1.0 Patient Admission & Initial Identification for VTE Risk Assessment

Purpose: To ensure every eligible patient admitted to BCMCH is promptly identified and flagged for mandatory VTE risk assessment within the specified timeframe, initiating the VTE prevention pathway.

Scope: Applies to all patients being admitted to inpatient units, including transfers from the Emergency Department (ED) or other facilities, unless meeting specific pre-defined exclusion criteria.

Responsibilities: Admitting Department Staff, ED Nursing Staff, Ward/Unit Nursing Staff, Admitting Physicians.

Procedure Steps:

• 1.1 Patient Presentation & Decision to Admit:

  • 1.1.1 Trigger: A patient presents to BCMCH (e.g., ED, direct admission desk, transfer intake) and a clinical decision is made by an authorized physician to admit the patient to an inpatient bed/unit.

  • 1.1.2 Confirmation: The admission order is placed in the hospital information system (HIS) / Electronic Health Record (EHR) or via standard paper-based admission forms.

• 1.2 Eligibility Screening:

  • 1.2.1 Identify Target Population: Confirm the patient meets the general inclusion criteria of the policy (e.g., adult or adolescent patient being admitted for an anticipated stay > 24 hours or undergoing procedures with known VTE risk).

  • 1.2.2 Identify Exclusions: Determine if the patient meets any pre-defined, specific exclusion criteria where routine VTE risk assessment is not initially required. (These criteria must be explicitly listed in a supporting BCMCH guideline document, e.g., pediatric patients covered under a separate policy, patients admitted solely for same-day outpatient procedures with immediate discharge, patients admitted directly to hospice/palliative care focus).

  • 1.2.3 Documentation of Exclusion: If a patient meets exclusion criteria, the reason for non-assessment must be documented clearly in the admission notes or designated EHR field by the admitting physician or initial assessing nurse, per BCMCH guidelines.

• 1.3 Flagging for Mandatory VTE Risk Assessment:

  • 1.3.1 System Trigger (Preferred - EHR): Upon processing the inpatient admission order, the EHR system should automatically:

    • Generate a task or alert for the receiving unit's nursing staff, clearly indicating "Mandatory VTE Risk Assessment Required within 24 hours."

    • Record the official admission time, which serves as the start time for the 24-hour window.

• • 1.3.2 Manual Trigger (Paper/Hybrid System or EHR Backup):

    • Admitting Department/ED: If an automated alert is not standard, the admitting clerk or ED nurse initiating the admission paperwork must place a designated VTE Assessment Alert sticker/form at the front of the patient's physical chart OR clearly note the requirement in the initial electronic/written nursing admission note and handoff report.

    • Receiving Unit Nurse: The nurse receiving the patient onto the inpatient unit is responsible for verifying that the need for VTE assessment has been flagged during the admission/handoff process. If not flagged, the receiving nurse must initiate the flag/alert process immediately upon patient arrival to the unit.

• 1.4 Establishing the 24-Hour Window:

  • 1.4.1 Start Time: The 24-hour timeframe for completing the initial VTE risk assessment begins at the official time of patient admission registration into the inpatient status, as recorded in the HIS/EHR.

  • 1.4.2 Visibility: This admission time and the corresponding deadline for VTE assessment should be clearly visible within the EHR task list or noted prominently on the relevant section of the paper chart/nursing Kardex.

• 1.5 Communication & Handoff:

  • 1.5.1 ED to Ward: If the patient is admitted via the ED, the transferring ED nurse must explicitly include the status of VTE risk assessment initiation (i.e., "Needs VTE assessment by [Time/Date]") in the verbal and written handoff report to the receiving ward nurse.

  • 1.5.2 Direct Admission/Transfer: For direct admissions or external transfers, the admitting nurse on the unit assumes primary responsibility for ensuring the VTE assessment process is initiated per steps 1.3 and 1.4 upon the patient's arrival.

• 1.6 Confirmation of Responsibility:

  • 1.6.1 Primary Nurse: The primary nurse assigned to the patient upon arrival to the inpatient unit holds the responsibility for ensuring the VTE risk assessment process (detailed in Section 2.0) is initiated and completed within the mandated 24-hour timeframe, either by performing the initial assessment steps or ensuring the assigned physician/team member is aware and completes their part.

2.0 VTE Risk Assessment

Purpose: To accurately and systematically assess every eligible patient's risk for developing a Hospital-Acquired Venous Thromboembolism (HAVTE) using a standardized, evidence-based tool, forming the foundation for appropriate prevention strategies.

Scope: Applies to all patients identified in Section 1.0 as requiring VTE risk assessment.

Responsibilities:

• Primary Nurse: Responsible for initiating and completing the data gathering and initial scoring using the approved tool. Responsible for ensuring the assessment occurs within the 24-hour window.

• Physician (Attending/Resident/Fellow): Responsible for reviewing the nurse-initiated assessment, validating the data points and score against the overall clinical picture, applying clinical judgment, potentially modifying the score based on factors not fully captured by the tool, finalizing the risk level, and documenting confirmation/sign-off.

Timing: The completed and confirmed VTE risk assessment must be documented in the patient's medical record within 24 hours of the official patient admission time (as defined in Section 1.4). The primary nurse monitors adherence to this timeframe.

Procedure Steps:

• 2.1 Accessing the Approved Tool:

  • 2.1.1 Tool Identification: Locate and utilize only the current, BCMCH-approved standardized VTE Risk Assessment Tool. [Specify the exact tool name here, e.g., "BCMCH Modified Caprini Score" or "Padua Prediction Score as adopted by BCMCH"]. Using unapproved or outdated tools is prohibited.

  • 2.1.2 Tool Location: Access the tool via:

    • EHR: Within the designated Nursing Admission Assessment module or specific VTE assessment flowsheet. [Specify EHR location if applicable].

    • Paper Chart: Utilize the official, printed BCMCH VTE Risk Assessment Form [Specify Form Number/Name]. Ensure the latest version is used.

• • 2.1.3 Staff Competency: Staff performing the assessment must be trained and deemed competent in the use of the specific BCMCH-approved tool.

• 2.2 Information Gathering:

  • 2.2.1 Responsibility: Primarily performed by the nurse initiating the assessment.

  • 2.2.2 Sources: Systematically gather required information from multiple sources:

    • Patient/Family Interview: Actively inquire about known VTE risk factors including personal or family history of VTE, history of cancer (active or recent), recent surgery or trauma, immobility prior to admission, estrogen use, pregnancy/postpartum status. Assess current mobility status.

    • Medical Record Review: Examine admission notes, history & physical, physician orders, transfer summaries, previous hospital records (if available) for: admitting diagnosis, comorbidities (e.g., heart failure, respiratory failure, inflammatory bowel disease, sepsis), presence of central venous catheter, known thrombophilia, BMI/obesity status, relevant laboratory values (e.g., platelets).

    • Current Orders/Plan: Review physician orders for planned major surgery, anticipated duration of immobility or bed rest.

• • 2.2.3 Considerations: If the patient is unable to provide information (e.g., unconscious, confused), rely on available medical records, information from family/carers, and clinical assessment. Document limitations in information gathering if applicable.

• 2.3 Completing the Assessment Tool:

  • 2.3.1 Data Entry: Accurately populate all relevant fields/checkboxes on the assessment tool based on the information gathered in step 2.2. Ensure no relevant risk factors are missed.

  • 2.3.2 EHR Integration: If using an EHR, some data points may auto-populate. Verify the accuracy of auto-populated data and manually enter/confirm all other required elements.

  • 2.3.3 Accuracy: Double-check entries for accuracy before proceeding to scoring.

• 2.4 Calculating the VTE Risk Score:

  • 2.4.1 Scoring: Sum the points assigned to each identified risk factor according to the specific instructions of the BCMCH-approved tool.

  • 2.4.2 EHR Calculation: If using an integrated EHR tool, the system may automatically calculate the total score. Verify the system calculation if possible, or understand how it is derived.

  • 2.4.3 Manual Calculation: If using a paper form or non-calculating electronic form, manually sum the points carefully. Consider a double-check by a second person or self-review for accuracy.

• 2.5 Determining the VTE Risk Level:

  • 2.5.1 Interpretation: Translate the calculated numerical score into the corresponding BCMCH-defined VTE risk level category. These categories must be clearly defined in the tool/guidelines.

    • (Example Categories - Replace with BCMCH's actual definitions):

      • Score 0-1: Low Risk

      • Score 2: Moderate Risk

      • Score 3-4: High Risk

      • Score 5+: Very High Risk

• • 2.5.2 Clarity: The final risk level (e.g., "High Risk") is the key output used for determining appropriate prophylaxis.

• 2.6 Physician Review, Confirmation, and Finalization:

  • 2.6.1 Notification: The nurse notifies the responsible physician (Attending or Resident/Fellow covering the patient) that the initial VTE assessment is ready for review, either through EHR task/notification or direct communication.

  • 2.6.2 Physician Action: The physician must:

    • Review the completed assessment form/screen and the calculated score.

    • Validate the contributing risk factors against their clinical knowledge of the patient.

    • Apply clinical judgment – consider if any significant risk factors are not adequately captured by the tool or if the patient's overall clinical status warrants adjusting the perceived risk (rationale for any adjustment must be documented).

