This Healthcare Safety Investigation Branch (HSIB) investigation focused on:
- the management of VTE risk in inpatients following thrombolysis for an acute stroke
- detection of medical problems (that impact on VTE risk) occurring in inpatients following thrombolysis for an acute stroke.
HSIB makes the following safety recommendation:
It is recommended that the Intercollegiate Stroke Working Party with support from the Joint Stroke Medicine Committee and NHS England and NHS Improvement develop a stroke specific venous thromboembolism (VTE) assessment tool and system for ordering the associated treatment for patients who have suffered a stroke. HSIB recommend that the Intercollegiate Stroke Working Party supports development of a tool that ensures that important information is recorded and reviewed at appropriate
intervals. The following points should be considered in the development of this tool:
• The aetiology/type of stroke (ischaemic and haemorrhagic).
• A record of the individual risk factors for VTE that are identified.
• Contraindications for VTE treatment measures.
• The VTE preventative treatment recommendation.
• The record of administration of that treatment.
• The reason that treatment is not administered.
• Patient’s level of mobility and activity (in relation to IPC administration).
• Frequency of IPC devices checking.
• Record of patient’s consent and understanding of risk/benefits of intervention, including patient’s decision.