Venous Thromboembolism Policy ( VTE Policy ) - Reducing avoidable harm

Publication: 04/03/2014  --
Last review: 04/03/2020  
Next review: 30/04/2022  
Clinical Policy
ID: 3713 
Supported by: Trust Thrombosis Steering Group
Approved By: Executive Team 
Copyright© Leeds Teaching Hospitals NHS Trust 2020  


This Clinical Policy is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Reducing avoidable harm from Venous Thromboembolism Policy (VTE Policy)

  1. Purpose and Objectives
  2. Background
  3. Definitions
  4. Policy Effect
  5. Roles and Responsibilities
  6. Equality Impact Assessment
  7. Consultation and review
  8. Standards/Key Performance Indicators
  9. Monitoring Compliance
  10. References

Staff Summary

This policy serves the purpose of supporting staff in understanding how they can reduce avoidable harm from venous thromboembolism (VTE) for patients managed by Leeds Teaching Hospitals.

Venous thromboembolism has the potential to cause either mortality or long term morbidity. Prevention is the best strategy to minimise this.

This policy documents how Leeds Teaching Hospitals implements risk assessment of adult hospital in patients and day cases for venous thromboembolism, using national and locally approved guidelines. Risk assessment leads to logical prevention strategies for every eligible patient, also underpinned by national and local guidelines.

This policy also covers how LTH will minimise harm to patients by ensuring prompt diagnosis and treatment of VTE in line with NICE guidance. Prevention and treatment processes are summarised below in flowcharts 1 and 2.

All LTH clinical staff are required to follow this policy. Roles and responsibilities are set out in detail in this document. Prevention of VTE is part of mandatory training in LTH and all clinical staff should ensure their mandatory training is up to date.

Staff should consult the VTE resource page on the Intranet for detailed guidance.

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Flow Chart 1: VTE Prevention

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Flow Chart 2: Investigation and Initial Management of VTE

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1. Purpose and Objectives

The purpose of this policy is to ensure that all patients receiving an episode of healthcare within the Trust undergo an appropriate VTE risk assessment and are subsequently managed appropriately to minimise the risk of VTE.

Patients staying in hospital will be re- assessed as regularly as their clinical condition dictates.

Patients who develop a VTE will be diagnosed promptly and treated according to best clinical practice.

The impact of the policy is to ensure Patient Safety and compliance with NICE Guidelines and Quality Standards.  It also supports the implementation of emerging national initiatives and goals to deliver better outcomes for patients.

The objective of this Policy is to reduce avoidable morbidity and mortality associated with VTE.

Failure to follow this policy could result in the instigation of disciplinary procedures

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2. Background

Pulmonary embolism is a common cause of sudden death in hospitalised patients and therefore prevention is important. Deep vein thrombosis (DVT) and pulmonary embolism (PE) are collectively known as venous thromboembolism (VTE).

In 2005 the Chief Medical Officer (CMO) wrote to NHS organisations highlighting the risks of venous thromboembolism and the benefits of prophylaxis. National policy has been developing since then with a National Commissioning for Quality and Innovations Framework (CQUIN) standard for VTE from 2010 - 2014. Since 2014 VTE has been included in the nationally-mandated Quality Requirements.

The policy is based on NICE CG92 Venous Thromboembolism-Reducing the Risk and NICE CG144 Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing; and incorporates the NICE Quality Standard for VTE Prevention and Treatment.

The Policy aims to underpin a systematic approach across the Trust to individual patient risk assessment and diagnosis and initial treatment of VTE. The development of local Guidelines which support compliance with National Standards also promotes best practice in patient safety and supports improved patient outcomes.

The Policy supports the requirements of the NHS Standard Operating Framework goals, NICE Quality Standards, NHS Litigation Authority Risk management standards and Commissioning for Quality and Innovations Framework standard.

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3. Definitions


Venous Thromboembolism (VTE) is a condition in which a blood clot (thrombus) forms in the veins. Venous Thrombosis commonly occurs in “deep veins” in the legs, thighs or pelvis. This can cause DVT or PE.

Deep Vein Thrombosis (DVT) is the formation of a blood clot in a deep vein.

Pulmonary Embolism (PE) is where a clot from the deep vein of the legs breaks off, moves and causes a blockage of the main artery of the lung or one of its branches.

Healthcare Associated Thrombosis (HAT) is the development of DVT or PE following a recent episode of healthcare.