    • Formally confirm or amend the final VTE risk score and associated risk level.

    • Electronically sign off, co-sign, or create an attestation note confirming their review and agreement with the final VTE risk level within the 24-hour window.

• 2.7 Documentation:

  • 2.7.1 Location: The completed VTE Risk Assessment must be documented in the designated, easily accessible location within the official patient medical record:

    • EHR: Designated VTE assessment flowsheet, admission assessment module, or specific VTE documentation section.

    • Paper Chart: The official BCMCH VTE Risk Assessment Form, placed in a standardized section of the chart (e.g., assessment section, physician order section divider).

• • 2.7.2 Required Elements: Documentation must include:

    • Date and time the assessment was completed.

    • Name and credentials of the nurse performing the initial assessment.

    • Name and credentials of the physician reviewing and confirming the assessment.

    • The specific BCMCH-approved tool used (e.g., "BCMCH Modified Caprini").

    • The final calculated VTE risk score.

    • The determined VTE Risk Level (e.g., Low, Moderate, High).

    • Physician signature/electronic confirmation.

• • 2.7.3 Visibility: Ensure the final VTE Risk Level is prominently displayed or easily found (e.g., on a patient summary screen, Kardex, or front of chart alert) for all members of the care team.

• 2.8 Linkage to Next Steps:

  • 2.8.1 Trigger: Completion and documentation of the VTE Risk Assessment immediately triggers the need for Bleeding Risk Assessment (Section 3.0) and subsequent determination and ordering of appropriate prophylaxis (Section 4.0) by the physician.

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Template for a robust VTE Risk Assessment Tool for Believers Church Medical College Hospital (BCMCH), based primarily on the widely used and validated Caprini Risk Assessment Model, adapted for hospital-wide use (medical and surgical patients).

Important Considerations Before Implementation:

1. Validation & Threshold Finalization: BCMCH clinical leadership (e.g., VTE Committee, Quality Dept, Pharmacy & Therapeutics Committee) MUST review, potentially modify, and formally approve this tool. Crucially, the exact score thresholds for Low, Moderate, High, and Highest Risk categories need to be defined by BCMCH based on international guidelines, local data (if available), and the specific prophylaxis protocols BCMCH adopts. The thresholds provided below are examples.

2. Integration: Ideally, this tool should be integrated into the hospital's Electronic Health Record (EHR) for ease of use, calculation, and tracking.

3. Training: Staff must be thoroughly trained on how to use this specific tool accurately.

4. Paired with Guidelines: This tool MUST be used in conjunction with BCMCH's official VTE Prophylaxis Guidelines, which will specify the recommended preventative actions for each risk level.

Believers Church Medical College Hospital (BCMCH)
VTE Risk Assessment Tool (Based on Modified Caprini Model)

Policy Reference: BCMCH-PSQ-VTE-001 | Form Number: [BCMCH-VTE-FORM-001 (Example)] | Version: 1.0 | Date Approved: [Date]

Patient Information:
Patient Name: _________________________ MRN: _______________ DOB: __________ Age: ____ Sex: M / F / Other
Admission Date: _______________ Assessment Date: _______________ Assessment Time: ________ (24hr Format)

Instructions:

1. To be completed for all eligible inpatients within 24 hours of admission by the primary nurse.

2. Gather information from patient interview, medical records, and clinical assessment. Check ALL applicable boxes.

3. Calculate the total score.

4. Notify Physician for review, confirmation, and finalization of risk level and prophylaxis plan. Physician must confirm assessment.

SECTION A: Patient Risk Factors (Check all that apply and sum points)

Risk Factor Points Check (✓) Notes / Clarification

Demographics & Baseline

Age 41-60 years 1

Age 61-74 years 2

Age 75 years or older 3

Body Mass Index (BMI) > 25 kg/m ² (Overweight/Obese) 1

If BMI unavailable, clinical assessment of obesity

History

History of prior VTE (DVT or PE) 3

Patient self-report or documented

Family history of VTE (1st degree relative) 3

Parent, sibling, child

Known Thrombophilia / Hypercoagulable State 3

E.g., Factor V Leiden, Prothrombin Gene Mut, ATIII Def, Protein C/S Def, APLS

History of Cancer (excluding basal/squamous cell skin cancer) 2

Even if in remission

Current Medical Conditions / Status

Active Cancer (diagnosed or treated within 6 months) 2

Sepsis / Serious Infection (within last month) 1

Serious Lung Disease (incl. Pneumonia, COPD exacerbation) (within last month) 1

Acute Myocardial Infarction (within last month) 1

Congestive Heart Failure (current or recent decompensation) 1

NYHA Class III/IV equivalent

Inflammatory Bowel Disease (Active - Crohn's/UC) 1

Central Venous Access (current CVC/PICC line) 1

Pregnancy or Postpartum (<6 weeks) 1

Use of Estrogen / Hormone Replacement Therapy (HRT) / SERMs 1

E.g., Tamoxifen

Significant Immobility / Paralysis 2

E.g., Paraplegia, quadriplegia, prolonged stroke deficit

Confined to Bed Rest (Strict physician order > 72 hrs anticipated/actual) 2

Includes medically induced paralysis

Surgery / Trauma

Minor surgery (planned or within last month) 1

Procedure duration < 45 minutes

Major surgery (planned or within last month) 2

Procedure duration > 45 minutes

Laparoscopic surgery > 45 minutes (planned or within last month) 2

Arthroscopic surgery (planned or within last month) 2

Major Trauma (within last month) 2

E.g., Multiple fractures, severe MVA

Spinal Cord Injury with paralysis (within last month) 5

Hip, Pelvis, or Femur Fracture (within last month) 5

Pre-op or post-op

Elective Major Lower Extremity Arthroplasty (planned or within last month) 5

Total Hip or Knee Replacement

SECTION B: Score Calculation

TOTAL VTE RISK SCORE (Sum of points from Section A): ___________

SECTION C: VTE Risk Level Determination (Based on BCMCH Approved Thresholds)

(Note: These thresholds are EXAMPLES ONLY and MUST be finalized by BCMCH)

Total Score Risk Level Check (✓) Final Risk Level

0 Lowest Risk

1 - 2 Low Risk

3 - 4 Moderate Risk

≥ 5 High / Highest Risk

SECTION D: Assessment Completion & Confirmation

Nurse Assessor:
Name: _________________________ Signature: _________________________ Date: ________ Time: ________

Physician Review & Confirmation:

• I have reviewed this VTE Risk Assessment.

• I confirm the final VTE Risk Score and Level.

• This assessment will inform the VTE Prophylaxis Plan (Proceed to Bleeding Risk Assessment & Prophylaxis Orders).

• (Optional field for physician comments/overrides, requires justification): ___________________________

Reviewing Physician:
Name: _________________________ Signature: _________________________ Date: ________ Time: ________

Instructions for Use with Procedure:

1. Complete this form within 24 hours of admission.

2. Physician confirms risk level.

3. Physician completes Bleeding Risk Assessment (Separate Tool/Process).

4. Physician orders appropriate prophylaxis based on VTE Risk Level, Bleeding Risk, and BCMCH VTE Prophylaxis Guidelines.

5. Place completed form in the designated section of the medical record (EHR or Paper Chart).

6. Re-assess VTE risk per BCMCH policy (e.g., change in clinical status, transfer of care level, pre/post-op, prolonged stay). 

3.0 Bleeding Risk Assessment

Purpose: To systematically evaluate the patient's risk of bleeding before initiating pharmacological VTE prophylaxis, allowing for a balanced decision between VTE prevention benefits and potential bleeding harm.

Scope: Applies to all patients undergoing VTE risk assessment (Section 2.0) for whom pharmacological VTE prophylaxis is being considered.

Responsibilities:

• Physician (Attending/Resident/Fellow): Solely responsible for performing the bleeding risk assessment, interpreting the findings, assigning a risk category, and documenting the assessment.

• Nursing Staff: May assist by gathering relevant data (e.g., reporting signs of bleeding, ensuring recent lab results like platelet count are available) but does not perform the risk assessment interpretation or categorization.

• Pharmacy: May assist by flagging potential drug interactions that increase bleeding risk during order verification.

Timing:

• Must be completed concurrently with or immediately following the finalization of the VTE Risk Assessment (Section 2.0).

• Must be completed BEFORE any order for pharmacological VTE prophylaxis is placed.

Procedure Steps:

• 3.1 Method Selection & Tool Access:

  • 3.1.1 Approved Method: Utilize the BCMCH-approved standardized method for bleeding risk assessment. This may be:

    • A specific validated Bleeding Risk Score adapted for BCMCH use (e.g., an institutional modification of HAS-BLED components, HEMORR2HAGES elements relevant to prophylaxis). [Specify the exact BCMCH-approved tool/checklist name here, e.g., "BCMCH Inpatient Bleeding Risk Checklist"]. OR

    • A structured clinical assessment guided by a BCMCH-approved checklist of critical bleeding risk factors.

  • 3.1.2 Location: Access the tool/checklist via:

    • EHR: Integrated assessment within the VTE prophylaxis workflow or a dedicated bleeding risk assessment flowsheet. [Specify EHR location].

    • Paper Chart: Utilize the official, printed BCMCH Bleeding Risk Assessment Form/Checklist [Specify Form Number/Name].

