R E S E A R C H P A P E R

Venous thromboembolism (VTE) risk assessment:Rural nurses’ knowledge and use in a rural

acute care hospital

Sherryl Gaston, RN BN Grad Dip Acute Nursing CF-JBI AFAAQHCLecturer in Nursing and Rural Health, University of South Australia Centre for Regional Engagement, Whyalla Norrie, South Australia,

Australia

Sarahlouise White, BSc (Hons) PhDResearch Fellow, Implementation Science, The Joanna Briggs Institute, Faculty of Health Sciences, The University of Adelaide, Adelaide,

South Australia, Australia

Accepted for publication July 2012

Gaston S, White S. International Journal of Nursing Practice 2013; 19: 60–64Venous thromboembolism (VTE) risk assessment: Rural nurses’ knowledge and use in a rural acute

care hospital

It is estimated that about 2000 people die as a result of venous thromboembolism (VTE) each year, with a further 30 000being hospitalized. Prophylaxis significantly reduces VTE morbidity and mortality, and thus represents a real long-termhealth-care benefit. The aim of this study was twofold: (i) to assess the current level of compliance to VTE risk assessmentand prophylaxis best practice guidelines within an Australian rural hospital; and (ii) to determine the effectiveness of nurseeducation on that compliance. VTE compliance information was obtained from auditing patient notes for a 3-month periodprior to nurse education and was repeated after the education. Nurse knowledge of VTE risk assessment and prophylaxisuse was also measured. Both compliance with and knowledge of best practice VTE risk assessment and prophylaxisincreased following nurse education. Although the sample size was relatively small, this study has shown nurse educationto be effective at increasing VTE compliance and awareness within an Australian rural hospital. This relatively inexpensiveand simple intervention bears consideration and could lead to reductions in the morbidity and mortality associated withVTE, as well as reduction in associated health-care costs.

Key words: best practice, prophylaxis, risk assessment, rural nurse, venous thromboembolism.

INTRODUCTIONVenous thromboembolism (VTE) is the collective namefor deep vein thrombosis (DVT) and pulmonary embo-lism (PE).1 DVT is where a blood clot forms in the deepveins of the leg (sometimes the pelvis). A DVT might

cause leg swelling, tenderness and pain.1 PE can occurwhen some or all of the clot breaks away and moves fromthe vein to lodge in the lungs. A PE can cause chest pain,bloody sputum, shortness of breath and heart failure.1

The incidence of VTE has been identified as being up to100 times greater in hospitalized patients than those livingin the community who are the same age.2 The NationalInstitute of Clinical Studies2 have estimated that about2000 people die as a result of VTE each year, with afurther 30 000 being hospitalized.2 Of the 2000 deaths,

Correspondence: Sherryl Gaston, University of South Australia Centrefor Regional Engagement, 111 Nicolson Avenue, Whyalla Norrie, SA5608, Australia. Email: sherryl.gaston@unisa.edu.au

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International Journal of Nursing Practice 2013; 19: 60–64

doi:10.1111/ijn.12028© 2013 Wiley Publishing Asia Pty Ltd

many could have been prevented with the use of prophy-lactic measures such as anti-embolic stockings and/orantithrombotic drugs.2 VTE is costly to treat and can leadto short-term as well as long-term morbidity and mortal-ity.1 Therefore, prevention of VTE by using the riskassessment tool and early prophylaxis is the best option toreduce the rates of VTE in the acute hospital setting.1

Appropriate prophylaxis has been shown to significantlyreduce VTE incidence, reducing the long-term costs toboth the patient and the health-care system.3

Due to the high prevalence of VTE, best practiceguidelines1 recommend that all adult patients admittedto hospital should be assessed for risk of developinga VTE, using a validated risk assessment tool. Oncecategorized by risk, appropriate prophylaxis could beprovided as necessary. There is evidence to suggest thatVTE risk assessment is being underutilized or performedsuboptimally.1

A recent study has demonstrated that VTE compliancewithin a metropolitan Australian hospital increased dra-matically from 27% to 85% over a 5-year period3 as adirect result of evidence-based education sessions, aimedat increasing nurse knowledge and empowering nurses totake responsibility for undertaking VTE risk assessments.3

VTE compliance within rural Australian hospitals has notbeen determined; however, as inequalities have beenidentified in areas of health care between urban and ruralregions,4 the underutilization of VTE risk assessment andnon-compliance with best practice guidelines is likely tobe greater in rural areas.

The aim of this study was twofold: (i) to determine thelevel of compliance with best practice recommendationsregarding VTE risk assessment in an Australian rural hos-pital; and (ii) to determine whether interventions aimed atincreasing nurse knowledge and awareness of the impor-tance of VTE risk assessment and appropriate prophylaxiswould lead to an increase in compliance.

