Improving VTE Prevention processes
It is important for facilities to monitor VTE prevention processes and cases of VTE to improve outcomes. Data collected should be regularly passed on to clinicians to raise VTE awareness and used to drive change through quality improvement initiatives.
If you would like to initiate a quality improvement initiative to improve local VTE outcomes, refer to the CEC VTE Prevention Toolkit for more guidance.
Any significant unexpected change in a patient's condition relating to VTE prophylaxis including embolism and bleeding, should be considered an adverse event and be recorded in ims+.
All patients who present on admission with a VTE resulting from a previous hospitalisation (within 90 days of discharge), or who develop a VTE during hospitalisation must have the incident documented in the patient's health care record and recorded into ims+.
The Non-Fatal VTE Incident Management Tool can be used for internal reporting and investigation.
The Quality Improvement Data System (QIDS) is available to NSW Health LHDs/SHNs and their facilities to monitor rates of hospital-associated VTEs.
The database extracts ICD-10 coded data from Health Information Exchange (HIE). Incidents can be viewed on LHD, facility or ward level, and be benchmarked against Peer Hospitals or NSW average (Note that you may require permission from your Clinical Governance or Patient Safety Unit to view data).
The Quality Audit Reporting System (QARS) is available to NSW Health LHDs/SHNs to conduct pre-made or custom quality audits to improve local outcomes, initiate relevant action plans, provide evidence for accreditation and/or evaluate performance.
QARS allows evaluation at LHD, facility or ward levels. Benchmarking against the NSW average and peer groups is also available.
A simple VTE Prevention audit is available within QARS to assist facilities with assessing compliance with Policy Directive: Prevention of Venous Thromboembolism (PD2019_057). The questionnaire (ID: 1563) can be modified by adding or removing questions to suit local needs.
The following document has been developed to provide guidance for the auditor and assist with the interpretation of percentages in the 'Compliance Rate of Audit by Question' report. This report can be generated by accessing the 'Reports' function in QARS.
Annual audits are recommended, or more frequently if compliance is low.
Before commencing a VTE audit in QARS, log into QARS and read the user manual, located in the 'Help' section on the homepage.
For more information or to obtain access, please contact your LHD's QARS administrator, or contact the CEC via email.
Additional audit measures are available to facilities to audit VTE processes, including: