Venous thromboembolism (VTE) pre-operative screening requirements for surgery in a non-hospital facility

The following information and recommendations are being shared to assist facilities in their continuous quality improvement.

The Non-Hospital Medical and Surgical Facilities Accreditation Program (NHMSFAP) Patient Safety Incident Review Panel has reviewed incidents of venous thromboembolism (VTE), as well as bleeding requiring transfer to hospital following plastic surgery procedures, where screening was not apparent or clearly documented in the clinical chart. VTE risk stratification using a standardized tool such as the Caprini risk assessment model should be used. Chemoprophylaxis use should be determined based on score.

Facilities and individual registrants are reminded that a patient’s pre-admission assessment must include appropriate VTE screening, and documentation of the VTE screening must provide an accurate account of the patient’s status including any decisions, interventions or actions taken as a result of this screening.

The screening form used, including score, must be clearly documented in the patient record. Checking a box on a preoperative checklist indicating that it was completed is not acceptable practice.

See the NHMSFAP accreditation standards Pre-admission Evaluation and Selection and Medical Records and Documentation for further details.