title: The implementation of NICE guidance on venous thromboembolism risk assessment and prophylaxis: a before-after observational study to assess the impact on patient safety across four hospitals in England.
abstract: BACKGROUND
  Venous thromboembolism (VTE) is a major cause of morbidity and mortality in hospitalised patients. VTE prevention has been identified as a major health need internationally to improve patient safety. A National Institute for Health and Clinical Excellence (NICE) guideline was issued in February 2010. Its key priorities were to assess patients for risk of VTE on admission to hospital, assess patients for bleeding risk and evaluate the risks and benefits of prescribing VTE prophylaxis. The aim of this study was to evaluate the implementation of NICE guidance and its impact on patient safety.
  
  
  METHODS
  A before-after observational design was used to investigate changes in VTE risk assessment documentation and inappropriate prescribing of prophylaxis between the year prior to (2009) and the year following (2010) the implementation of NICE guidance, using data from a 3-week period during each year. A total of 408 patients were sampled in each year across four hospitals in the NHS South region.
  
  
  RESULTS
  Implementation strategies such as audit, education and training were used. The percentage of patients for whom a VTE risk assessment was documented increased from 51.5% (210/408) in 2009 to 79.2% (323/408) in 2010; difference 27.7% (95% CI: 21.4% to 33.9%; p < 0.001). There was little evidence of change in the percentage who were prescribed prophylaxis amongst patients without a risk assessment (71.7% (142/198) in 2009 and 68.2% (58/85) in 2010; difference -3.5% (95% CI: -15.2% to 8.2%; p =0.56) nor the percentage who were prescribed low molecular weight heparin amongst patients with a contraindication (14% (4/28) in 2009 and 15% (6/41) in 2010; RD = 0.3% (95% CI: -16.5% to 17.2%; p =0.97).
  
  
  CONCLUSIONS
  The documentation of risk assessment improved following the implementation of NICE guidance; it is questionable, however, whether this led to improved patient safety with respect to prescribing appropriate prophylaxis.
authors.affiliation: PenCLAHRC, National Institute for Health Research, Plymouth University Peninsula Schools of Medicine and Dentistry, N6 ITTC Building, Tamar Science Park, Derriford, Plymouth PL6 8BX, UK. alice.bateman@pcmd.ac.uk
authors.forename: Alice G
authors.initials: AG
authors.lastname: Bateman
authors.forename: Rod
authors.initials: R
authors.lastname: Sheaff
authors.forename: Susan
authors.initials: S
authors.lastname: Child
authors.forename: Olga
authors.initials: O
authors.lastname: Boiko
authors.forename: Obioha C
authors.initials: OC
authors.lastname: Ukoumunne
authors.forename: Tim
authors.initials: T
authors.lastname: Nokes
authors.forename: Adrian
authors.initials: A
authors.lastname: Copplestone
authors.forename: Christian A
authors.initials: CA
authors.lastname: Gericke
mesh_terms: D000925:Anticoagulants / Q000627:therapeutic use; D018890:Chemoprevention / Q000706:statistics & numerical data*; D000075202:Contraindications; D004739:England; D019983:Guideline Adherence; D006495:Heparin, Low-Molecular-Weight / Q000627:therapeutic use; D006761:Hospitals; D006801:Humans; D061214:Patient Safety / Q000706:statistics & numerical data*; D018570:Risk Assessment; D012307:Risk Factors; D054556:Venous Thromboembolism / Q000453:epidemiology / Q000517:prevention & control*
chemical_list: D000925:Anticoagulants; D006495:Heparin, Low-Molecular-Weight