NHS GG&C Thrombosis Committee

Constitution & Terms of Reference

Terms of Reference

1. To develop and promote best practice in the prevention of Venous Thrombosis [VTE: primarily DVT and pulmonary embolism]
2. To develop and promote implementation of a risk assessment based approach to thromboprophylaxis
3. To develop and promote best practice in the diagnosis & treatment of VTE
4. To develop and implement, across the Board, common local protocols based on National Guidelines; and update these as and when necessary
5. To promote an effective and efficient education & training programme on VTE prevention and treatment for all relevant clinical and support staff
6. To promote and facilitate local audits of compliance with, and effectiveness of, thromboprophylaxis policies
7. To monitor clinical effectiveness of NHS GG&C thromboprophylaxis protocols across hospital sites and specialties, and encourage local review where there is evidence of poor compliance or apparent lack of efficacy. In addition the committee will review a summary of, and comment on, anticoagulant medication incidents.
8. To ensure Clinical Governance in VTE prevention and management and demonstrate overall quality and equity of services across the Board

Accountability

Accountability will be primarily to the Health Board and the Medical Director, with an annual report being submitted to the Clinical Governance Committee and the ADTC. Reports will also be copied to Acute Division Clinical Governance Committee and SMG. Minutes from meetings will be circulated to committee members and to each Clinical Directorate.

Frequency of Meetings

Three to four meetings per year.

Membership

The committee will be multidisciplinary and encompass all relevant acute sector sites and Divisions within NHS GGC. As such the committee should include representative(s) from the following:

• NHSGGC Acute Division Clinical Governance Committee
• NHSGGC Management Representation
• each Local Hospital Thrombosis Service
  • [GRI/Stobhill, WIG/GGH, Victoria/SGH, RAH/VoL, IRH]
• Clinical Effectiveness
• Pharmacy [ADTC]
• DVT Nurse Specialist (representing NHSGGC DVT Nurse Specialists)
• Consultant ‘expert’ in Haemostasis & Thrombosis
• each (relevant) Clinical Specialty/Directorate                           
  •   [S&A: Orthopaedics, General Surgery, Anaesthetics; W&C: Obstetrics & Gynaecology;   EC&MS: Medicine, Emergency Medicine, Respiratory Medicine; RAD: Stroke, Medicine for Elderly; Regional Services: Oncology, INS/ENT/Max-Facs.]
• General Practitioner
• Radiologist / Interventionist
• Representative from GCAS [Glasgow & Clyde Anticoagulant Service]
• Other co-opted members as thought necessary by the committee [e.g. GJNH, Cardiology, Orthotics]

It is anticipated that a single individual may act as representative for 2 of the above categories, however to be quorate any committee meeting must have ≥6 members present. Attendance of a designated deputy is encouraged, when a committee member is unavailable.

A Chair and Secretary will be elected from within the committee to serve for a 3 year term. Chair and Secretary may serve no more than 2 consecutive terms in that post.