L. C. Barwell1, L. Almasri1, H. B. Ahmed1, C. Johnstone2, D. Philpott3, R. Sabaratnam3, K. E. Nicholson3

1King's College London, UK

2St Thomas' Hospital, Guy's & St Thomas' NHS Trust, London, UK

3Evelina London Children's Hospital, London, UK


Venous Thromboembolism (VTE) is an uncommon peri-operative risk in children, occurring in 0.04-8.9% of surgical cases (Mets et al., 2020) but can cause significant morbidity.  Royal College of Anaesthetists (RCoA) Guidelines for the Provision of Anaesthetic Services (GPAS) have mandated that paediatric anaesthesia services have a VTE guideline (GPAS, 2024).  National Institute for Health and Care Excellence (NICE) state that patients 16 years plus require VTE assessment within 24 hours (NICE, 2023).  Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) published paediatric VTE guidelines in 2017 (APAGBI, 2017).  Services need a consistent way to assess and document VTE risk for paediatric surgical patients to minimise events.


Baseline data from Evelina London Children’s Hospital (ELCH) - a tertiary NHS hospital - revealed no VTE guidelines. A retrospective 3-month case review using modified APAGBI criteria (age 13-18yrs, weight >40kg) in Autumn 2022, found 345 patients eligible for VTE assessment. 30 (8.12%) met criteria for further assessment, revealing 29 were having orthopaedic or spinal surgery, and deemed eligible for prophylaxis, yet only 10 (2.89%) received any.  Documentation justifying this decision was limited.  This revealed a population needing assessment and appropriate documentation and decision tools were required.

Strategy for Change

Two Plan-Do-Study-Act (PDSA) cycles were developed.

PDSA Cycle 1 (9 spinal & orthopaedic patients)

Implementation of approved paediatric VTE guideline for patients aged <16yrs (NICE mandate adult guidelines >16yrs). Targeted implementation was spinal and orthopaedic patients as most eligible.  Hospital guideline mandates further VTE assessment for patients aged between 13-16, >40kg and immobile for >48hrs, compared to their baseline.

PDSA Cycle 2 (14 spinal & orthopaedic patients)

Introduction of a logic based VTE assessment & documentation tool into the electronic patient record. This was restricted to anaesthetists only.

Improvement Measures

The electronic assessment tool was not used, which was disappointing.  Despite this, most of the patients received correct VTE measures (which was no prophylaxis), but there was no documentation indicating an assessment had taken place.  It is also possible that no assessment was done. One patient was prescribed VTE prophylaxis which the audit team felt was not guideline indicated, but the surgeon wrote free text justification for the prescribing in notes. We felt hopeful about the documentation tool but it seemed unsuccessful.  This may have been due to rapid implementation to anaesthetists only, or not enough verbal and written communications.

Message for Others

Electronic solutions do not provide imminent fixes. Running this parallel to continued education is required. Moving forward, establishing whose responsibility documentation of VTE prophylaxis is, is essential for maintaining continuity. Exploring assessment and prescribing for the older age group patient, e.g. >16 years, will provide interesting opportunities to expand in this important landscape.


  1. Mets EJ, McLynn RP, Grauer JN. Venous thromboembolism in children undergoing surgery: Incidence, risk factors and related adverse events. World Journal of Pediatric Surgery. 2020 Apr 14;3(1). doi:10.1136/wjps-2019-000084
  2. National Institute for Health and Care Excellence (NICE). Overview: Venous thromboembolism in over 16s: Reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism: Guidance [Internet]. 2018 [cited 2024 Feb 8]. Available from: https://www.nice.org.uk/guidance/NG89
  3. Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI). Prevention of peri operative venous - APAGBI [Internet]. 2017 [cited 2024 Feb 8]. Available from: https://www.apagbi.org.uk/sites/default/files/inline-files/APA%20Thromboprophylaxis%20guidelines%20final.pdf
  4. The Royal College of Anaesthetists. Chapter 10: Guidelines for the provision of paediatric anaesthesia services 2024 [Internet]. 2023 [cited 2024 Feb 8]. Available from: https://rcoa.ac.uk/gpas/chapter-10
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