• 3.2 Information Gathering & Review:

  • 3.2.1 Responsibility: Physician performing the assessment.

  • 3.2.2 Sources: Actively review and assess the following:

    • Patient History: Known history of bleeding disorders (e.g., hemophilia, von Willebrand disease), previous major bleeding events (e.g., intracranial hemorrhage, GI bleed requiring transfusion), history of peptic ulcer disease (especially recent), chronic liver disease (cirrhosis), chronic kidney disease/failure, known brain metastases or intracranial pathology.

    • Current Clinical Status: Evidence of active bleeding (hematemesis, melena, hematochezia, epistaxis, hemoptysis, hematuria, bleeding from surgical sites/drains/catheters , expanding hematoma). Signs of potential occult bleeding (unexplained drop in hemoglobin, tachycardia, hypotension). Severe uncontrolled hypertension (BCMCH to define threshold, e.g., SBP > 180 mmHg or DBP > 110 mmHg). Planned invasive procedures with high bleeding risk (e.g., lumbar puncture, epidural placement, major surgery) within the next 12-24 hours.

    • Laboratory Data: Most recent platelet count (BCMCH to define critical low threshold for prophylaxis, e.g., < 50,000/µL), INR (if available, especially if baseline coagulopathy suspected or known liver disease; BCMCH to define threshold, e.g., > 1.5 in absence of therapeutic anticoagulation), Hemoglobin/Hematocrit (baseline and recent trend), Renal function tests (e.g., Creatinine, eGFR/CrCl – important for dosing renally cleared anticoagulants and uremic bleeding risk; BCMCH to define threshold indicating significantly increased risk, e.g., CrCl < 30 mL/min).

    • Medication Review: Current use of therapeutic anticoagulants, antiplatelet agents (aspirin, clopidogrel, ticagrelor, etc. - especially dual therapy), NSAIDs, SSRIs, systemic corticosteroids (may increase GI bleed risk).

• 3.3 Performing the Assessment using Approved Method:

  • 3.3.1 Systematic Evaluation: Systematically work through the BCMCH-approved tool or checklist, addressing each risk factor based on the information gathered in step 3.2.

  • 3.3.2 Clinical Judgment: Apply clinical judgment. The tool/checklist guides the assessment, but the overall clinical picture is paramount. Consider the combination and severity of risk factors. For example, a patient with moderate renal impairment and on dual antiplatelet therapy might be deemed high risk even if individual factors don't cross a specific threshold on the tool.

• 3.4 Assigning the Bleeding Risk Category:

  • 3.4.1 Categorization: Based on the assessment and clinical judgment, assign the patient to one of the BCMCH-defined bleeding risk categories. Typically:

    • Low Bleeding Risk: No significant risk factors identified, or risk factors present are deemed minor and unlikely to be exacerbated by prophylactic anticoagulation. Pharmacological prophylaxis may be considered.

    • High Bleeding Risk: Presence of one or more significant risk factors (e.g., active bleeding, platelet count below threshold, recent major bleed/surgery, planned high-risk procedure, severe coagulopathy, combination of multiple moderate risk factors) where the initiation of pharmacological prophylaxis is deemed likely to cause unacceptable bleeding. Pharmacological prophylaxis is generally contraindicated at this time.

  • 3.4.2 Ambiguous Cases: If uncertain, err on the side of caution (consider High Risk) or consult with a specialist (e.g., Hematology, senior physician).

• 3.5 Documentation:

  • 3.5.1 Responsibility: Physician performing the assessment.

  • 3.5.2 Location: Document the assessment clearly in the designated section of the patient's medical record (EHR flowsheet, progress note, or specific paper form).

  • 3.5.3 Required Elements: Documentation must include:

    • Confirmation that a bleeding risk assessment was performed.

    • Date and time of assessment.

    • Specific tool/checklist used (e.g., "BCMCH Bleeding Risk Checklist").

    • Notation of key risk factors identified (especially if categorizing as High Risk).

    • The final determined Bleeding Risk Category (Low Bleeding Risk or High Bleeding Risk).

    • Physician's name, credentials, and signature/electronic confirmation.

• 3.6 Linkage to Next Steps:

  • 3.6.1 Decision Input: The determined Bleeding Risk Category is a critical input, alongside the VTE Risk Level (from Section 2.0), for the physician's decision-making process in Section 4.0 regarding the appropriate type (or omission) of VTE prophylaxis.

  • 3.6.2 High Risk Implication: A finding of "High Bleeding Risk" generally precludes the initiation of pharmacological VTE prophylaxis. The focus shifts to mechanical prophylaxis (if not contraindicated) and frequent reassessment of bleeding risk.

• 3.7 Reassessment:

  • 3.7.1 Requirement: Bleeding risk is dynamic and must be reassessed:

    • Daily (or per BCMCH policy) for patients receiving pharmacological prophylaxis.

    • If there is a significant change in clinical status (e.g., new bleeding event, drop in platelets, acute kidney injury, need for urgent procedure).

    • Before resuming pharmacological prophylaxis if it was previously held due to high bleeding risk.

  • 3.7.2 Documentation: Document all reassessments of bleeding risk.

4.0 Determination and Ordering of VTE Prophylaxis

Purpose: To translate the assessed VTE risk level and bleeding risk category into an evidence-based, individualized VTE prophylaxis plan, and to ensure this plan is clearly ordered and documented in a timely manner.

Scope: Applies to all patients for whom VTE Risk Assessment (Section 2.0) and Bleeding Risk Assessment (Section 3.0) have been completed.

Responsibilities:

• Physician (Attending/Resident/Fellow): Solely responsible for synthesizing risk assessments, consulting guidelines, determining the final prophylaxis plan, placing accurate orders, and documenting the rationale.

Timing: This process should occur immediately following the completion and physician confirmation of the VTE Risk Assessment (Section 2.0) and the Bleeding Risk Assessment (Section 3.0). Prophylaxis orders should ideally be placed within hours of the finalized risk assessments.

Procedure Steps:

• 4.1 Review of Assessments:

  • 4.1.1 Physician Action: The responsible physician must carefully review the finalized outputs of the preceding sections:

    • Final VTE Risk Score and Level (e.g., Score 6, High Risk) from Section 2.0.

    • Final Bleeding Risk Category (e.g., Low Bleeding Risk or High Bleeding Risk) and key contributing factors from Section 3.0.

• 4.2 Consultation of BCMCH Guidelines:

  • 4.2.1 Access Protocol: The physician must access and consult the current, official BCMCH VTE Prophylaxis Guidelines.

  • 4.2.2 Identify Correct Protocol: Select the specific protocol/guideline relevant to the patient's primary condition or reason for admission (e.g., Medical Patients, General Surgery Patients, Orthopedic Surgery Patients, ICU Patients, Obstetric Patients, Neurosurgery Patients, etc.), as recommendations may vary.

  • 4.2.3 Locate Recommendation: Within the appropriate guideline, identify the recommended prophylaxis strategy based on the patient's determined VTE Risk Level (from 4.1.1) and Bleeding Risk Category (from 4.1.1).

• 4.3 Consideration of Patient-Specific Factors:

  • 4.3.1 Physician Action: Before finalizing the plan, the physician must consider individual patient factors that may influence the choice or dosing of prophylaxis:

    • Contraindications to Pharmacological Agents: Known allergies to specific anticoagulants (e.g., heparin, LMWH), history of Heparin-Induced Thrombocytopenia (HIT), severe active bleeding precluding any anticoagulation, intractable vomiting preventing oral medication absorption (if applicable).

    • Contraindications to Mechanical Devices: Severe Peripheral Artery Disease (PAD), current Deep Vein Thrombosis (DVT) in the limb(s), significant leg/foot deformity, extensive skin breakdown/grafts/ulceration on the lower limbs, patient refusal or documented inability to tolerate devices.

    • Renal Function: Assess recent renal function (e.g., Creatinine Clearance or eGFR). Specific dose adjustments or agent selection changes may be required for patients with renal impairment, particularly for Low Molecular Weight Heparins (LMWHs) or Direct Oral Anticoagulants (DOACs, if used). Consult BCMCH guidelines or Pharmacy for specific recommendations.

    • Body Weight: Consider extremes of body weight (very low weight or severe obesity) which may require dose adjustments for certain pharmacological agents, per BCMCH guidelines.

    • Concurrent Medications: Review current medications for potential interactions (e.g., other anticoagulants, potent antiplatelet therapy, certain antibiotics/antifungals affecting DOAC levels).

    • Upcoming Procedures: Consider timing of planned surgeries or invasive procedures. Prophylaxis may need to be held or adjusted peri-procedurally according to specific BCMCH protocols (e.g., neurosurgery, epidural placement).

    • Patient Preference/Refusal: If a competent patient refuses a recommended form of prophylaxis, this must be discussed, documented, and alternative strategies considered if appropriate.

• 4.4 Decision-Making: Selecting the Prophylaxis Strategy:

  • 4.4.1 Synthesize Information: Based on the VTE risk level, bleeding risk category, guideline recommendations, and patient-specific factors, the physician determines the most appropriate VTE prophylaxis plan. The typical decision pathways are:

    • Low VTE Risk (e.g., Score 0-1): Usually No pharmacological or mechanical prophylaxis required. Emphasis on Early Ambulation. Mechanical prophylaxis might be considered only if the patient is temporarily immobile for reasons unrelated to the primary low-risk condition.