Root Cause Analysis (RCA) is a form completed for patients with a positive diagnosis of DVT or PE, if the patient has been in hospital for > 24 hours or has had a general or regional anaesthetic and the VTE occurred during admission or within 90 days of discharge.  The investigation and RCA findings are used to determine whether the VTE may be associated with the hospital care and aims to identity if additional measures could be taken to reduce the risk of occurrence further.

Thromboprophylaxis is a measure aimed at reducing the risk of blood clots forming in veins which includes mechanical and chemical thromboprophylaxis.

Mechanical Thromboprophylaxis includes devices such as Anti- Embolism Stockings (AES); intermittent pneumatic compression (IPC) devices, Geko devices and venous foot pumps. All increase venous outflow to reduce stasis within the leg veins.

Chemical Thromboprophylaxis is when a pharmaceutical intervention is used to decrease the clotting ability of the blood.

VTE Risk Assessment - an approach or a tool used prior to or at the start of an episode of healthcare to assess an individual patient’s balance of risk in developing a VTE or suffering from unwanted bleeding. The risk assessment is used to help determine the best approach to thromboprophylaxis for each individual.

Cohort Risk Assessment - The "cohort approach" allows Medical Directors (local and national) to make a clinical decision regarding a group of patients admitted for the same procedure.  These will be for patients who are felt to have a similar risk profile and are assessed as a group as being at low risk of VTE regardless of individual risk factors.  This is done using the DH/NICE risk assessment categories and detailed NICE guidance.

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4. Policy Effect

4.1       Identifying patients at risk of VTE

The Trust approved Risk Assessment documentation is available for reference through the VTE resource pages

A VTE risk assessment must be completed for all adult patients (aged 16 years or over) who are admitted to hospital or receiving day case interventional care.

The VTE risk assessment tool is available in electronic format which is accessible through PPM+. When the form is completed the symbol in the VTE column on the electronic whiteboard will automatically change to a green tick to show the risk assessment has been completed.

The initial VTE risk assessment must be completed within 24 hours of admission. It is important to reassess patients during their inpatient stay this should be done 24 to 48 hours after admission, at consultant review and if the patient’s clinical condition changes. When the risk assessment has been completed the symbol on the e-whiteboard will change to an amber exclamation mark after 24 hours highlighting the need to repeat the risk assessment. Relevant risk factors, compliant with National Guidelines, are included in all LTHT risk assessment tools. The identification of one or more VTE risk factors or bleeding risks should prompt careful consideration of thromboprophylaxis according to local guidelines. The details of speciality based guidelines should form part of a local induction package for clinical staff.  Reference can be made to the detailed documents within the clinical area or through the VTE resource pages of Leeds Health Pathways at:


4.2       Patient Information

Most patients admitted to hospital will receive a written standard patient information booklet called “Preventing blood clots (Deep vein thrombosis and pulmonary embolism)” Information for patients. The booklet contains information relevant to all patients giving advice pertinent to the patient prior to admission, during admission and following discharge from hospital.

This is available in a standard printed format on all wards and admissions areas and can be viewed through the VTE resource pages of Leeds Health Pathways at:

Patients with active cancer should receive a copy of the patient information booklet “Cancer and blood clots. What you should know when you are in hospital” Information for patients. The booklet contains information relevant to cancer patients giving advice pertinent to the patient prior to admission, during admission and following discharge from hospital.

This is available in a standard printed format on all oncology/haematology wards and admissions areas and can be viewed through the VTE resource pages of Leeds Health Pathways at:

Pregnant patients should receive a copy of the patient information booklet “Preventing blood clots in pregnancy”. Information for patients. The booklet contains information relevant to pregnant patients giving advice pertinent to the patient prior to admission, during admission and following discharge from hospital.

This is available in a standard printed format on all maternity wards and admissions areas and can be viewed through the VTE resource pages of Leeds Health Pathways at:

All written information is supported by a conversation with a healthcare professional.  The professional will ensure that a patient (and his/her carer, if appropriate) has received information on, and understood, what can be done to reduce the risk of VTE. This includes ensuring appropriate mobilisation, movement and hydration.

All the VTE leaflets are available on the LTHT website; if the leaflet is needed in a different format or language it must be printed off and given to the patient unless the patient prefers to read it online.


4. 3      Thromboprophylaxis to reduce the risk of VTE

These measures usually consist of the use of mechanical methods and/or pharmacological methods (usually low molecular weight heparin prescribed in prophylactic doses)

Detailed resources are available in clinical areas or through the VTE resource pages of Leeds Health Pathways at:

Anti Embolism Stockings (AES):

These are used in both medical and surgical patient pathways.  When AES are required it is essential that the patient is measured to ensure the appropriate size of stocking is used. Detailed Guidelines and AES care plan tools are available as printed documents in ward areas or through reference to the VTE resource pages detail.aspx?id=2435

Alternative Mechanical devices:

The use of intermittent pneumatic compression (IPC) and Geko devices are recommended in some speciality guidelines. When IPC or Geko devices are required it is essential that they are fitted and used by trained personnel and that the equipment is appropriately managed.

