1. 

For service change, provide the title of the

Project Outline Document or Business

Case and Reference Number  

Policy for the prevention of venous thromboembolism (VTE)  in adult and teenage inpatients

Reference Number – UHB 106 Version 3 (previous reference number 362) 

2. 

Name of Clinical Board / Corporate Directorate and title of lead member of

staff, including contact details 

Haematology Directorate/Specialist Services 

Marilyn Rees Lead VTE CNS Marilyn.Rees2@wales.nhs.uk

3. 

Objectives of strategy/ policy/ plan/

procedure/ service

To ensure the Health Board delivers its aims, objectives, responsibilities and legal requirements transparently and consistently, it is the policy of Cardiff and Vale University Health Board (UHB) to follow the guidance as set out in the NICE NG89 and those measures required by the Welsh Assembly Government (WAG):  

• All adult and teenage patients admitted to hospital are assessed, using an appropriate UHB Risk Assessment tool within 14 hours of admission, and appropriate preventative measures are instituted as a result.
• All episodes of hospital associated VTE will be reviewed to establish if potentially preventable
• RCA of potentially preventable cases will be undertaken by each clinical board and actions and learning outcomes reported to WAG on a quarterly basis

The objectives of this policy and associated procedure are to provide a rational and practical framework on which to maximise patient safety during and following their hospital stay minimising their risk of developing hospital associated thrombosis 

4. 

Evidence and background information considered. For example

• population data 
• staff and service users data, as applicable
• needs assessment
• engagement and involvement findings

Cardiff & Vale University Local Health Board (LHB) area is the smallest and most densely populated LHB area in Wales, primarily due to Wales’ capital city: Cardiff. 72.1 and 27.9 percent of the LHB area population live within Cardiff and the more rural Vale of Glamorgan respectively

• research
• good practice guidelines
• participant knowledge
• list of stakeholders and how stakeholders have engaged in the development stages
• comments from those involved in the designing and development stages

Population pyramids are available from

Public Health Wales Observatory[2] and the UHB’s ‘Shaping Our Future Wellbeing’ Strategy provides an overview of health need[3]. 

The policy details the assessment and management of VTE in the adult patient. The assessment ensures that all patients are individually assessed for their risk of VTE, risk of bleeding and appropriate clinical intervention/management is delivered.

Each year, one in every 1,000 people in the UK is affected by DVT. Anyone can develop it but it becomes more common with age. As well as age, risk factors include:

• previous venous thromboembolism
• a family history of thrombosis
• medical conditions such as cancer and heart failure
• inactivity (for example, after an operation)
• being overweight or obese

VTE assessment provides a standardised approach that will help identify those with differential health outcomes and lead to positive action where required. There may potentially be an impact on patients understanding of information and use of a clear concise risk assessment utilising an appropriate educational approach for the patient or carers requirements should be utilised.

Google search for Thromboprophylaxis Policy /Thromboprophylaxis Policy Equality / In-patient thromboprophylaxis equality impact assessment accessed 24th October 2020

1. Thromboprophylaxis Policy and Guidelines – Sherwood Forest Hospitals 2016

1. Policy for Reducing the Risk of VTE in Adult Patients Admitted to Hospital  Portsmouth Hospitals NHS Trust 2019
2. Prevention of Venous Thromboembolism Policy Lincolnshire Community Health Service NHS Trust June 2020
3. VTE Risk assessment Policy  Mersey Care NHS Foundation June 2019 
4. Thrombosis Prevention and Anticoagulation Policy – Royal Cornwall NHS Trust 2016

Comparison made with these policies of equality impact taking into account age, race, disability, gender, sexual orientation, religion or cultural beliefs. All policies accessed support the content of this policy

and the approach recommended to patient groups and risk assessment for venous thromboembolism.

Welsh Government supports and is committed to reducing the incidence of hospital acquired thrombosis and this is described in the Quality Delivery Plan (QDP) for the NHS: Achieving Excellence generating a tier 1 approach and focus. 2012.

5. 

Who will be affected by the strategy/ policy/ plan/ procedure/ service 

Population Group – All adult patients and teenagers from 13yrs and over admitted to Cardiff and Vale UHB. There are no foreseen specific language/religious /cultural issues.

How will the strategy, policy, plan, procedure and/or service impact on:-

Potential positive and/or negative impacts 

Recommendations for

improvement/ mitigation

Action taken by Clinical Board / Corporate Directorate. 