    • Moderate/High VTE Risk (e.g., Score ≥ 2 or ≥ 3 depending on BCMCH thresholds) AND Low Bleeding Risk: Initiate appropriate Pharmacological Prophylaxis (see 4.5.1). Consider adding Mechanical Prophylaxis (see 4.5.2), especially for the highest VTE risk patients (e.g., Score ≥ 5) or those with significant immobility, unless contraindicated.

    • Moderate/High VTE Risk AND High Bleeding Risk: Pharmacological Prophylaxis is CONTRAINDICATED. Initiate Mechanical Prophylaxis (SCDs preferred over GCS if possible, unless contraindicated). Document the contraindication to pharmacological prophylaxis clearly. Crucially, plan for frequent reassessment of bleeding risk (daily or more often) to determine if/when pharmacological prophylaxis can be safely initiated.

    • Contraindications to BOTH Pharmacological AND Mechanical Prophylaxis: Focus intensely on Early and Frequent Ambulation and leg exercises. Document the contraindications to both methods clearly. Recognize this patient remains at high risk for VTE.

  • 4.4.2 Adherence to Guidelines: Deviations from the standard BCMCH guidelines for the assessed risk levels require strong clinical justification and clear documentation (see 4.7).

• 4.5 Selecting Specific Prophylaxis Agents and Methods:

  • 4.5.1 Pharmacological Agents: If pharmacological prophylaxis is indicated, select the specific agent, dose, route, and frequency as per the relevant BCMCH guideline (e.g., Unfractionated Heparin 5000 units SubQ Q8H or Q12H; Enoxaparin 40mg SubQ daily (adjust dose for CrCl < 30 mL/min or obesity per guideline); Dalteparin; Fondaparinux; DOACs like Rivaroxaban or Apixaban if specifically approved and guideline-directed for VTE prophylaxis in the specific patient population at BCMCH).

  • 4.5.2 Mechanical Methods: If mechanical prophylaxis is indicated, specify the type:

    • Intermittent Pneumatic Compression Devices (SCDs): Preferred mechanical method when available and tolerated. Specify application (e.g., bilateral calf or thigh-high).

    • Graduated Compression Stockings (GCS): May be used if SCDs are contraindicated or unavailable, but generally considered less effective than SCDs or pharmacological methods alone for higher-risk patients. Specify type (e.g., knee-high, thigh-high). Ensure proper measurement and fitting protocols are followed (Nursing responsibility).

• 4.6 Ordering Prophylaxis:

  • 4.6.1 Method: Place orders using the BCMCH Electronic Health Record (EHR) system whenever possible.

  • 4.6.2 Use Standardized Order Sets: Utilize BCMCH-approved VTE Prophylaxis standardized order sets whenever available. These promote adherence to guidelines, reduce errors, and ensure completeness (e.g., include necessary baseline labs like platelets if ordering heparin/LMWH).

  • 4.6.3 Order Clarity: Orders must be clear, specific, and complete, including:

    • Pharmacological: Drug name, dose, route, frequency, start date/time, and duration (or "until further order"). Include parameters for holding (e.g., hold for platelet count < X, hold prior to procedure Y).

    • Mechanical: Device type (SCDs or GCS), location (e.g., bilateral calves), and frequency of use (e.g., "Apply and maintain while in bed or chair," "Remove for ambulation and skin assessment Q Shift").

  • 4.6.4 Timeliness: Place orders promptly after the decision is made to avoid delays in initiating prevention.

• 4.7 Documentation of Rationale:

  • 4.7.1 Location: Document the decision-making process and rationale in the physician's progress note for the day or in a dedicated order rationale field if available in the EHR.

  • 4.7.2 Content: Documentation should clearly state:

    • The final VTE Risk Level and Bleeding Risk Category.

    • The chosen VTE prophylaxis plan (e.g., "Enoxaparin 40mg SubQ daily + Bilateral SCDs").

    • The rationale linking the plan to the risk assessments and BCMCH guidelines.

    • Explicit justification if deviating from guidelines.

    • Explicit documentation of contraindications if recommended prophylaxis is omitted (e.g., "Pharmacological VTE prophylaxis contraindicated due to active GI bleeding and Platelets < 50k," or "SCDs contraindicated due to severe PAD documented by ABI < 0.5").

    • Documentation of patient refusal if applicable, including discussion of risks/benefits.

• 4.8 Communication:

  • 4.8.1 Nursing & Pharmacy: Ensure the orders are clear and visible to nursing staff (for administration/application) and pharmacy (for verification and dispensing of pharmacological agents). Verbal communication may supplement written/electronic orders during handoffs or for urgent initiation.

• 4.9 Linkage to Next Steps:

  • 4.9.1 Trigger: Completion of orders triggers the implementation phase (Section 5.0) by Nursing and Pharmacy.

5.0 Implementation of Prophylaxis

Purpose: To ensure the timely, correct, and safe application or administration of the VTE prophylaxis methods ordered in Section 4.0, coupled with ongoing monitoring for adherence and immediate side effects.

Scope: Applies to Nursing Staff, Pharmacy Department, and potentially Physiotherapy, responsible for carrying out the physician's VTE prophylaxis orders.

Responsibilities:

• Nursing Staff: Primary responsibility for administering pharmacological agents, applying and managing mechanical devices, promoting early ambulation, educating the patient, monitoring for compliance and adverse effects, and documenting implementation activities.

• Pharmacy Department: Responsible for verifying pharmacological orders, dispensing medications accurately, and providing drug information support.

• Physiotherapy Department: May be involved in patient mobilization plans, assisting with initial fitting/education for mechanical devices if requested, and prescribing specific exercises.

Procedure Steps:

• 5.1 Pharmacological Prophylaxis Implementation:

  • 5.1.1 Order Verification (Pharmacy & Nursing):

    • Pharmacy: Upon receiving the order, pharmacists verify the appropriateness of the drug, dose, route, and frequency against BCMCH guidelines, patient-specific factors (e.g., allergies, weight, renal function based on available data/flags), and potential significant drug interactions. Any discrepancies or concerns are communicated promptly to the ordering physician.

    • Nursing: Before administration, the nurse verifies the order in the patient's chart/EHR against the Medication Administration Record (MAR), confirming the "rights" of medication administration (Right Patient, Right Drug, Right Dose, Right Route, Right Time). The nurse also notes any specific administration instructions or parameters (e.g., hold if platelets < X).

  • 5.1.2 Medication Dispensing & Handling (Pharmacy/Nursing): Medications are dispensed by Pharmacy and stored appropriately on the unit. Nurses retrieve and prepare the dose immediately prior to administration.

  • 5.1.3 Administration (Nursing):

    • Administer the medication via the specified route (typically subcutaneous injection for heparin/LMWH) using correct technique (e.g., appropriate site selection, injection angle, not aspirating or massaging site for anticoagulants per BCMCH nursing protocol).

    • Administer as close to the scheduled time as possible to maintain consistent levels. Document any deviations from scheduled time and the reason.

  • 5.1.4 Initial Monitoring (Nursing): Observe the injection site for immediate signs of hematoma or reaction. Monitor patient for any immediate adverse effects.

  • 5.1.5 Documentation (Nursing): Document administration immediately and accurately in the MAR, including date, time, dose, route, site (if applicable), and signature/initials. Document any patient refusal, held doses (with reason), or adverse events in the MAR and nursing progress notes, notifying the physician as appropriate.

• 5.2 Mechanical Prophylaxis Implementation (SCDs/GCS):

  • 5.2.1 Device Acquisition & Sizing (Nursing/Supply Chain): Obtain the correct type of device (SCD sleeves or GCS) as ordered. Crucially, select the correct size based on patient leg measurements using the manufacturer's guidelines or BCMCH sizing charts. Incorrect sizing can lead to ineffectiveness or harm (e.g., constriction, skin damage).

  • 5.2.2 Application (Nursing/Physiotherapy):

    • Apply the device smoothly and correctly to the specified limbs (e.g., bilateral calves). Ensure GCS are free of wrinkles. Ensure SCD sleeves are positioned properly and connected securely to the pump.

    • Verify SCD pump is turned on, functioning correctly (audible inflation/deflation cycles, appropriate pressure settings per device specifications), and alarms are set appropriately.

  • 5.2.3 Patient Education (Nursing/Physiotherapy): Explain the purpose of the device, how it works, and the importance of wearing it consistently when in bed or chair (as ordered). Instruct the patient on when it can/should be removed (e.g., bathing, ambulation) and to report any pain, numbness, tingling, or skin irritation immediately.

  • 5.2.4 Monitoring & Care (Nursing):

    • Compliance: Regularly assess and encourage patient adherence to device use. Document compliance levels (e.g., "Worn consistently," "Refuses intermittently," "Removed due to discomfort").

    • Functionality: Check SCD pump function at least once per shift (or per BCMCH policy) and ensure sleeves are inflating/deflating correctly. Troubleshoot minor issues (e.g., kinked tubing) or request biomedical assistance for malfunctions.

