Endorsed scope - Queensland Health

Translating evidence into best clinical practice
Exclusions:
Investigation and diagnosis of VTE in pregnancy and/or the puerperium
Acute management of VTE occurring in pregnancy and/or the puerperium
Table 3. Existing outcomes measures used in clinical audit for VTE
VTE outcome measures
Source
Clinical audit standards*
Australian
Council of
Healthcare
Standards:
Obstetric
indicators
Royal College of
Obstetricians
and
Gynaecologists:
Green-top
Guideline 37a
(2004)
Indicator Area 6: Pharmacological thromboprophylaxis and caesarean section:
CI. 6.1 Numerator: Total number of high risk women undergoing caesarean section who receive
appropriate pharmacological thromboprophlylaxis
Denominator: Total number of high risk women undergoing caesarean section
Thromboprophylaxis during pregnancy, labour and after vaginal delivery
Proportion of women with previous venous thromboembolism who undergo screening for
thrombophilia
Proportion of women with previous venous thromboembolism who receive six weeks postnatal
Low Molecular Weight Heparin
Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary
embolism) in patients admitted to hospital
National
Institute for
Health and
Clinical
Excellence:
Guideline CG92,
Audit support
Selected items for ‘All patients:
Criterion 1: Was the patient assessed for risk of VTE on admission?
Criterion 2: Was the patient assessed for risk of bleeding before being offered
pharmacological VTE prophylaxis?
Criterion 3: Was the risks of bleeding and VTE reassessed within 24 hours of admission?
Criterion 4: Was there evidence that the patient was encouraged to mobilise as soon as
possible?
Criterion 7: How long after the risk assessment was completed was pharmacological VTE
prophylaxis started?
Criterion 8: Was pharmacological VTE prophylaxis stopped when the patient was no longer at
increased risk of VTE?
Selected items for ‘Surgical patients’:
Criterion 9, 11, 13, 17, 18: Does the patient fall into any of the following categories, if so, was
the patient offered mechanical VTE prophylaxis?:
Has had a surgical procedure with a total anaesthetic and surgical time of more than 90
minutes, or 60 minutes if the surgery involves the pelvis or lower limb
Expected significant reduction in mobility
Acute surgical admission with inflammatory or intra-abdominal condition
One or more of the following risk factors:
Active cancer or cancer treatment
Critical care admission
Dehydration
Known thrombophilias
Obesity (BMI over 30 kg/m2)
One or more significant medical co-morbidities
Personal history or first-degree relative with a history of VTE
Use of hormone replacement therapy
Use of oestrogen-containing contraceptive therapy
Varicose veins with phlebitis
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