Make reference to where the mitigation is included in the document, as appropriate

6.1 Age 

For most purposes, the main categories are: 

• under 18; 
• between 18 and 65; and 
• over 65

This policy applies to all adults over the age of 16. Regardless of their age, uniform assessment will be undertaken, which is free from bias or discrimination according to protected characteristics. Where an age is considered to be an individual risk factor, this is considered within the context of the whole risk assessment process, which is based on national guidance

Not applicable

Not applicable

How will the strategy, policy, plan, procedure and/or service impact on:-

Potential positive and/or negative impacts 

Recommendations for

improvement/ mitigation

Action taken by Clinical Board / Corporate Directorate. 

Make reference to where the mitigation is included in the document, as appropriate

6.2 Persons with a

disability as defined in the

Equality Act 2010

Those with physical impairments, learning disability, sensory loss or impairment, mental health conditions, long-term medical conditions such as diabetes

This policy applies to all adults over the age of 16. Regardless of whether they have cancer or any other

disability, uniform assessment will be undertaken, which is free from bias or discrimination according to protected characteristics. Where cancer, or any other disability eg long term condition is considered to be an individual risk factor, this is considered within the context of the whole risk assessment process, which is based on national

guidance

How will the strategy, policy, plan, procedure and/or service impact on:-

Potential positive and/or negative impacts 

Recommendations for

improvement/ mitigation

Action taken by Clinical Board / Corporate Directorate. 

Make reference to where the mitigation is included in the document, as appropriate

6.3 People of different genders: 

Consider men, women, people undergoing gender reassignment

NB Gender-reassignment is anyone who proposes to, starts, is going through or who has completed a process to change his or her gender with or without going through any medical procedures. Sometimes referred to as Trans or

Transgender  

This policy applies to all adults over the age of 16. Regardless of their gender, uniform assessment will be undertaken, which is free from bias or discrimination according to protected characteristics. Where the use of hormonal therapy for gender reassignment  is considered to be an individual risk factor, this is considered within the context of the whole risk assessment process, which is based on national guidance

How will the strategy, policy, plan, procedure and/or service impact on:-

Potential positive and/or negative impacts 

Recommendations for

improvement/ mitigation

Action taken by Clinical Board / Corporate Directorate. 

Make reference to where the mitigation is included in the document, as appropriate

6.4 People who are married or who have a civil partner.

There appears not to be any impact. No documented evidence found from the assessment review of the information available

Not applicable

Not applicable

6.5 Women who are expecting a baby, who are on a break from work after having a baby, or who are breastfeeding.  They are protected for 26 weeks after having a baby whether or not they are on maternity leave.

There is specific guidance within the Obstetric

Directorate for assessment and management of risk in patients during pregnancy and following birth for those patients found to require thromboprophylaxis   

Not applicable

Not applicable

6.6 People of a different race, nationality, colour, culture or ethnic origin including non-English speakers,

There appears not to be any impact regarding race, nationality, colour, culture or ethnic origin. No

documented evidence found

Would need to ensure patient information leaflets were accessible to patients requiring them.

This would be provided by the relevant clinical teams

How will the strategy, policy, plan, procedure and/or service impact on:-

Potential positive and/or negative impacts 

Recommendations for

improvement/ mitigation

Action taken by Clinical Board / Corporate Directorate. 

Make reference to where the mitigation is included in the document, as appropriate

gypsies/travellers, migrant

workers

from the assessment review of the information. Patients whose first language is not English may require written information in the language of their choice to enable understanding of the need for thromboprophylaxis  

These can be accessed from thrombosis.org

6.7 People with a religion or belief or with no religion or belief.   

The term ‘religion’ includes a religious or philosophical

belief

There is a need to be aware that heparins are of animal origin and this may be of concern to some patients. Discuss the alternatives with patients who have concerns about using animal products, after discussing their suitability, advantages and disadvantages with the person. 

Not applicable

This would be done by the relevant clinical teams

How will the strategy, policy, plan, procedure and/or service impact on:-

Potential positive and/or negative impacts 

Recommendations for

improvement/ mitigation

Action taken by Clinical Board / Corporate Directorate. 

Make reference to where the mitigation is included in the document, as appropriate

6.8 People who are attracted to other people of:

• the opposite sex

(heterosexual);

• the same sex (lesbian or gay);
• both sexes (bisexual)

There appears not to be any

impact on staff or patients

Not applicable

Not applicable

6.9 People who communicate using the Welsh language in terms of correspondence, information leaflets, or

service plans and design 

Well-being Goal – A Wales

of vibrant culture and thriving

Welsh language 

Bilingually patient information leaflets will be available for patients. This is in line with our current Welsh Language Standards.

