Quality Account 2010/11 - James Paget University Hospitals

Metric 3 – Venous Thromboembolism (VTE)
An all Party Parliamentary Thrombosis Group in 2005 estimated there were 25,000
preventable deaths per annum nationally due to VTE.
Local Improvement Aim (and CQUIN)
1. 90% of patients receive an admission VTE risk assessment.
2. 80% of inpatient and obstetric patients receive appropriate thromboprophylaxis.
Current Position:
VTE Risk Assessment Compliance Rates 2010/11
100
90
80
70
% Compliance
60
50
40
Monthly Compliance
Trajectory %
30
20
10
0
Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11
Month and Year
Data collected from medication charts indicates a consistent achievement of between 90-
95% compliance with appropriate thromboprophylaxis prescribing.
Successes:
• The Trust has achieved VTE Exemplar Site status
• Bespoke IT system developed to register risk assessment completion
• Inclusion of VTE on induction and mandatory training
• General raised awareness of VTE
• Attendance at external training attendance
Concerns:
• Delays in registration of risk assessment
• Variation in compliance with risk assessment completion
• Process for supporting Waveney GPs when patients are transferred to Lowestoft
Hospital
• Lack of resources within Patient Safety Team to support implementation of remaining
NICE VTE Quality Standards.
James Paget University Hospitals NHS Foundation Trust
Quality Account 2010/11 Page 34 of 62