of achievement and excellent team working 2. 80% of actions completed by March 2008 3. Audit programme set up by linking to junior doctors foundation training 4. Need high level trust support for success 5. Set up a multidisciplinary team with representation from key stake holders 6. Try to achieve the main objectives within a short timescale to maintian enthusiasm. 7. Do as much as you can within current resources to show commitment before asking for more resource. 8. Produce an action plan and report back on progress at regular intervals to a high level trust committee. 9. Publicise ahievements and progress 10. Use technology to help achieve your aims - for audit, distributing guidelines, encouraging implementation 11. Risk assess areas of non-implementation and alert trust management 12. The most difficult things to implement are those requiring extra staffing - try to get round this - utilise current staff in different ways, use technology, find champions in the trust to push your requirements 13. Training and competency assessment are very difficult to implement because they require a large staffing resource.

View the supporting material

Contact Details

Name:Dr. Janet Shirley
Job Title:Consultant Haematologist
Organisation:Royal Surrey County Hospital NHS Trust
Address:Egerton Road
Postcode:GU2 7XX
Phone:01483 464027
Fax:01483 464072


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This page was last updated: 09 September 2008

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Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.

Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.