The aim of the ‘active offer’ is that staff should ask for the language choice (of either Welsh or English) of the patient. The language choice should then be

The policy will prompt staff to ask patients which language the patient/service users would like to communicate

This will need to be done by the relevant clinical teams

How will the strategy, policy, plan, procedure and/or service impact on:-

Potential positive and/or negative impacts 

Recommendations for

improvement/ mitigation

Action taken by Clinical Board / Corporate Directorate. 

Make reference to where the mitigation is included in the document, as appropriate

integrated into the patients’ treatment. In other words the patient could request their treatment be in Welsh. If we are unable to provide a fluent Welsh speaker to consult with the person then an interpreter would be provided through video consulting services.

in, either English or Welsh, in line with the ‘Active Offer’ requirements of the Welsh Governments’ More than Just Words Strategy.

6.10 People according to their income related group: 

Consider people on low income, economically inactive,

unemployed/workless, people who are unable to

work due to ill-health

There appears not to be any impact

Not applicable

Not applicable

How will the strategy, policy, plan, procedure and/or service impact on:-

Potential positive and/or negative impacts 

Recommendations for

improvement/ mitigation

Action taken by Clinical Board / Corporate Directorate. 

Make reference to where the mitigation is included in the document, as appropriate

6.11 People according to where they live: Consider people living in areas known to exhibit poor economic and/or health indicators, people unable to access

services and facilities

There appears not to be any impact on staff, and this policy has a positive impact on people on low income as the policy is applicable to all people. 

All patients admitted to hospital risk of thrombosis according to clinical presentation and following risk assessment tools for their particular speciality

6.12 Consider any other groups and risk factors relevant to this strategy, policy, plan, procedure and/or service

Other groups to be considered would include carers/family members who may need education with regards administering thromboprophylaxis for those requiring extended thromboprophylaxis. It would

Patient/family member/carer education prior to discharge as well as patient information leaflets to support understanding following

discharge into the community

How will the strategy, policy, plan, procedure and/or service impact on:-

Potential positive and/or negative impacts 

Recommendations for

improvement/ mitigation

Action taken by Clinical Board / Corporate Directorate. 

Make reference to where the mitigation is included in the document, as appropriate

also be important for those family members/carers as well the patient to understand symptoms suggestive of development of thrombosis following discharge from hospital as the risk remains in place for up to 90 days.   

How will the strategy, policy, plan, procedure and/or service impact on:-

Potential positive and/or negative impacts and any particular groups affected

Recommendations for improvement/ mitigation

Action taken by Clinical

Board / Corporate

Directorate

Make reference to where the mitigation is included in the document, as appropriate

7.1 People being able to access the service offered:  Consider access for those living in areas of deprivation and/or those experiencing

health inequalities

Well-being Goal - A more equal Wales

Access to risk assessment for thromboprophylaxis is not affected by living conditions. On discharge these patients may require additional support to ensure the extended thromboprophylaxis treatment plan is enabled 

7.2 People being able to improve /maintain healthy lifestyles: 

Consider the impact on healthy lifestyles, including healthy eating, being active,  no smoking /smoking cessation, reducing the harm caused by alcohol and /or non-prescribed drugs plus access to services that support disease prevention

(eg immunisation and

As a policy, there will be no impact.

As thrombosis risk increases in patients with higher BMI it is imperative to encourage and support patients in healthy living/eating strategies and make services known to them as per the ‘healthier Wales’ goal by sign posting to available services. General advice would also include reducing alcohol

This will need to be actioned by each clinical board

How will the strategy, policy, plan, procedure and/or service impact on:-

Potential positive and/or negative impacts and any particular groups affected

Recommendations for improvement/ mitigation

Action taken by Clinical

Board / Corporate

Directorate

Make reference to where the mitigation is included in the document, as appropriate

vaccination, falls prevention). Also consider impact on access to supportive services including smoking cessation services, weight management

services etc

Well-being Goal – A healthier Wales

intake to within national guidelines and reduce or stop smoking utilising smoking cessation services for example 

7.3 People in terms of their income and employment status: 

Consider the impact on the availability and accessibility of work, paid/ unpaid employment, wage levels, job security, working conditions

Well-being Goal – A prosperous Wales

As a policy, there will be no impact.

How will the strategy, policy, plan, procedure and/or service impact on:-

Potential positive and/or negative impacts and any particular groups affected

Recommendations for improvement/ mitigation

Action taken by Clinical

Board / Corporate

Directorate

Make reference to where the mitigation is included in the document, as appropriate

7.4 People in terms of their use of the physical environment: 

Consider the impact on the availability and accessibility of transport, healthy food, leisure activities, green spaces; of the design of the built environment on the physical and mental health of patients, staff and visitors; on air quality, exposure to pollutants; safety of neighbourhoods, exposure to crime; road safety and preventing injuries/accidents; quality and safety of play areas and

open spaces

Well-being Goal – A resilient

Wales

As a policy, there will be no impact.