    • Skin Integrity: Remove devices at least once per shift (or per BCMCH policy, e.g., Q8-12H) for a minimum of 30 minutes to inspect skin for redness, irritation, breakdown, or pressure areas, particularly over bony prominences. Document skin assessment findings.

    • Neurovascular Status: Assess distal pulses, skin color/temperature, capillary refill, sensation, and movement in the affected limbs at least once per shift (or per BCMCH policy).

  • 5.2.5 Documentation (Nursing): Document in nursing notes or flowsheets: device type, size, location, date/time applied, confirmation of correct function (SCDs), skin assessment findings, neurovascular checks, patient tolerance, compliance, and education provided. Document removal times and reasons if applicable.

• 5.3 Early Ambulation & Mobilization Implementation:

  • 5.3.1 Assessment & Goal Setting (Nursing/Physiotherapy/Physician): Based on physician orders for activity level and assessment of the patient's condition (e.g., stability, pain, fall risk), establish appropriate mobility goals.

  • 5.3.2 Encouragement & Assistance (Nursing/Physiotherapy):

    • Actively encourage and assist the patient with ambulation (in room, hallways) as appropriate for their condition and orders, multiple times per day if possible.

    • For patients on bed rest, encourage and assist with active or passive range-of-motion exercises, position changes, and deep breathing/coughing exercises.

    • Assist patient out of bed to a chair for meals and activities whenever feasible.

  • 5.3.3 Coordination (Nursing/Physiotherapy): Collaborate with Physiotherapy for specialized mobility plans, gait training, or if patient requires significant assistance or rehabilitation.

  • 5.3.4 Documentation (Nursing/Physiotherapy): Document all mobility activities undertaken in nursing/physiotherapy notes or flowsheets, including type of activity (e.g., ambulated X feet, up to chair), frequency, duration, level of assistance required, patient tolerance, and any barriers encountered.

• 5.4 Addressing Implementation Barriers:

  • 5.4.1 Identification: Promptly identify any barriers preventing the implementation of ordered prophylaxis (e.g., patient refusal, inability to tolerate device, medication unavailability, conflicting orders, device malfunction).

  • 5.4.2 Action:

    • Patient Refusal/Non-tolerance: Re-educate the patient on the risks/benefits. Explore reasons for refusal/intolerance and try to mitigate (e.g., different SCD sleeve size/type, pain management before mobilization). If refusal persists, document thoroughly and inform the physician immediately to discuss alternative strategies or acceptance of risk.

    • Device Issues: Troubleshoot basic issues. Report malfunctions or unavailability to charge nurse/biomedical engineering/supply chain promptly. Inform physician if mechanical prophylaxis cannot be implemented as ordered.

    • Medication Issues: Clarify any order discrepancies with the physician/pharmacy. Report unavailability to pharmacy/physician.

  • 5.4.3 Escalation & Documentation: Escalate unresolved issues through the nursing chain of command. Document all barriers and actions taken in the medical record.

6.0 Patient & Family Education

Purpose: To empower patients and their families/carers with knowledge regarding VTE, their individual risk, the specific prevention plan implemented, their active role in prevention, and critical signs/symptoms to report, thereby enhancing adherence, safety, and early detection of potential complications.

Scope: Applies to all patients identified as being at risk for VTE and/or receiving VTE prophylaxis, and their designated family members or caregivers. Education should be tailored to the patient's cognitive ability, health literacy, and preferred language.

Responsibilities:

• Nursing Staff: Primary responsibility for delivering initial and ongoing VTE education, reinforcing key messages during routine care, assessing understanding, and documenting educational activities.

• Physicians (Attending/Resident/Fellow): Responsible for explaining the rationale for the prophylaxis plan, reinforcing the importance of prevention during patient encounters, and answering complex medical questions.

• Pharmacists: May provide specific medication counseling upon request or as part of medication reconciliation/discharge planning.

• Physiotherapists: Educate on specific exercises and the importance of mobility related to VTE prevention.

• All Team Members: Responsible for providing consistent messaging aligned with BCMCH policy and guidelines.

Timing:

• Initial Education: Should be initiated as early as possible after the VTE risk assessment is completed and the prophylaxis plan is determined (ideally within the first 24-48 hours of initiation of prophylaxis).

• Ongoing Reinforcement: Key messages should be reinforced throughout the hospital stay, particularly when administering medications, applying/checking devices, or assisting with mobility.

• Discharge Education: Specific instructions must be provided upon discharge if prophylaxis is continued or if the patient remains at elevated risk.

Procedure Steps:

• 6.1 Identification of Recipient(s):

  • Determine the appropriate recipient(s) for education: the patient (if alert, oriented, and capable), designated family members, or legally authorized representative/caregiver, especially if the patient has cognitive impairment, language barriers, or severe illness. Document who received the education.

• 6.2 Delivery Method and Environment:

  • Verbal Communication: Conduct education through direct, clear, and simple verbal communication. Avoid overly technical jargon. Allow ample time for questions.

  • Written Materials: Supplement verbal education with standardized, BCMCH-approved patient education materials (e.g., brochures, handouts) written in plain language. Provide materials in the patient's preferred language whenever available (utilize hospital translation services as needed).

  • Visual Aids: Utilize diagrams or pictures if helpful (e.g., showing how SCDs work, location of potential clots).

  • Environment: Choose a time and place conducive to learning, minimizing distractions and ensuring privacy.

• 6.3 Core Educational Content:

  • 6.3.1 What is VTE?: Explain briefly what blood clots (DVT) in the legs and clots traveling to the lungs (PE) are. Emphasize that they are serious potential complications of being unwell or having surgery, but that steps can be taken to prevent them.

  • 6.3.2 Personalized Risk: Explain why the patient is considered at risk in simple terms related to their condition (e.g., "Because of your surgery," "Because you need to rest in bed," "Because of your specific medical condition").

  • 6.3.3 Prevention Plan Explanation: Clearly describe the specific methods being used for this patient:

    • Medication (if applicable): State the name (simple trade/generic), explain its purpose (e.g., "a blood thinner shot/pill to help prevent clots"), how and when it will be given, and the importance of taking/receiving it as scheduled. Mention common side effects like bruising and the importance of reporting any signs of bleeding (see 6.3.5).

    • Mechanical Devices (if applicable): Identify the device ("leg squeezers/SCDs," "special stockings/GCS"), explain its purpose ("helps blood flow back to the heart," "prevents blood from pooling"), demonstrate correct application/function briefly, and stress the importance of wearing it consistently as ordered (e.g., "whenever you are in bed or sitting in the chair"). Explain when it can be removed (bathing, walking) and the need to report discomfort or skin issues.

    • Mobility: Explain that movement is crucial ("walking and exercises help keep blood moving"). Encourage adherence to activity orders (getting out of bed, walking, leg exercises).

  • 6.3.4 Patient/Family Role & Actions: Emphasize their active participation:

    • Taking medications reliably.

    • Wearing mechanical devices as instructed.

    • Getting up and moving as much as safely possible, performing prescribed exercises.

    • Reporting any problems with medications or devices immediately.

    • MOST IMPORTANTLY: Reporting Symptoms.

  • 6.3.5 Critical Signs & Symptoms to Report IMMEDIATELY: Clearly list and explain the key warning signs, instructing the patient/family to alert the nurse or doctor without delay if any occur:

    • Signs of DVT (Leg Clot):

      • New pain or tenderness in the calf or thigh (often in one leg)

      • Swelling in the leg, ankle, or foot

      • Redness or warmth of the skin on the leg

    • Signs of PE (Lung Clot):

      • Sudden shortness of breath or difficulty breathing

      • Sharp chest pain, especially when taking a deep breath

      • Rapid heartbeat

      • Coughing (may cough up blood)

      • Feeling lightheaded, dizzy, or fainting

    • Signs of Bleeding (if on pharmacological prophylaxis):

      • Unusual or excessive bruising

      • Bleeding that doesn't stop (e.g., nosebleeds, gums, cuts)

      • Red or black, tarry stools

      • Red or pink urine

      • Vomiting blood or material that looks like coffee grounds

      • Severe headache or vision changes (could indicate intracranial bleed)

• 6.4 Assessing Understanding (Teach-Back Method):

  • 6.4.1 Technique: After explaining key concepts, use the "teach-back" method to assess comprehension. Ask open-ended questions like:

    • "Can you tell me in your own words why you are getting the leg squeezers?"

    • "We talked about some important warning signs. What symptoms should you tell the nurse about right away?"

    • "Just to make sure I explained it clearly, how often should you wear the special stockings?"

  • 6.4.2 Action: If understanding is incomplete, re-explain the information using different words or approaches, and re-assess understanding until comprehension is achieved. Document the use of teach-back and the outcome.

• 6.5 Documentation:

  • 6.5.1 Location: Document all patient/family education activities in the designated section of the medical record (e.g., EHR education module, nursing progress notes, interdisciplinary education form).

  • 6.5.2 Content: Documentation should include:

    • Date and time education was provided.

    • Topics covered (e.g., VTE risk, rationale for prophylaxis, medication details, device use, mobility, signs/symptoms of DVT/PE/Bleeding).

    • Who was educated (patient, family member name/relationship).

    • Method used (verbal, written materials provided [specify brochure name/code], teach-back).

