HSIB: Investigation into management of venous thromboembolism risk in patients following thrombolysis for an acute stroke (October 2020)

Summary

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.

Content

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.