How will the strategy, policy, plan, procedure and/or service impact on:-

Potential positive and/or negative impacts and any particular groups affected

Recommendations for improvement/ mitigation

Action taken by Clinical

Board / Corporate

Directorate

Make reference to where the mitigation is included in the document, as appropriate

7.5 People in terms of social and community influences on their health:  Consider the impact on family organisation and roles; social support and social networks; neighbourliness and sense of belonging; social isolation; peer pressure; community

identity; cultural and spiritual

ethos

Well-being Goal – A Wales of cohesive communities

As a policy, there will be no impact.

7.6 People in terms of macro-economic, environmental and

As a policy, there will be no impact.

How will the strategy, policy, plan, procedure and/or service impact on:-

Potential positive and/or negative impacts and any particular groups affected

Recommendations for improvement/ mitigation

Action taken by Clinical

Board / Corporate

Directorate

Make reference to where the mitigation is included in the document, as appropriate

sustainability factors: Consider the impact of government policies; gross domestic product; economic development; biological diversity; climate

Well-being Goal – A globally responsible Wales

Approved By: QSE 

8.1 Please summarise the potential positive and/or negative impacts of the strategy, policy, plan or service

On reviewing the previous policy and writing the latest version, overall, there appears to be very limited impact on the protected characteristics and health inequalities as a result of this policy.  

Reference Number: UHB 106

Next Review Date: 13 Apr 2024

Version Number: 

Date of Publication: 15 Apr 2021

Approved By: QSE 

Action 

Lead

Timescale 

Action taken by

Clinical Board /

Corporate

Directorate

8.2  What are the key actions identified as a result of completing the EHIA? 

On reviewing the previous policy and writing the latest version, overall, there appears to be very limited impact on the protected characteristics and health inequalities as a result of this policy.  

There is a need to ensure risk assessments are available for each clinical

board to ensure appropriate risk is assessed and treatment prescribed as required There is a need to ensure patient information leaflets are available during their hospital stay and following discharge to risk of reduce hospital acquired thrombosis 

M Rees

Action 

Lead

Timescale 

Action taken by

Clinical Board /

Corporate

Directorate

8.3 Is a more comprehensive

Equalities Impact Assessment or Health Impact Assessment required?  

This means thinking about relevance and proportionality to the Equality Act and asking: is the impact significant enough that a more formal and full consultation is required? 

As there has been potentiall very limited negative impact identified, it is unnecessary t undertake 

a more detailed assessment

yM Rees

Action 

Lead

Timescale 

Action taken by

Clinical Board /

Corporate

Directorate

8.4  What are the next steps?

Some suggestions:-

• Decide whether the strategy,  policy, plan, procedure and/or service proposal:
  • continues unchanged as there are no significant negative impacts
  • adjusts to account for the negative impacts
  • continues despite potential for adverse impact or missed opportunities to advance equality (set out the justifications for doing so)
  • stops.
• Have your strategy, policy, plan, procedure and/or service proposal approved
• Publish your report of this impact assessment
• Monitor and review

On reviewing this policy minor positive changes will need to been made.  The EHIA has been consulted. 

It has been approved by………..  

The EHIA will be placed on  intranet once approved

Adherence to the policy will be monitored through ………………….

The UHB standard is that all policies are reviewed within 3 years (1 year if a statutory requirement).

Document Title: EHIA VTE in adults and teenage patients  

25 of 27

Reference Number: UHB 106

Version Number: 

Approved By: QSE 

Document Title: EHIA VTE in adults and teenage patients  

26 of 27

Reference Number: UHB 106

Version Number: 

Approved By: QSE 

Tips



Be clear about the policy or decision’s rationale, objectives, delivery method and stakeholders.



Work through the Toolkit early in the design and development stages and make use of it as the work progresses to inform you of those most affected and inform mitigating actions



Allow adequate time to complete the Equality Health Impact

Assessment 



Identify what data you already have and what are the gaps.



Engage with stakeholders and those most affected early.  View them as active partners rather than passive recipients of your services.



Remember to consider the impact of your decisions on your staff as well as the public.



Record which organisations and protected characteristic groups you engaged with, when you engaged with them and how you did so (for example, workshop, public meeting, written submission).



Produce a summary table describing the issues affecting each protected group and what the potential mitigations are.



Report on positive impacts as well as negative ones.  



Remember what the Equality Act says – how can this policy or decision help foster good relations between different groups?



Do it with other people! Talk to colleagues, bounce ideas, seeks views and opinions.