MINUTES OF THE TRUST THROMBOSIS GROUP

HELD ON MONDAY 28th SEPTEMBER 2015

Present

LA / Compliance Manager
SD / Consultant Haematologist
MD / Measurement, Effectiveness & Audit Facilitator
GF / Clinical Quality & Patient Safety Analyst
AT / Consultant in Acute Medicine

Apologies:

LV / Vascular Nurse Specialist
EW / Pharmacist
SS / Clinical Nurse Specialist
LP / Consultant in Care of the Elderly
CM / Associate Director of Nursing - Medicine
001/09.15 / Apologies/Introductions
Apologies for absence were noted.
002/09.14 / Draft Minutes
The minutes were agreed as an accurate reflection of the meeting.
003/09.15 / Action Log
The action log was reviewed in full and updates made directly into the log.
004/09.15 / Review of VTE Work Plan
The VTE Work Plan is nearly complete and LA will circulate the document to the group before the next VTE Meeting in November.
AT asked for the electronic version of the VTE Prophylaxis form to be added to the work plan.
005/09.15 / HAVTE Incident Reporting and Investigation – including incident data from Safety Thermometer
GF circulated the Trust VTE incident data for the period 12 months to August 2015.
Beacon Oncology had the highest recorded number of new VTE incidents but overall the data revealed no cause for concern.
Gould Ward showed an elevated number of new recorded VTE’s so GF agreed to check the criteria for identifying VTE cases and will liaise with SH who leads on Safety Thermometer and SF to examine the process for incident reporting.
Action:
·  GF will talk to SH and SF about the criteria and reporting process for identifying VTE cases following the elevated numbers on Gould Ward.
006/09.15 / VTE Risk Assessment performance Review
GF Circulated the results of the VTE Risk Assessment Audit which showed over a 95% performance for June, July and August. Both Acute Medicine and Surgical achieved a high performance, whilst Women & Children dropped below the 95% target.
GF will contact GKD about the low compliance figures for VTE risk assessments in ENT.
Action:
·  GF will contact GKD about the low compliance figures for VTE risk assessments in ENT.
007/09.15 / NICE Guidance Compliance Monitoring – Risk Assessment /progress update on low limb cast prophylaxis
LA handed out the register of NICE guidance for information.
The risk assessment for Trauma and Orthopaedics for non-conformity with NICE Guidance CG92 regarding VTE risk assessment for patients with lower limb casts was discussed. The risk highlights the Trusts failure to identify patients who are at high risk of VTE when they have lower limb casts. LA will talk to CP and feedback to SD for advice on the appropriate prophylaxis and form to use.
CG144 Venous thromboembolic diseases – AT is unable to sign this off until he has spoken to JJ about identifying a link person in the CCG to discuss the pathway of the NICE guidance.
Actions:
·  LA will talk to CP about NICE guidance CG92, VTE risk for patients with lower limb casts and feedback information to SD for advice on appropriate Prophylaxis and form to be used.
008/09.15 / Policies and Guidance Review
LA provided a list of Policies for review and the departments owning them.
The Prevention and Treatment of VTE and Anticoagulation for AF Policies are both currently over their review date. LA will inform DM that the Anticoagulation for AF Policy is out of date.
The link to Trust Policies can be accessed via share point on the intranet site.
LA advised that the CCG were due to visit the Trust in January 2016 so updates to the out of date polices would be needed by this date.
SD Circulated the Trust Policy for Prevention and treatment of venous thromboembolism and use of anticoagulants for feedback. AT agreed to be co-author for this policy. The group agreed to take out the pink risk assessment form.
009/09.15 / Any other business
LA advised the group that the CQC will be visiting the Trust in January 2016.
All-Party Parliamentary Thrombosis Group Form was discussed and AT provided some updates. There is no instant data available to complete the form so Safety Thermometer data will be used.
Date of next meeting:
23rd November 2015 at 12.30 – 14.00 – Board Room 2

1

Enc 1