    • Patient/family response and level of understanding (e.g., "Patient verbalized understanding of need for SCDs and 3 signs of DVT," "Family demonstrated understanding via teach-back").

    • Any barriers encountered (language, literacy, cognitive issues) and interventions taken (e.g., "Used certified interpreter," "Provided simplified handout").

    • Signature and credentials of the staff member providing education.

• 6.6 Discharge Education Specifics:

  • If prophylaxis continues after discharge, provide detailed instructions on medication (dose, frequency, duration, administration technique if injectable, importance of follow-up labs if needed).

  • Reinforce signs/symptoms of VTE and bleeding, emphasizing when to seek urgent/emergency care after discharge.

  • Provide contact information for questions or concerns.

  • Document discharge education clearly in the discharge summary and instructions provided to the patient.

7.0 Ongoing Monitoring & Reassessment

Purpose: To ensure the VTE prevention plan remains appropriate, effective, and safe throughout the patient's entire hospital stay by systematically reassessing risk factors, monitoring adherence, checking for complications of therapy, and maintaining clinical surveillance for signs of VTE.

Scope: Applies to all patients admitted under the HAVTE prevention policy, particularly those receiving active prophylaxis or identified as being at moderate/high risk.

Responsibilities:

• Nursing Staff: Primary responsibility for ongoing monitoring of compliance, device function, skin integrity, patient mobility, recognizing and reporting changes in condition, signs/symptoms of VTE/Bleeding, and often initiating the reassessment process based on triggers.

• Physicians (Attending/Resident/Fellow): Responsible for formally reassessing VTE and bleeding risk based on triggers or changes, adjusting the prophylaxis plan accordingly, evaluating reported signs/symptoms, and ordering diagnostic tests.

• All Clinical Staff: Responsible for maintaining awareness of VTE risk and reporting any concerning observations or patient-reported symptoms promptly.

Procedure Steps:

• 7.1 VTE Risk Reassessment:

  • 7.1.1 Rationale: A patient's risk for VTE is not static and can change significantly during their hospital stay due to evolving clinical conditions, procedures, or changes in mobility.

  • 7.1.2 Triggers for Formal Reassessment: A formal reassessment of VTE risk (repeating the process outlined in Section 2.0 using the BCMCH-approved tool) MUST be performed and documented by the Physician (often prompted or initiated by Nursing) under the following circumstances:

    • Significant Change in Clinical Condition: E.g., new diagnosis of sepsis, heart failure exacerbation, stroke, respiratory failure requiring increased support, development of significant immobility not previously present.

    • Transfer Between Levels of Care: E.g., Admission to Intensive Care Unit (ICU) from ward, transfer from ICU to ward.

    • Peri-operative Status: Both pre-operatively (to confirm plan) and post-operatively (risk often increases significantly after major surgery).

    • Significant Change in Mobility Status: Marked decrease OR improvement in ability to ambulate/mobilize.

    • Prolonged Hospital Stay: At predefined intervals determined by BCMCH policy (e.g., Weekly for patients with hospital stays exceeding 7 days), even if no other specific trigger occurs.

  • 7.1.3 Process: When triggered, repeat steps 2.2 (Information Gathering) through 2.7 (Documentation), culminating in a potentially revised VTE risk score and level.

  • 7.1.4 Action Following Reassessment: Based on the reassessed VTE risk level, the physician must re-evaluate the current prophylaxis plan (revisiting Section 4.0). This may result in initiating, stopping, or modifying pharmacological or mechanical prophylaxis. Changes must be ordered and documented.

• 7.2 Bleeding Risk Reassessment:

  • 7.2.1 Rationale: Bleeding risk is highly dynamic, influenced by medications, procedures, organ function, and underlying conditions. It requires frequent reassessment, especially in patients receiving pharmacological prophylaxis.

  • 7.2.2 Frequency & Triggers for Reassessment (Physician Responsibility):

    • Daily: For all patients receiving pharmacological VTE prophylaxis, a brief daily clinical assessment for signs of bleeding and review of relevant labs (if ordered, e.g., platelets, Hgb trends) is essential.

    • Formal Reassessment Triggered by:

      • Any new signs or symptoms of bleeding (even minor).

      • Significant drop in Hemoglobin or Hematocrit.

      • Platelet count falling below the BCMCH-defined threshold (e.g., < 100,000/µL requires review, < 50,000/µL often requires holding prophylaxis).

      • Development or worsening of renal or hepatic impairment.

      • Initiation of new medications known to increase bleeding risk (e.g., NSAIDs, antiplatelets).

      • Prior to any invasive procedure or surgery.

      • Before resuming pharmacological prophylaxis that was previously held due to high bleeding risk.

  • 7.2.3 Process: When triggered for formal reassessment, repeat the process outlined in Section 3.0 (reviewing risk factors, using checklist/tool if applicable) to determine the current bleeding risk category (Low vs. High).

  • 7.2.4 Action Following Reassessment: Based on the current bleeding risk, the physician must decide whether to continue, adjust the dose of, temporarily hold, or permanently discontinue pharmacological prophylaxis. This decision must be documented clearly, along with the rationale. If pharmacological prophylaxis is stopped due to bleeding risk, ensure appropriate mechanical prophylaxis is implemented (if not contraindicated).

• 7.3 Compliance Monitoring (Nursing Responsibility):

  • 7.3.1 Pharmacological: Check MAR for completed/missed doses during each shift. Investigate and document reasons for any missed doses and notify the physician if clinically significant or recurrent.

  • 7.3.2 Mechanical: During routine patient rounds and care:

    • Verify devices (SCDs/GCS) are correctly applied and worn as ordered (e.g., continuously while in bed/chair).

    • Check SCD pump function (power on, cycling, alarms silent).

    • Assess patient tolerance and inquire about adherence. Address reasons for non-adherence (discomfort, misunderstanding) through re-education, troubleshooting, or reporting to the physician if unresolved.

  • 7.3.3 Documentation: Document compliance levels (e.g., % of shift worn, refused doses) and interventions taken in nursing notes or flowsheets.

• 7.4 Adverse Event Monitoring (Nursing Responsibility for Initial Detection & Reporting):

  • 7.4.1 Bleeding: Continuously monitor for any signs of bleeding as listed in patient education (Section 6.3.5), including inspection of skin, IV/catheter sites, surgical wounds, urine, stool (if possible), and patient reports. Report any suspected bleeding to the physician IMMEDIATELY.

  • 7.4.2 Skin Integrity: Inspect skin under mechanical devices during routine checks (Section 5.2.4) for redness, blistering, pressure areas, or breakdown. Report issues promptly. Implement preventative skin care measures as needed.

  • 7.4.3 Heparin-Induced Thrombocytopenia (HIT): For patients receiving unfractionated heparin or LMWH, monitor platelet counts according to BCMCH protocol (e.g., baseline, then every 2-3 days for a period). Be alert for a significant drop in platelets (e.g., >50% from baseline) or new thrombosis, and report suspected HIT IMMEDIATELY to the physician for further investigation and management (requires stopping all heparin products).

  • 7.4.4 Other Reactions: Monitor for allergic reactions to medications or device materials.

  • 7.4.5 Reporting & Documentation: Report all suspected adverse events to the physician promptly. Document the event, actions taken, and physician notification in the medical record. Utilize hospital incident reporting system as per BCMCH policy for significant events.

• 7.5 VTE Surveillance (Clinical Detection):

  • 7.5.1 High Index of Suspicion: All clinical staff must maintain a high index of suspicion for VTE, even in patients receiving prophylaxis (as it is not 100% effective).

  • 7.5.2 Symptom Monitoring: Be vigilant for patient complaints or clinical signs suggestive of DVT or PE (as listed in Section 6.3.5). Perform focused assessments (e.g., limb inspection, respiratory assessment) if suspicion arises.

  • 7.5.3 Prompt Investigation: Report any signs/symptoms suggestive of VTE to the physician IMMEDIATELY. The physician will determine the need for diagnostic workup (e.g., D-dimer, Doppler Ultrasound of legs, CT Pulmonary Angiogram).

  • 7.5.4 Documentation: Document all suspected VTE events, physician notification, investigations ordered/performed, and final diagnoses in the medical record. Confirmed HAVTE events require specific tracking for quality improvement (Section 10.0).

8.0 Patient Transfer & Discharge

Purpose: To ensure that appropriate VTE prophylaxis is seamlessly continued or appropriately adjusted during patient transfers within BCMCH, and that patients are discharged with a clear plan and understanding regarding VTE prevention, including the potential need for extended prophylaxis and warning signs.

Scope: Applies to all patients under the HAVTE prevention policy undergoing internal transfer between units/levels of care or being discharged from BCMCH.

Responsibilities:

• Physicians (Sending/Receiving/Discharging): Responsible for ensuring VTE plan continuity during transfer, reassessing risk upon transfer if indicated, making decisions regarding post-discharge prophylaxis, and documenting the plan.

• Nursing Staff (Sending/Receiving/Discharging): Responsible for communicating the VTE plan during handoff, implementing orders on the receiving unit, providing discharge education, and documenting related activities.

• Pharmacists: Involved in medication reconciliation during transfer and discharge, ensuring correct prescriptions and providing counseling for post-discharge medications.

