13.1 Local implementation

Implementation of national clinical guidelines is the responsibility of each NHS Trust and is an essential part of clinical governance. It is acknowledged that every Trust cannot implement every guideline immediately on publication, but mechanisms should be in place to ensure that the care provided is reviewed against the guideline recommendations and the reasons for any differences assessed and, where appropriate, addressed. These discussions should involve both clinical staff and management. Local arrangements may then be made to implement the national guideline in individual hospitals, units and practices, and to monitor compliance. This may be done by a variety of means including patient-specific reminders, continuing education and training, and clinical audit.

Following publication of the original guideline in 1995, most acute hospital trusts in Scotland appear to have established local guidelines for prophylaxis of VTE.^26,27,28,29 The revised guideline includes several major changes to the recommendations of the pilot guideline (summarised in section 1).

It is recommended that hospitals in Scotland should:

• ensure that local guidelines are in place for relevant surgical, medical and family planning patients
• update existing local guidelines in accordance with the revised national guideline
• perform clinical audit at appropriate intervals.

13.2 Key points for audit

• presence of a local guideline,²⁶ updated in accordance with the present national guideline
• audit of compliance with local guideline.²⁹

13.3 Resource implications

A recent national audit of VTE prophylaxis in NHS hospitals across Scotland showed a high level of compliance with the local guideline.²⁹ It is therefore unlikely that there are major new resource implications overall in implementing the current revised national guideline.

The major new recommendation with cost implications is that general medical patients be prescribed heparin prophylaxis (section 8.3.1): LMWHs are noted to carry a lower risk of bleeding than UFH.

On the other hand, for patients undergoing major orthopaedic surgery prophylaxis with mechanical methods or aspirin is recommended at a similar level of evidence to heparins (section 5), at potentially lower cost.

The current revised national guideline notes that for prophylaxis in surgical patients there is no evidence to prefer LMWH to UFH for efficacy or safety (section 3). However, LMWH is safer for prophylaxis in general medical patients (section 8.3.1) and in pregnancy (section 9). LMWH is increasingly used for outpatient treatment of established DVT⁶ and for treatment of unstable angina, in which situations it is more effective than UFH. Acute trusts in Scotland may therefore wish to consider their overall purchasing strategy for heparins when developing their local guidelines for prophylaxis of VTE (current guideline), treatment of VTE (SIGN guideline 36)⁶ and treatment of unstable angina. While LMWHs are more expensive than UFH according to the British National Formulary⁹⁴, there may be cost savings due to bulk purchase contracts, and staff time (LMWHs require fewer injections than UFH).

13.4 Key messages for patients admitted to hospital

This example patient information leaflet is provided for possible use, or adaptation, when discussing treatment options with patients.