METHODSThis study had two objectives. The first was to determinethe current level of VTE risk assessment and prophylaxiscompliance within a rural South Australian hospital,which has 82 staffed beds and a 20-bed day surgery unit.The approach used was similar to what Collins et al.3 usedin a metropolitan Brisbane hospital (Australia). Ethicsapproval was obtained from the Hospital Executive Com-mittee and the primary researcher’s University ethicscommittee prior to commencement of the study.

A baseline assessment of VTE risk assessment andprophylaxis details were obtained from an audit of 100patient notes (50 medical and 50 surgical admissions) overa 3-month period. The case notes were selected randomlyfrom admissions by the Patient Services Officer at the ruralhospital. Eligible case notes were those of adults, admittedduring the allocated time period, and that they wereadmitted under either the surgical or medical streams. Theaudit was completed by a registered nurse who is a Lec-turer in Nursing and Rural Health, at the University ofSouth Australia’s Centre for Regional Engagement. Thedates for the retrospective audit were from 1 September2010 to 30 November 2010, and the follow-up audit dateswere from 1 March 2011 to 31 May 2011. Patients’ noteswere audited for presence of a completed VTE risk assess-ment form, whether prophylaxis was initiated, informa-tion to identify patient/clients’ risk factors used to assesswhether the prophylaxis provided was appropriate (basedon National Health and Medical Research Council(NHMRC) best practice guidelines1), and to identifywhether discharge information was provided.

After the baseline audit, a nurse education session wasconducted. The education session was conducted by thesame registered nurse who conducted the audit. This nurseis currently teaching the Bachelor of Nursing to both ruraland external students, and has previously taught theEnrolled Nurse course and Bachelor of Nursing course inthe Northern Territory. The education sessions gave anoverview of what VTE is as well as introducing the statis-tics, and explained the main reasons for hospitalization ofpatients with VTE. It identified who should be riskassessed and it was explained how to do a risk assessmentusing the organization risk assessment form. It wentthrough the levels of risk and what prophylaxis measuresthe hospital guidelines advise to be taken for each level. Itexplained barriers to risk assessments being completed andexplained the mechanical and chemical preventions avail-able. There was a discussion on graduated compressionstockings and what patient education is needed. Thenurses who attended the sessions were provided with aconsumer brochure in English, and directed to where theycan print them off in 14 different languages to provide totheir patients. The sessions were conducted as a Power-Point presentation using a standardized lecture format thatran for approximately 1 h, supplemented with Hospitalnursing guideline for VTE, thrombosis risk assessmenttool and patient information brochures. Study partici-pants were invited to attend the education session. The

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invitations were in the form of posters placed in staffrooms, unit Managers alerted staff and it was advertised inthe hospital newsletter. After the staff education was com-plete, there was a repeat audit of 100 patient notes for a3-month period, using the same best practice audit criteriaand inclusion/exclusion criteria as the baseline audit.

The second objective was to assess nurse knowledge ofVTE risk assessment and when to use prophylaxis, basedon NHMRC best practice guidelines.1 The study assessedthe prior knowledge of the participants about VTE riskassessment and prophylaxis, and then reassessed followingthe education session. The survey questionnaire (availablefrom the author on request) was developed specifically forthis study and the posteducation one had extra questionsto elicit the feeling of the nurses attending about thebenefits and provided the opportunity to identify any gapsfor future education. The hospital risk assessment toolwhich was developed using the NHMRC guidelines wasutilized to develop the questionnaire given to nurses.1

RESULTSCompliance with best practice

recommendationsCompliance with best practice recommendations wasdetermined by the presence of documented evidence(patient case notes) of nurse VTE risk assessment anddetails of any prophylactic treatment. An audit softwarefrom the Joanna Briggs Institute, called Practical Applica-tion of Clinical Evidence Systems (PACES), was used todetermine the level of compliance, using five (5) auditcriteria. PACES is an online tool for practitioners to inputaudit data; it analyses that data and produces a report thatcan be used by organizations to improve patient outcomesthrough the change process.

During the case note audit, patient files were examinedfor the presence of a completed VTE risk assessmentform; if prophylaxis had been put in place, documentationthat discharge information was given to the patient inrelation to his/her VTE prophylaxis.

As the VTE risk of a patient should be reassessed fol-lowing a change in condition,1 case notes were alsoassessed to see whether any relevant reassessment wasdocumented. One patient fell into this category, whereasthe others remained in a stable condition. There was noevidence of reassessment of VTE risk in this patient fromavailable case notes, and therefore this criterion is notreflected in Figure 1.

The same audit criteria were used to determine com-pliance after a 3-month period, following the educationintervention. The results are presented as changes in posi-tive responses to the audit criteria at reaudit.