Procedure Steps:

8.1 Internal Transfer (Between BCMCH Units/Levels of Care)

• 8.1.1 Trigger: Patient requires transfer from one inpatient unit or level of care to another (e.g., ED to Ward, Ward to ICU, ICU to Ward, Ward to Step-Down Unit).

• 8.1.2 Communication - Sending Team (Physician & Nurse):

  • Handoff Report Content: The sending nurse and/or physician MUST explicitly communicate the current VTE prevention plan as part of the standardized handoff report (verbal and written/electronic). This must include:

    • Current assessed VTE Risk Level.

    • Current assessed Bleeding Risk Category.

    • Specific pharmacological prophylaxis order details (Drug, Dose, Route, Frequency, Time of last dose administered).

    • Specific mechanical prophylaxis order details (Device type, Location, Usage schedule - e.g., "SCDs bilateral calves while in bed/chair").

    • Any known contraindications or reasons for deviation from standard protocol.

    • Relevant monitoring parameters (e.g., recent platelet trend if on heparin/LMWH).

  • Documentation: Ensure the VTE plan details are accurately documented in the transfer summary notes or relevant EHR fields.

• 8.1.3 Responsibility - Receiving Team (Physician & Nurse):

  • Verification: The receiving nurse and physician must actively seek and verify the VTE prophylaxis plan information during the handoff process.

  • Order Reconciliation: The receiving physician must review and reconcile/re-order the VTE prophylaxis measures promptly upon patient arrival to the new unit to ensure no interruption in therapy. Use standardized order sets where appropriate.

  • Continuation of Care: The receiving nurse must ensure timely continuation of the ordered prophylaxis (e.g., applying SCDs, administering next medication dose on schedule).

  • Risk Reassessment: The receiving physician MUST determine if the transfer itself constitutes a trigger for VTE risk reassessment (per Section 7.1.2, e.g., transfer to ICU). If triggered, perform and document the reassessment and adjust the prophylaxis plan accordingly (per Sections 2.0, 3.0, 4.0).

• 8.1.4 Documentation: Receiving team documents confirmation of VTE plan, continuation of orders, and any reassessment/changes made in the receiving unit's admission/progress notes and EHR.

8.2 Discharge from BCMCH

• 8.2.1 Decision Point - Discharge Planning: As part of discharge planning for any patient admitted under the VTE policy, the need for post-discharge VTE prophylaxis MUST be actively considered by the discharging physician.

• 8.2.2 Assessment for Extended Prophylaxis (Discharging Physician Responsibility):

  • Review the patient's VTE risk factors at the time of discharge. Consider factors such as:

    • Type of surgery performed (especially major orthopedic, major abdominal/pelvic cancer surgery).

    • Presence of ongoing significant risk factors (e.g., active cancer, previous VTE, known thrombophilia).

    • Anticipated mobility limitations after discharge.

    • Length of hospital stay and period of immobility.

    • BCMCH guidelines/protocols specifying standard durations of extended prophylaxis for certain procedures/conditions.

  • 
    

  • Assess the patient's bleeding risk at discharge.

  • Evaluate the patient's ability to manage extended prophylaxis (cost, insurance coverage, ability to self-inject or obtain injections, cognitive ability, support system).

  • Decision: Determine if extended VTE prophylaxis (typically pharmacological) is indicated, and if so, for what duration (e.g., 10 days, 4 weeks, 3 months – based on guidelines and clinical judgment).

• 8.2.3 Discharge Orders & Prescriptions:

  • If extended prophylaxis is indicated:

    • Write a clear prescription including drug, dose, route, frequency, and specific duration.

    • Ensure necessary arrangements for medication supply and administration (e.g., patient education for self-injection, visiting nurse referral).

  • If prophylaxis is being stopped at discharge: Ensure discontinuation orders are clear.

• 8.2.4 Discharge Education (Nursing & Physician Responsibility, Delivered by Nurse primarily):

  • Provide clear verbal and written instructions (in patient's preferred language, considering health literacy) covering:

    • Prophylaxis Plan: If continuing prophylaxis: medication name, dose, how/when to take/administer, exact duration, importance of adherence, any required follow-up (lab tests, appointments). If stopping: explicitly state that prophylaxis medication is stopped.

    • Mobility: Importance of staying active, walking, and doing prescribed exercises after discharge.

    • Signs & Symptoms: Reiterate and reinforce the signs/symptoms of DVT and PE (Section 6.3.5).

    • Bleeding Risk (if applicable): If continuing pharmacological prophylaxis, reiterate signs of bleeding to watch for.

    • Action Plan: Clear instructions on when and who to contact if symptoms of VTE or significant bleeding occur (e.g., "Call your surgeon's office immediately," "Go to the nearest Emergency Department").

  • Teach-Back: Use teach-back method (Section 6.4) to confirm patient/family understanding of critical elements (e.g., medication duration, warning signs, when to seek emergency care).

• 8.2.5 Documentation (Physician & Nurse):

  • Physician: Document the decision regarding post-discharge VTE prophylaxis (including duration if prescribed, or rationale if indicated but not prescribed due to contraindications/patient factors) clearly in the Discharge Summary.

  • Nurse: Document the specific discharge education provided (topics covered, materials given, teach-back confirmation, who was educated) in the nursing discharge notes or EHR education record. Ensure patient receives a written copy of instructions.

9.0 Staff Education & Competency

Purpose: To ensure that all relevant clinical staff at BCMCH possess the necessary knowledge, skills, and understanding of the HAVTE Prevention Policy and Procedure to effectively perform their roles in risk assessment, prophylaxis implementation, patient education, and monitoring, thereby contributing to the overall success and safety of the VTE prevention program.

Scope: Applies to all clinical staff involved in the direct care of patients covered by the HAVTE policy, including but not limited to Physicians (Attendings, Residents, Fellows), Nursing Staff (RNs, LPNs/ANMs, Nursing Assistants involved in care/mobility), Pharmacists, Physiotherapists, and potentially others as identified by BCMCH (e.g., Medical Students, Interns during relevant rotations).

Responsibilities:

• Department Heads (Medicine, Surgery, Nursing, Pharmacy, Physiotherapy, etc.): Responsible for ensuring their staff complete mandatory training and maintain competency relevant to their roles.

• Nursing Education Department: Responsible for developing, coordinating, delivering, and tracking VTE prevention education and competency assessments for nursing staff.

• Medical Education Department / Residency Program Directors: Responsible for incorporating VTE prevention training into physician orientation, residency curricula, and continuing medical education programs.

• Pharmacy Department: Responsible for providing education on pharmacological agents used for prophylaxis, including dosing, monitoring, and interactions, particularly to pharmacists and potentially contributing to nursing/physician education.

• Physiotherapy Department: Responsible for education related to mobilization techniques and potentially assisting with mechanical device competency for relevant staff.

• Quality & Patient Safety Department: May coordinate overall program education strategy, provide data/feedback for educational content, and assist in monitoring training compliance.

• Individual Staff Members: Responsible for actively participating in required training, seeking clarification when needed, and applying learned knowledge and skills in practice.

Procedure Steps:

• 9.1 Core Educational Content: Training programs must cover, at a minimum, the following topics tailored to the specific roles and responsibilities of the staff group:

  • VTE Pathophysiology & Epidemiology: Basic understanding of DVT/PE, risk factors, and the significance of HAVTE as a patient safety issue.

  • BCMCH HAVTE Policy & Procedure: Overview of the hospital's commitment, policy scope, and the step-by-step procedural outline (Sections 1-10).

  • Roles & Responsibilities: Clear definition of what is expected from each discipline (Physician, Nurse, Pharmacist, Physio) at each stage of the process.

  • VTE Risk Assessment Tool: Detailed instruction on how to accurately use the BCMCH-approved VTE risk assessment tool (e.g., Modified Caprini), including data gathering, scoring, and interpretation of risk levels.

  • Bleeding Risk Assessment: Understanding the factors contributing to bleeding risk, how to use the BCMCH-approved bleeding risk assessment method/checklist, and its importance in decision-making.

  • BCMCH Prophylaxis Guidelines: Familiarity with the hospital's specific recommendations for pharmacological and mechanical prophylaxis based on VTE risk level, bleeding risk, and patient population (Medical, Surgical, ICU, etc.).

  • Pharmacological Agents: Knowledge of commonly used agents (Heparins, LMWHs, potentially DOACs if used), including mechanisms, standard dosing for prophylaxis, common side effects (esp. bleeding, HIT), necessary monitoring, contraindications, and dose adjustments (e.g., renal impairment, obesity).

  • Mechanical Devices: Proper application technique for SCDs and GCS (including sizing), operation and troubleshooting of SCD pumps, required skin assessment, contraindications, and importance of monitoring patient compliance and tolerance.

  • Patient Education Techniques: How to effectively educate patients and families about VTE risk, the prevention plan, device use, medication adherence, mobility, and critical signs/symptoms to report (including use of teach-back method).

  • Documentation Standards: Understanding the specific documentation requirements within the EHR or paper chart for risk assessments, prophylaxis orders, administration/application, monitoring, education, and reassessments.

  • Quality Improvement: Awareness of how compliance and outcome data are tracked and used for program improvement.

• 9.2 Training Delivery Methods: A blended approach should be utilized:

  • New Employee/Staff Orientation: Mandatory introductory session covering the core elements of the VTE prevention program for all new clinical hires and credentialed physicians.