Low molecular weight heparins:

These medicines are the mainstay of pharmacological thromboprophylaxis in the Trust. The actual product used is detailed within the Speciality Guideline. Choice is also supported through details in the Trust Net Formulary and in Frequently Asked Question guides.

Extended thromboprophylaxis with either a low molecular weight heparin or an oral anticoagulant licensed for VTE prophylaxis (e.g. Rivaroxoban) is incorporated within certain speciality guidelines e.g. elective total hip or knee arthroplasty and general surgery guidelines.

Cancer patients:

Patients with cancer have a significantly elevated risk of VTE.

Inpatient stays for patients with cancer are managed according to a Guideline “VTE Prophylaxis for Patients with Cancer”. detail.aspx?id=2032

General measures:

Where possible, all patients should undergo early mobilisation or regular leg exercises for those unable to mobilise. Patients should be adequately hydrated and regularly reviewed.

Regional anaesthesia may reduce the risk of VTE compared to general anaesthesia.  Therefore, appropriate guidelines incorporate a standard approach to the management of patients undergoing regional anaesthesia and the planning of appropriate methods and timing of thromboprophylaxis


4.4       Procedure to be followed if VTE is suspected or a diagnosis confirmed

The management of any patient who is suspected to have a deep vein thrombosis (DVT) or Pulmonary embolism (PE) will follow a standard clinical diagnostic assessment involving appropriate investigations. Details are available in the “Guideline for Investigation and initial management of venous thromboembolism (VTE) in Leeds Teaching hospitals (LTH)”


If required a standard low molecular weight heparin or unfractionated heparin based treatment regimen will be initiated on suspicion of VTE unless contra-indicated due to bleeding risk factors.

The acute medical assessment areas at LTHT manage patients presenting acutely with suspected deep vein thrombosis and suspected pulmonary embolism according to a standard protocol. This is used as an individual patient booklet format to ensure a standard pathway of care and forms part of the patient’s medical record. It is available for reference through the Leeds Emergency Medicine Information Bank 'EMIBank' website on the Trust intranet http://lthweb/sites/emibank

If a DVT or PE is confirmed the patient will require ongoing anticoagulation unless contra-indicated “Guidance on the use of treatment dose low molecular weight heparins to treat venous thromboembolism in adults” detail.aspx?ID=3212 and “Guidance for Starting and Maintaining Adult Patients on Anticoagulants” are available through the VTE resource pages detail.aspx?ID=1409 and additional detailed medicinal product information is available through the standard resource of the NetFormulary

There are also specific Guidelines for the Treatment of patients with Cancer Related Venous Thromboembolic Disease (VTE Adults) and pregnancy related VTE. All documents are available in the relevant clinical location or through reference to the VTE resource pages

4.5       Staff Education and Training

Training and awareness raising in relation to VTE management and risk assessment is contained within the Trust Mandatory Training Policy http://hub/Policies/Documents/Forms/AllStaff.aspx?Paged=TRUE&p_FileLeafRef=Information%20Governance%20Policy%2edoc&p_ID=125&PageFirstRow=61&&View={28AD0E5C-D7E8-4520-B7CF-2008E9D99BFF}.

VTE Training at local and corporate induction is provided to all clinical staff including all Medical and Dental staff, Nursing/Midwifery staff and Pharmacists.  Induction information provided to temporary, bank, agency, Honorary contract, seconded and locum staff includes information on VTE prevention and identifies local procedure and information needs

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5. Roles and Responsibilities

5.1 Executive Lead

The Trust Chief Medical Officer is the Executive lead for VTE Prevention who will report to the Trust board as required.

5.2 Management Responsibilities

Clinical Directors - CSUs 

The Clinical Directors are responsible for:

  • ensuring that Specialties in their CSU are achieving the agreed VTE goals 
  • receiving assurance of local performance in compliance with the NICE Preventing VTE Quality Standards  
  • ensuring there is a CSU approach to the assessment of hospital associated thrombosis (HAT) and learning from root cause analysis (RCA)  
  • The Clinical Director will work closely with clinical colleagues to ensure that:
    • appropriate speciality guidelines are made available through the Leeds Health Pathways resource;
    • local audit of speciality VTE pathways are undertaken as part of the Trust annual audit programme;
    • appropriate multidisciplinary review of healthcare associated thrombosis (HAT) occurs and learning from root cause analysis is shared across specialities and the CSU;
    • Performance monitoring criteria are agreed and reported as part of their performance discussions e.g. documented risk assessment, frequency of HAT, completed RCA investigations, completed VTE audits and Guideline development. 

