Venous thrombosis prevention – more than just guidelines Peter Clark, 1 Olivia Wu, 2 Ian A. Greer 3 and Gordon D. O. Lowe 4 1 Department of Transfusion Medicine, Ninewells Hospital and Medical School, Dundee, 2 Section of Public Health and Health Policy, University of Glasgow, Glasgow, 3 Hull-York Medical School, University of York, York, and 4 Division of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK Summary Hospital-associated venous thromboembolism remains a major international cause of avoidable mortality and morbid- ity. Although the publication of national guidelines does increase the use of thromboprophylaxis, we present the results of a recent audit of thrombosis prevention in UK hospitals which, despite published guidelines, shows continuing signif- icant variations in guideline implementation and practice. The results of this audit are paralleled with UK and international data on hospital-acquired thrombosis prevention and the potential solutions to these problems, particularly the lessons which can be learned from other areas of clinical practice, are discussed. Keywords: hospital-associated venous thromboembolism, thrombosis prevention, guideline implementation, audit. Venous thromboembolism (VTE) remains a substantial cause of preventable death, despite national and international guidelines for prevention. Although it is clear that the publication of such guidelines does result in an increased usage of thromboprophylaxis (Walker et al, 1999), recent large studies continue to highlight a lack of appropriate thrombo- prophylaxis in hospitalized patients internationally (Kahn et al, 2007, Cohen et al, 2008). In the UK, both the Scottish Ombudsman (Scottish Public Services Ombudsman, 2006) and the UK House of Commons Parliamentary Health Committee (House of Commons Health Committee, 2005) recently expressed concerns as to the prevention and manage- ment of VTE. Indeed, both highlight problems with awareness of VTE risk, whilst recommending more widespread risk assessment, greater use of preventative therapies, and a uniform approach underpinned by audit against current guidelines. Here, we consider the awareness of VTE risk, the status of guideline implementation and the availability of appropriate information for staff and patients in the UK to determine what deficiencies have been identified and what action is required to improve patient care. Available guidelines Guidance on thromboprophylaxis for medical, surgical, obstetric and gynaecological patients was published in the UK in 1992 (Thromboembolic Risk Factors (THRIFT) Con- sensus Group, 1992) with Scottish national guidelines pub- lished in 1995 (SIGN, 1995). More recently, the National Institute for Clinical Excellence (NICE, 2007) has also produced a guideline on VTE prevention in surgery and is developing further guidelines to address other at-risk groups. There have been relevant guidelines in North America for many years with the most recent published in 2008 (Geerts et al, 2008). In addition, there are a variety of international guidelines covering specific clinical specialties. For example, multiple international guidelines concerning obstetrics have been available for many years (Clark & Bates, 2009). All such documents stress the need for the routine assessment of VTE risk in patients admitted to hospital and for specific antithrombotic prophylaxis in those at significant risk. Current practice in the UK The National Health Service (NHS) Quality Improvement Scotland (QIS) recently commissioned a stock-take exercise to assess the implementation and dissemination of current VTE guidelines in NHS Scotland (Wu et al, 2007). Medical directors from all health boards responded to a questionnaire on the presence of existing policies/protocols within their area. Evidence was also sought on the dissemination of these policies through staff induction, as well as the presence of any additional specific staff and/or patient information. In addi- tion, the boards were requested to provide evidence of completed audit. All sites reported written policies/protocols on VTE prevention for use in obstetrics/gynaecology (Fig 1). However, significant deficiencies were noted with regard to other specialties. Where policies/protocols existed, the vast majority specifically included VTE in staff induction. More than two-thirds indicated that there was some form of additional information available (e.g. either additional educa- Correspondence: Dr Peter Clark, Department of Transfusion Medicine, East of Scotland Blood Transfusion Centre, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK. E-mail: peterclark@nhs.net annotation First published online 8 February 2010 doi:10.1111/j.1365-2141.2010.08080.x ª 2010 Blackwell Publishing Ltd, British Journal of Haematology, 149, 50–54