  • Annual Mandatory Training: Required refresher course (potentially online module with post-test) covering key policy points, updates, and areas identified through quality audits as needing reinforcement.

  • Skills Labs/Workshops: Hands-on sessions for nursing and physiotherapy staff focusing on correct application and troubleshooting of mechanical devices (SCDs/GCS).

  • Discipline-Specific Sessions: Targeted education for physicians (e.g., grand rounds, departmental meetings focusing on guidelines, ordering), pharmacists (e.g., updates on agents, dosing), etc.

  • Online Learning Modules: Development of self-paced online modules covering core content, accessible to staff anytime.

  • Point-of-Care Reminders: Job aids, pocket cards, posters, or EHR alerts reinforcing key steps or guidelines.

  • Case Reviews/Audits with Feedback: Discussing specific cases or audit results in departmental meetings to highlight best practices and areas for improvement.

• 9.3 Timing and Frequency:

  • Initial: Must be completed upon hire/credentialing before staff independently manage patients under this policy.

  • Annual: Mandatory refresher training required yearly for all relevant staff.

  • As Needed: Additional training provided when policies/procedures/guidelines are significantly updated, new devices/medications are introduced, or quality data indicates a specific educational need.

• 9.4 Competency Assessment & Validation:

  • Knowledge Assessment: Post-tests following educational sessions (classroom or online) to verify understanding of core concepts. Minimum passing scores should be established.

  • Skills Validation (Mechanical Devices): Direct observation using a standardized checklist for nursing/physio staff demonstrating correct sizing, application, pump setup (SCDs), and patient instructions for mechanical devices. Initial validation and periodic revalidation (e.g., annually or biennially).

  • Chart Audits: Retrospective or concurrent review of documentation (risk assessments, orders, administration records, education notes) with feedback provided to individuals or departments on adherence to procedures.

  • Direct Observation: Occasional observation of staff performing risk assessments or providing patient education during routine practice (e.g., by clinical educators, senior staff, or during quality rounds).

  • Documentation of Competency: Maintaining records of completed training and successful competency assessments for each staff member within their personnel file, departmental records, or a centralized education tracking system.

• 9.5 Resource Availability: Ensure easy access to the current HAVTE Prevention Policy, Procedures, Risk Assessment Tools, Prophylaxis Guidelines, and Patient Education Materials via the hospital intranet, EHR resources section, or designated unit binders.

10.0 Quality Improvement & Audit

Purpose: To establish a systematic process for monitoring the effectiveness and safety of the HAVTE Prevention Procedure, measuring compliance with key steps, identifying areas for improvement, and driving continuous enhancement of VTE prevention practices at BCMCH.

Scope: Encompasses all aspects of the HAVTE prevention process across all relevant inpatient units and clinical staff.

Responsibilities:

• Quality & Patient Safety (QPS) Department: Primary responsibility for coordinating the overall VTE quality improvement program, designing audit tools, overseeing data collection and analysis, generating reports, and facilitating action planning.

• VTE Committee (or designated Patient Safety Subcommittee): Provides clinical leadership and expertise, reviews audit data and HAVTE cases, recommends changes to policy/procedure/guidelines, champions improvement initiatives, and reviews outcome data.

• Clinical Department Heads (Medicine, Surgery, Nursing, etc.): Responsible for reviewing department-specific data, disseminating findings to their staff, implementing action plans within their areas, and fostering a culture of compliance and safety.

• Pharmacy Department: Monitors appropriate prescribing patterns, contributes data on medication usage and potential errors/adverse drug events related to prophylaxis.

• Health Information Management (HIM) / Medical Records: Assists in identifying patient cohorts for audit and potentially abstracting specific data points.

• All Clinical Staff: Responsible for participating in QI initiatives, providing feedback on process barriers, and adhering to updated procedures.

Procedure Steps:

• 10.1 Data Collection & Monitoring:

  • 10.1.1 Key Performance Indicators (KPIs): BCMCH will track a defined set of process and outcome measures, including but not limited to:

    • Process Measures:

      • % of eligible patients with documented VTE risk assessment completed within 24 hours of admission.

      • % of patients with moderate/high VTE risk who have appropriate prophylaxis ordered (considering both VTE risk level and bleeding risk assessment).

      • % of ordered pharmacological prophylaxis doses administered as prescribed (MAR audit).

      • % of patients ordered for mechanical prophylaxis with documented appropriate application/use (e.g., compliance checks, skin assessments documented).

      • % of patients with appropriate documentation of contraindications when indicated prophylaxis is withheld.

      • % of patients receiving appropriate patient/family education documented.

      • % of patients reassessed for VTE risk upon meeting predefined triggers (e.g., ICU transfer, surgery).

    • Outcome Measures:

      • Rate of confirmed Hospital-Acquired VTE (DVT and PE) per 1000 patient discharges or per 1000 patient days (using standardized definitions, e.g., AHRQ PSI 12).

      • Rate of major bleeding events potentially attributable to VTE prophylaxis.

  • 10.1.2 Data Sources: Data will be collected through:

    • Manual or electronic chart audits (using standardized audit tools).

    • EHR reporting capabilities (if available for automated data extraction).

    • Hospital incident reporting systems (for VTE events and bleeding complications).

    • Pharmacy dispensing records.

    • Coding data (ICD codes for VTE/Bleeding – use with caution, requires clinical validation).

• 10.2 Audit Process:

  • 10.2.1 Frequency: Regular audits (e.g., monthly or quarterly) will be conducted by the QPS Department or designated auditors.

  • 10.2.2 Methodology: Audits will typically involve retrospective review of a representative sample of patient records (e.g., random sampling across units, targeted sampling of high-risk populations, or review of all confirmed HAVTE cases). Concurrent audits may be performed periodically for real-time feedback.

  • 10.2.3 Audit Tool: A standardized audit tool, reflecting the KPIs and procedural steps, will be used to ensure consistency in data collection.

• 10.3 Data Analysis:

  • 10.3.1 Calculation: Collected data will be aggregated and analyzed to calculate compliance rates, event rates, and trends over time.

  • 10.3.2 Comparison: Data may be stratified by clinical unit, service line, or patient population to identify specific areas of high performance or opportunity. Benchmarking against available external data sources may be performed where feasible.

  • 10.3.3 Root Cause Analysis: For identified gaps in performance (e.g., low compliance rates, clusters of HAVTE events), root cause analyses (RCAs) or focused reviews will be conducted by the VTE Committee/QPS to understand underlying barriers (e.g., knowledge gaps, workflow issues, communication failures, system problems). All confirmed HAVTE events should undergo a detailed review.

• 10.4 Reporting & Feedback:

  • 10.4.1 Reports: Regular performance reports summarizing KPI trends, audit findings, and HAVTE event reviews will be generated by QPS.

  • 10.4.2 Dissemination: Reports will be shared with relevant stakeholders including:

    • VTE Committee / Patient Safety Committee

    • Medical Executive Committee (MEC)

    • Nursing Leadership

    • Pharmacy & Therapeutics (P&T) Committee

    • Clinical Department Heads and frontline staff (e.g., via unit meetings, dashboards, newsletters).

  • 10.4.3 Format: Feedback should be timely, clear, specific, non-punitive, and focused on system improvements. Data visualization (e.g., run charts, bar graphs) should be used to illustrate trends effectively.

• 10.5 Action Planning & Improvement Cycle (PDSA):

  • 10.5.1 Identify Opportunities: Based on data analysis and RCA findings, the VTE Committee and QPS, in collaboration with clinical departments, will identify specific opportunities for improvement.

  • 10.5.2 Develop Action Plans: Develop targeted action plans to address identified gaps. Plans should include specific interventions (e.g., focused re-education, revision of order sets, EHR modifications, workflow changes), responsible parties, timelines, and measurable goals.

  • 10.5.3 Implement Actions: Implement the approved action plans.

  • 10.5.4 Monitor Impact: Continue monitoring relevant KPIs after implementation to evaluate the effectiveness of the interventions and determine if the desired improvements have been achieved. Adjust the plan as needed based on ongoing monitoring.

• 10.6 Policy & Procedure Review:

  • 10.6.1 Regular Review: The HAVTE Prevention Policy, associated Procedures, Risk Assessment Tools, Bleeding Risk Tools, and Prophylaxis Guidelines will undergo formal review by the VTE Committee (or equivalent) and relevant stakeholders at predefined intervals (e.g., annually or biennially), or sooner if indicated.

  • 10.6.2 Triggered Review: Reviews will also be triggered by:

    • Publication of significant new national/international VTE prevention guidelines (e.g., CHEST, ASH, ESC).

    • Significant changes in internal performance data or trends identified through audits.

    • Introduction of new prophylactic agents or technologies at BCMCH.

    • Feedback from frontline staff regarding process barriers or effectiveness.

  • 10.6.3 Update & Dissemination: Any revisions to policy, procedures, or tools must be formally approved, documented, and effectively communicated to all relevant staff, accompanied by necessary re-education (linking back to Section 9.0).

• 10.7 Culture of Safety: Promote a hospital culture where VTE prevention is recognized as everyone's responsibility, and staff feel empowered to speak up about concerns, report near misses or events, and contribute to ongoing improvement efforts without fear of blame.