Venous Thromboembolism Prophylaxis (VTE) Medicine Accreditation ROP Compliance 2016

Medical and Surgical Clients at risk of venous Thromboembolism (DVT and PE) are identified and provided with appropriate thromboprophylaxis

Venous Thromboembolism (VTE) is the collective term for deep vein thrombosis (DVT) and pulmonary embolism (PE)

VTE Serious and common complication for those in hospital or undergoing surgery. The incidence of VTE can be reduced or prevented by identifying clients at risk and providing appropriate, evidence informed, thromboprophylaxis.

VTE Widespread human and financial impact of Thromboembolism is well documented Is associated with increased client mortality Most common preventable cause of hospital death Appropriate prophylaxis reduces cost and median length of stay

Major Tests for Compliance There is a written Venous Thromboembolism (VTE) prophylaxis policy or guideline http://www.compassionnet.ca/Policies/VII-B-370.pdf

Major Tests for Compliance Clients at risk for VTE are identified and provided with appropriate, evidenced informed VTE prophylaxis.

VTE @ Covenant Assessment for Venous Thromboembolism Risk Every adult (18 years of age and older) acute care hospitalized patient shall be assessed for venous Thromboembolism risk at the time of admission to hospital, at the time of a significant change in clinical status, at the time of transfer from one type of care to another, and at discharge.

VTE @ Covenant Commencement of Venous Thromboprophylaxis Optimal, evidence-based thromboprophylaxis shall be provided to every adult acute care patient in whom it is indicated based on their risk of thrombosis, their risk of bleeding, and available options in the facility. http://www.compassionnet.ca/Policies/VII-B-370.pdf

Minor Tests of Compliance Measures for appropriate VTE prophylaxis are established, the implementation of appropriate VTE prophylaxis is audited, and the information is used to make improvements to services.

VTE @ Covenant The Canadian Patient Safety Institute (CPSI) Audit Tool will be used for VTE Prophylaxis audits to assist with the coordination of measurement and reporting. The purpose of the audits is to measure and provide feedback to the sites about how they are doing with implementing the VTE prophylaxis policy and guideline. This will ensure that patients are receiving safe care and is one component of the VTE Required Organizational Practice (ROP) for accreditation requirements.

Major Tests of Compliance Major orthopedic surgery clients who require post discharge prophylaxis are identified and there is a process to provide them with appropriate post discharge prophylaxis Noted in policy http://www.compassionnet.ca/Policies/VII-B-370.pdf

Minor Test of Compliance Information is provided to clients and team members about the risks of VTE and how to prevent it.

VTE @ Covenant Patient Information Brochure Patient education provided by staff *Remember to document patient education!!

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