Lead Clinicians

CSU Lead Clinicians are responsible for:

  • ensuring that all medical staff comply with the content of this policy.
  • ensuring that all medical staff follow other related policies and guidelines to enable appropriate assessment of VTE/bleeding risk in all patients who are admitted to LTHT.
  • ensuring that all medical staff follow guidelines for investigation and initial management of VTE.
  • monitoring the Specialty achievement of the agreed VTE goals and lead improvement plans as required 
  • ensuring performance in all aspects of VTE best practice is monitored and improved by working with CSU Clinical Director
  • overseeing the speciality performance of the investigation and shared learning derived from RCA of hospital associated VTE instances
  • leading the development and maintenance of appropriate prophylactic Guidelines and/or CSU specific documentation.
  • ensuring the implementation locally of guidelines for investigation and treatment of VTE.
  • ensuring that relevant prevention/treatment audits occur within the Specialty and results are acted upon to support improvement 


The Thrombosis Steering Group

The Chair of the Thrombosis Steering group will be an appointed clinical leader responsible for collating CSU performance and information relating to Trust wide preventative action and learning.

The Chair will work with a vice chair and group members from across the CSUs to:  

  • support and direct data collection and performance monitoring criteria
  • review and advise on data submission required Regionally or Nationally
  • designate and monitor patient cohort risk assessment groups, in line with the Department of Health recommendations.  
  • lead multi professional audit of the use of thromboprophylaxis
  • coordinate the learning obtained from the VTE related RCA processes
  • promote best practice through local documents based on National Guidelines.
  • ensure Trust wide Policies and procedures are up to date, communicated and monitored and encompass the prevention, diagnosis and treatment of VTE.
  • lead effective meetings consistent with the requirements of the Trust Clinical Governance  framework and collate and review assurance reports
  • be responsive to relevant current and emerging Patient Safety and Quality Standards and promote appropriate education and training


CSU Head of Nursing

The CSU Head of Nursing will ensure that nursing staff are aware of their responsibilities relating to this policy, that they are trained and that the policy can be applied in every day practice.


The Matron will:

  • monitor local performance and ensure systems are in place within clinical areas which support adherence to all aspects of this policy and associated patient safety and quality standards
  • support the implementation of Speciality Guidelines by providing leadership to all staff working in their clinical area
  • support the Lead Clinician in the speciality performance management of the investigation and shared learning derived from RCA of Hospital Associated VTE instances

Clinical Director of Medicines Management and Pharmacy

The Clinical Director of Medicines Management and Pharmacy will:

  • through the Consultant Pharmacist Anticoagulation and Thrombosis, oversee all medicines management
  • aspects of VTE prevention and treatment standards ensure pharmacy staff are appropriately trained and follow policy and associated guidelines.

Trust Chief Medical Officer

The Trust Chief Medical Officer is responsible for any agreement within a speciality to undertake a cohort approach

5.3 Duties and Responsibilities of Clinical Teams


  • are responsible for ensuring that all patients admitted to LTHT under their care receive an initial risk assessment for VTE and bleeding risk and that appropriate thromboprophylaxis is instigated as clinical need dictates. It is the prescriber’s responsibility to ensure that the correct thromboprophylaxis regimen is initiated. Guidance can be found on the intranet  resource pages at . 
  • will ensure that medical staff are appropriately trained to enable them to follow relevant speciality guidelines, instigate appropriate thromboprophylaxis measures and complete all necessary documentation.  
  • are responsible for ensuring that there is a robust local procedure to ensure thorough documentation of risk assessment and clinical decision making and risk assessment is followed by appropriate prophylaxis where indicated. 
  • will ensure all patients under their care are monitored regularly and that their VTE/bleeding risk status is re-assessed as clinically indicated and acted upon. 
  • will ensure that audits of compliance with this policy are undertaken as agreed within their speciality. 
  • must participate in RCA investigations when patients under their care may have developed a hospital associated thrombosis (HAT). 
  • will follow local guidelines for initial investigation and treatment when VTE is suspected 
  • work to ensure NICE Quality standards (VTE-prevention and treatment) are met 


Registered Nurses/Midwives:

  • will work as part of the multidisciplinary team to ensure that all adult patients admitted to LTHT have had a VTE risk assessment on admission and that a risk assessment has been documented as clinical need dictates.  Support can be found at the VTE resource pages  
  • are responsible for monitoring patients throughout their inpatient stay and ensuring they are reassessed if the medical condition changes
  • are responsible for ensuring patients have received and understood verbal and written information on VTE and reducing their risk. In line with the Interpreting and Translation Policy, this includes ensuring the information is provided in a format and language which meets any specific communication needs of the patient.


