During this period of research, a number of external topic experts delivered a concurrent national survey of VTE leads, endorsed and supported by the ‘Getting it Right First Time (GIRFT)’ national project team. This survey has since been published as an online report and quantifies many aspects of current practice relevant to the VTEAM study.150
Our PMG chose not to repeat this work, due to the scale and credibility of the GIRFT project and likelihood of survey fatigue in the relevant clinical population. We opted instead to supplement GIRFT data through a further abbreviated national survey of VTE leads at acute NHS hospitals across the UK, focused on practicalities of risk assessment and future research proposals. In particular, we sought to determine (1) local methods used to record VTE risk-assessment data and (2) willingness to participate in an implementation study of risk-assessment tools, in line with our original protocol.
Methods
A national cross-sectional online survey reported using the consensus-based Checklist for Reporting of Survey Studies (CROSS).151
Population
We identified local VTE leads through the National Nursing and Midwifery Network, VTE exemplar centre network and the collated list utilised by the recently published GIRFT project. VTE leads represented a range of clinical disciplines, including anticoagulation pharmacists, specialist nurses, doctors and ward managers.
Survey design and dissemination
We designed the survey using Smartsurvey.co.uk. We utilised the VTEAM PMG to refine the questions through iterative development. The final survey included free text answers, radio button responses and multiselect options. Regarding VTE risk assessment, we included questions on positive characteristics (recording the definitive presence of a risk factor) and negative characteristics (recording the definitive absence of a risk factor). The survey was trialled on three members of the PMG prior to circulation, with incorporated feedback. A copy of the survey is available in Appendix 4.
We used single-stage sampling over a four-week period, from 20 October 2021 to 17 November 2021 inclusive. We disseminated the survey by personal e-mail, with facilitated access through a weblink, QR code and direct web address. We sent weekly reminders to all potential participants throughout the survey duration. We asked for trust identification to guard against multiple participant responses. Given the time frame, need for site identification and direct personal contact through an established list of VTE leads, we did not add security measures to the survey. We did not seek specific ethical approval for this survey work and assumed implied consent from clinicians for participation in the survey.
Statistical analysis
We did not perform a sample size calculation for this survey. All analyses were proportional or descriptive. No weighting was applied to any variables.
Results
We received 65 total responses to the survey, with 25 full completions. The survey was sent originally to 105 potential participants, representing a partial response rate of 61.9% and a total response rate of 23.8%. A summary of responding sites is included in Appendix 4.
Methods of VTE risk assessment and data capture
The majority of respondents (48%) reported using EHR to conduct VTE risk assessment within an NHS setting, although 20% respondents reported using a hybrid approach (paper prof orma and EHR) at site dependent on ward environment. A large proportion of sites (32%) reported use of a paper pro forma only.
The majority of respondents noted their site method of risk assessment to report positive VTE characteristics (57% for paper pro forma, 73% for EHR) and the final decision on thromboprophylaxis (57% for paper pro forma, 64% for EHR). Routine capture of negative risk characteristics was lower overall, with only 19% of sites using paper pro forma and 32% of sites reporting capture.
The majority of sites (52%) responding reported that they were uncertain as to whether they could access granular data from VTE risk assessments conducted within routine care, through local business intelligence requests.
Willingness to participate in future research
Enthusiasm appeared higher for participation in future research overall. More respondents were willing to participate in future observational research on VTE risk assessment (100%) compared to interventional research, including randomisation to different models of assessment (72%). When further questioned on potential methodologies for future interventional research, most respondents favoured either allocation of the whole trust site or certain wards to intervention/control within the context of a wider national cluster RCT, above a longitudinal step wedge design or individual patient randomisation. This preference continued through scenarios involving comparison of RAMs, higher dosing strategies for higher-risk patients and opt-out strategies for default prescribing. Pie chart summaries of proportional response are shown in Figure 26 below.
FIGURE 26 Proportional summary preferences for research design methods on future prophylaxis studies. (Figure not reproduced here; see the original article.)
Thematic analysis of free text responses
We received 21 free text responses, listed in Appendix 4. Themes of response included support for potential study designs evaluating opt-out strategies for prophylaxis/mandatory prescribing, higher dosing strategies for higher-risk patients and further refinement of bleeding risk scores. Several responses highlighted support for cluster or broad implementation study designs in this area, citing the existing challenges of standardisation and the potential for individual randomisation strategies to increase confusion. In particular, several respondents referred to the ‘tick box’ nature of VTE risk assessment and highlighted the increasing medical scrutiny on the value of complex risk assessment.
Several respondents highlighted areas of VTE risk assessment they felt required further specific research: exclusion of medical patients at ‘baseline’ mobility; better clarification of dehydration and other subjective risks; evidence that routine care follows national guidance on assessment and prescribing; validity of the Department of Health risk assessment tool; defining higher-risk categories.
Concerns were highlighted regarding the variation in care by speciality group, and the potential for more nuanced risk assessment to benefit certain elective surgical groups. In addition, several responders highlighted the potential delays in adapting EHRs as a concern for future research designs looking to change the manner/standard of risk assessment. Finally, several respondents noted concern about an opt-out strategy as moving away from current evidence themes on individualisation of approach.
Summary and key findings
- Recently published GIRFT data suggest that the vast majority of UK sites (87%) continue to use the Department of Health VTE risk assessment tool to guide pharmacological prophylaxis decisions on admission to hospital. A high proportion (80%) of these sites also use weight-adjusted prescribing strategies.
- Less than half of respondents to our survey report consistent use of an EHR to facilitate and record VTE risk assessment. Less than a third of sites record the absence of VTE risk characteristics. Half of our respondents were uncertain as to whether they could access granular data on risk characteristics through local business intelligence/information technology support services. This implies future studies using routinely collected data on individual VTE risk characteristics at admission are likely to be untenable.
- VTE leads appear enthusiastic for further research in this area. Regarding interventional research, respondents appeared to prefer implementation designs (whole clinical areas randomised to a new intervention) rather than an individual patient randomised design.