There was an increase in the number of completed VTErisk assessment forms in both the surgical (2%) andmedical (10%) admission patient notes. Overall, this gavean increase for this audit criterion of 12% from baseline(Fig. 1a).

The number of patients provided with VTE informa-tion as part of their discharge plan increased for bothsurgical (8%) and medical (6%) admissions. Overall, thisgave an increase for this audit criterion of 14% frombaseline (Fig. 1b).

The number of patients determined at risk of VTEfollowing the risk assessment given prophylaxis increaseddramatically in both surgical (8%) and medical (31%)admissions. Overall, this gave an increase for this auditcriterion of 39% from baseline (Fig. 1c).

The number of patients with reduced mobility that hadbeen encouraged to mobilize had increased for both sur-gical (27%) and medical (33%) admissions. Overall, thisgave an increase for this audit criterion of 60% frombaseline (Fig. 1d).

Nurse knowledge of best practicerecommendations

There were 20 nurses and 4 student nurses that attendedthe education sessions and completed the pre- and post-training questionnaire; this was made up of 12 registerednurses, 7 enrolled nursed, 1 midwife and 4 nursing stu-dents (a copy of this questionnaire is available by contact-ing the author). Of the 24 participants, only two had

Figure 1. Increases in compliance with venous thromboembolism

best practice recommendations following nurse education at 3-month

follow up. , % compliance increase.

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previously attended VTE education. The number ofnurses that correctly identified that a VTE risk assessmentshould be performed for all adult admissions increased by23% following the education session (Fig. 2a)

The number of participants that correctly indicated thatanti-embolism stockings are recommended for patientsassessed as having a VTE risk factor of moderate or moreincreased by 10% following the education session (Fig. 2b)

The was a small (2%) increase in the number of par-ticipants that were confident that they could apply anti-embolic (Graduated compression stockings) appropriatelyfrom 21% to 23%, following the education session(Fig. 2c).

Currently, as nurses are unable to prescribe pharmaco-logical prophylaxis, best practice recommendationsrequire them to notify a doctor if pharmacologicalprophylaxis is required.

The number of participants that correctly identifiedthat pharmacological prophylaxis might be required foradults who were categorized as being of moderate (andupwards) risk of VTE, increased by 18% (Fig. 2d).

The best practice guidelines recommend that allpatients should be provided with VTE information as partof their discharge plan. Aspects include: signs and symp-toms of DVT and PE, the correct use and recommendedduration of use of VTE prophylaxis at home (if dischargedwith prophylaxis), the importance of using VTE prophy-laxis correctly (and continuing treatment for the recom-mended duration), as well as the signs and symptoms ofadverse events related to VTE prophylaxis.1–3 Nurseknowledge in this area increased by 35% following theeducation session (Fig. 2e).

Identification of knowledge gapsPosteducation feedback revealed a general lack of knowl-edge of VTE and risk assessment recommendations for all

adult admissions to hospital. Some participants reportedbeing surprised in the statistics of VTE in people admittedto hospital or recently discharged. There was an assump-tion from some of the medical ward nursing staff that VTErisk assessment was an area of concern only for surgicalward admissions and therefore not part of their role.

DISCUSSIONAbout one third of Australia’s population lives outside ofmajor cities, and people in rural and remote areas face asignificant health disadvantage.5 Small rural and remotecommunities are identified as having higher hospitalizationrates and higher incidence of health risk factors whencompared with metropolitan areas.5 People living in theseareas are at risk of having a poorer health status due toreduced access to health services and primary health-careproviders.5 This has been partly the result of medical andhealth staff shortages which have been reflected in lowerutilization than in urban areas.5 There is also evidence thatin primary care there was a health deficit in rural andremote Australia of around $2.1 billion in 2006–2007,with this leading to acute hospital expenditure for theseareas increasing by $830 million.6 Molinari and Monserudfound that nursing positions are more difficult to fill inrural areas, and others state that rural nurses are generallyless educated and older in age than their urban counter-parts.7 Therefore, in rural areas there is not only lessaccess to health-care resources than in urban areas, butrural nurses also have less access and opportunities fortraining and education.5

Although this study used a small sample size and was ofshort duration, it has shown that a relatively simple andinexpensive intervention is able to lead to noticeableincreases in the compliance with best practice VTE riskassessment and nurse knowledge of VTE. This ultimatelyimproves the health outcomes for patients and thereforereduces the health-care burden related to morbidity andmortality of VTE. To our knowledge, this is the first studyassessing VTE compliance and nurse knowledge under-taken in a rural Australian hospital. A similar study wasundertaken in a metropolitan hospital in Brisbane and wasconducted over a 5-year period.3 During that studyperiod, programme effectiveness was monitored.3 Therewere 2063 patients audited and the rates of prophylaxisbeing used appropriately increased from 27% in 2005 to85% in 2009.3

The study has shown improvements across all of thebest practice audit criteria and nurse awareness of VTE,

Figure 2. Increase in nurse knowledge and awareness of venous

thromboembolism best practice recommendations following nurse

education. , % knowledge increase.