Ward and Clinical Area Managers:

  • are responsible for ensuring that an agreed and implemented process within their clinical area ensures all patients receive the appropriate VTE risk assessment.
  • are responsible for ensuring that the above is documented and appropriate interventions are given to the patient
  • are responsible for ensuring that documents and resources relating to risk assessment and  thromboprophylaxis regimens applicable to their clinical areas are available, particularly if the intranet or Leeds Health Pathways is inaccessible.  
  • must participate in appropriate RCA investigation of healthcare associated VTE.


  • will work as part of the multidisciplinary team to ensure that patients are appropriately risk assessed and will advise on the optimum pharmacological intervention suitable for the individual.
  • will check that all the patients they review have undergone an initial assessment of their risk for VTE/bleeding, ensure this is documented and when necessary advise colleagues  regarding appropriate intervention.
  • will ensure that a patient is appropriately monitored throughout their care and will highlight to the responsible clinician if reassessment may be required.
  • will participate in RCA investigation of HAT as required.
  • support speciality leads in the development of guidelines, audit tools and medicines management improvement strategies as required.

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6. Equality Impact Assessment

This policy has been assessed for its impact upon equality. The Equality Analysis can be seen in annex 1."The Leeds Teaching Hospitals Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflect individual needs, promote equality and does not discriminate unfairly against any particular individual or group.

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7. Consultation and review

The NICE Clinical Guideline 92 was published in January 2010 (updated June 2015). Since then there have been a number of initiatives led by the Patient Safety work stream for VTE Prevention and later by the Trust Thrombosis Steering Group that have put guidelines and processes in place to action the best practice recommendations. There has been extensive consultation, awareness raising events and communication about these initiatives. NICE CG144 was published in June 2012. In response to this, local LTH Guidelines on Initial Investigation and Management of VTE have been prepared after consultation with stakeholders. This Policy reflects the approaches already agreed.

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8. Standards/Key Performance Indicators

  • 95% of patients 16 years and over are risk assessed on admission
  • 100% of patients requiring an RCA for hospital associated VTE have one completed
  • 90% of patients audited are on appropriate thromboprophylaxis
  • 90% of patients with a suspected VTE have imaging within 24 hours from receipt of radiology request

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Record: 3713
Clinical condition:

Venous Thromboembolism

Target patient group: Patients at risk of VTE
Target professional group(s): Pharmacists
Secondary Care Doctors
Secondary Care Nurses
Allied Health Professionals
Adapted from:

Evidence base

10. References

Scottish Intercollegiate Guidelines Network (SIGN), Prophylaxis of Venous Thromboembolism. A National Clinical Guideline. October 2002

Health Committee Report Prevention of VTE in hospitalised patients March 2005

Report of the independent expert working group on the prevention of venous thromboembolism in hospitalised patients. Department of Health, A report to Sir Liam Donaldson, Chief Medical Officer. 2007

All-party parliamentary thrombosis group Thrombosis: Awareness, Management and Prevention November 2007 and APPTG Annual Audit reports 2008 & 2009.

NICE Clinical Guideline 46 Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery 2007

Safer Anticoagulant Therapy Alert 18 National Patient Safety Agency March 2007

National Risk Assessment Tool Sept 2008

NICE Clinical Guideline 92 Venous thromboembolism: reducing the risk. Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. January 2010, updated June 2015

Revised National Risk Assessment Tool Guidance 2010

Reducing treatment dose errors with LMWH: National Patient Safety Agency RRR10/004

White Paper High Quality Care for All

The NHS Standard Operating Framework 2011/12

NICE Clinical Guideline 144: Venous Thromboembolic Diseases: The Management of Venous Thromboembolic Diseases and the Role of Thrombophilia Testing. June 2012

NICE Quality Standards for VTE prevention 2010, updated June 2015

NICE Quality Standards for diagnosis and management of VTE 2013

NICE guideline NG89: Venous thromboembolism in over 16s: reducing the risk of hospital-acquired    deep vein thrombosis or pulmonary embolism: March 2018   


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Approved By

Executive Team

Document history

LHP version 2.0

Related information

Not supplied

Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.