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© 2013 Wiley Publishing Asia Pty Ltd

following the education session. A follow-up audit after adesignated period of time (such as 6 or 12 months) woulddetermine whether the increases in compliance andawareness were being maintained.

An initiative that the Australian metropolitan hospitalstudy3 utilized was to appoint a VTE clinical nurse con-sultant.3 This nurse had the responsibility of maintainingthe VTE programme once the research was complete toensure continuity of VTE awareness and compliance. Thisposition can be thought of as being a VTE champion, andhaving a nurse champion who is educated in VTE riskassessment and prophylaxis could be an optimal way toincrease nurse awareness and empower nurses to lead theway in evidence-based patient care. Appointing a desig-nated VTE Clinical Nurse Consultant may not be feasiblein rural hospitals due to a limited number of staffing posi-tions. It may be possible to incorporate a VTE role as partof a current nursing position, thereby providing a refe-rence person for other staff, as well as having someone tocoordinate staff and patient education.

Given that in rural Australian hospitals there are oftena few doctors,4 on the basis of the results of this study itis recommended that all nursing staff attend VTE educa-tion sessions, as this would potentially increase the com-pliance with VTE best practice recommendations forVTE risk assessment and reduce the incidence of VTE inrural hospitals. Due to local general practitioners beingresponsible for patients in some rural hospitals, it wouldbe an advantage to conduct education session with thegeneral practice network to encourage these practition-ers to support the nurses in their role. There could alsobe a benefit to opening up the education session to anyallied health practitioner that is involved with thepatient, such as pharmacist, physiotherapists, occupa-tional therapists as well as doctors.

A second recommendation would be that these sessionsare repeated at regular intervals to ensure that awarenessis being maintained. The duration at which the sessionsshould be repeated remains to be investigated.

With regard to recommendations for furtherresearch, this study recommends replication of thisquality improvement project in other acute rural hospi-tals in order to provide an estimate of the level of VTEcompliance countrywide, with the aim of improving thehealth outcomes for rural patients at risk of developingVTE.

CONFLICTS OF INTERESTThere are no conflicts of interest to declare.

ACKNOWLEDGEMENTSThis study formed the basis of a Joanna Briggs InstituteClinical Fellowship Project. The authors would like tothank Alexa McArthur, RN, RM, MPHC, for facilitatingthe Clinical Fellowship project, and the University ofSouth Australia’s Centre for Regional Engagement forsupporting the project.

REFERENCES1 National Health and Medical Research Council. Clinical Prac-

tice Guideline for the prevention or venous thromboembolism inpatients admitted to Australian Hospitals, Commonwealth ofAustralia, ACT. 2009. Available from URL: http://www.nhmrc.gov.au/guidelines/publications/cp115. Accessed 28June 2012.

2 National Institute of Clinical Studies. Stop the Clot: IntegratingVTE prevention guideline recommendations into routine hospitalcare, National Health and Medical Research Council, Can-berra. 2008. Available from URL: http://www.nhmrc.gov.au/nics/nics-programs/vte-prevention-guideline/nics-vte-prevention-programs-australian-hospitals/stop-c. Accessed28 June 2012.

3 Collins R, MacLellan L, Gibbs H, MacLellan D, Fletcher J.2010. Venous thromboembolism prophylaxis: The role ofthe nurse in changing practice and saving lives. AustralianJournal of Advanced Nursing 27 83–89 http://www.ajan.com.au/Vol27/27-3_Collins.pdf. Accessed 24 August 2010.

4 Humphreys J, Wakerman J. Primary health care in rural andremote Australia: achieving equity of access and outcomesthrough national reform. A discussion paper commissionedby the National Health and Hospitals Reform Commission.2008. Available from URL: http://www.health.gov.au/internet/nhhrc/publishing.nsf/Content/16F7A93D8F578DB4CA2574D7001830E9/$File/Primary%20health%20care%20in%20rural%20and%20remote%20Australia%20-%20achieving%20equity%20of%20access%20and%20outcomes%20through%20national%20reform%20(J%20Humph.pdf. Accessed 24 August 2010.

5 Wakerman J, Humphreys JS, Wells R, Kuipers P, EntwistleP, Jones J. Primary health care delivery models in rural andremote Australia – A systematic review. BMC Health ServicesResearch 2008; 8: 276.

6 National Rural Health Alliance. Two reports confirm $2.1billion rural health deficit. Australian Journal of Rural Health2011; 19: 107.

7 Molinari DL, Monserud MA. Rural nurse job satisfaction.Rural and Remote Health 2008; 8: 1055.

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