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HOSPITAL POLICY - Prevention and Treatment of VTE in Patients Admitted to Hospital

 

Please Note:  This policy is currently under review and is still fit for purpose.

 

Venous Thromboembolism (VTE) –

Prevention and Treatment of VTE in

Patients Admitted to Hospital

This procedural document supersedes and combines:  PAT/T 44 v.2 – Prevention of

Venous Thromboembolism (VTE) – Deep Vein Thrombosis and Pulmonary Embolism in

Patients Admitted to Hospital and PAT/T 46 v.2 Guideline for the Management of Venous Thromboembolism

 

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Author/reviewer: (this version)

Ben Kumar – Respiratory Physician, Trust Lead for VTE Treatment

Co-author Tracy Evans-Phillips – IPOC Manager 

Stuti Kaul – Consultant Haematologist Lee Wilson – Consultant Pharmacist

Date written/revised:

May 2014

Approved by:

Policy Approval and Compliance Group

Date of approval:

18 June 2014

Date issued:

2 July 2014

Next review date:

May 2017 – Extended to November 2017

Target audience:

Trust wide

 

 

Venous Thromboembolism (VTE) – Prevention and Treatment of VTE in Patients Admitted to Hospital

 

Amendment Form

 

 

Please record brief details of the changes made alongside the next version number.  If the APD has been reviewed without change, this information will still need to be recorded although the version number will remain the same.

 

 

Version

 

Date issued

 

Brief Summary of Changes

 

Author

 

Version 3

 

 

 

 

2 July 2014

 

  • This is a new policy – please read in full.  
  • VTE Investigation and Treatment IPOC amended in response to 2012 NICE guidance on VTE.
  • New Patient Information Leaflets produced – see Appendix 7 and 8

NOTE: supersedes: PAT/T 44 v.2 - Prevention of

Venous Thromboembolism (VTE) - Deep Vein

Thrombosis and Pulmonary Embolism in Patients

Admitted to Hospital and combines PAT/T 46 v.2 - Guideline for the Management of Venous Thromboembolism.

 

Stuti Kaul

Ben Kumar

Tracy Evans-

Phillips

Lee Wilson

 

 

 

 

 

 

 

 

Venous Thromboembolism (VTE) – Prevention and Treatment of VTE in

Patients Admitted to Hospital

 

Contents

Section

 

Page No.

1

Introduction

4

2

Purpose

4

3

Duties and Responsibilities

5

4

Procedure

6

5

Training / Support

7

6

Monitoring and Compliance

8

7

Definitions

8

8

Equality Impact Assessment

9

9

References

9

Appendices

 

 

Appendix 1

 

VTE Risk Assessment

10

Appendix 2

 

Women’s VTE Risk Assessment

11

Appendix 3

 

Lower Limb POP Risk Assessment

13

Appendix 4

 

How to complete the VTE Risk Assessment

14

Appendix 5

 

Preventing blood clots while you are in hospital

15

Appendix 6

 

DVT & PE IPOC

19

Appendix 7

 

Patient Information Leaflet on Deep Vein Thrombosis (DVT PIL)

35

Appendix 8

 

Patient Information Leaflet on Pulmonary Embolism (PE PIL)

37

 

 

 

 

 

1. 

INTRODUCTION

 

The House of Commons Health Committee reported in 2005 that an estimated 25,000 people in the UK die from preventable hospital-acquired venous thromboembolism (VTE) every year. This includes patients admitted to hospital for medical care and surgery. The inconsistent use of prophylactic measures for VTE in hospital patients has been widely reported.

 

VTE is a condition in which a blood clot (thrombus) forms in a vein. It most commonly occurs in the deep veins of the legs; this is called deep vein thrombosis. The thrombus may dislodge from its site of origin to travel in the blood – a phenomenon called embolism.

 

VTE is an important cause of death in hospital patients, and treatment of non-fatal symptomatic VTE and related long-term morbidities is associated with considerable cost to the health service. 

 

The risk of developing VTE depends on the condition and/or procedure for which the patient is admitted and on any predisposing risk factors (such as age, obesity and concomitant conditions). 

This guideline makes recommendations on:

 

  1. Assessing and reducing the risk of VTE in patients in hospital. The recommendations take into account the potential risks of the various options for prophylaxis and patient preferences. 
  2. Management of VTE

 

The guideline assumes that prescribers will use a drug’s summary of product characteristics to inform decisions made with individual patients.

 

2. 

PURPOSE

 

 

2.1 

Prevention

2.2

       Treatment  

Patients (and relatives and carers as appropriate) should have the opportunity to be involved in decisions. 

The clinical decision making regarding management of VTE should be made with consideration of the latest NICE guidance on DVT and PE.

If VTE is suspected, prescribers should follow the latest version of the Trust DVT & PE IPOC.

The DVT & PE IPOC contains the following sections

  1. Renal impairment
  2. Pregnancy (see also MSG 20)
  3. IVDUs
  4. Investigations for VTE associated with cancer
  5. Thrombophilia testing
  6. Mechanical interventions

 

3. 

DUTIES AND RESPONSIBILITIES

 

 The signs and symptoms of DVT and PE

 The correct use of prophylaxis at home

 The implications of not using the prophylaxis correctly.

4.

PROCEDURE

 

Pharmacological VTE prophylaxis

Dalteparin is the low molecular weight heparin (LMWH) recommended for use in Doncaster and Bassetlaw Hospitals NHS Trust for those indications for which it is licensed.  Fondaparinux sodium should be used in individuals who are allergic to heparin.

4.1

Prevention  

link:http://www.dbh.nhs.uk/Library/Pharmacy_Medicines_Management/Formulary/Fo rmulary_S2/Orthopaedic_DVT_guidelines.pdf

Clinical Guideline 92 – Venous Thromboembolism: Reducing the Risk

7.

4.2

Treatment  

http://www.dbh.nhs.uk/Library/Pharmacy_Medicines_Management/Formulary/For mulary_S2/Section%202.8.pdf

5.

TRAINING/SUPPORT

 

 

Staff Function

Training Needs

How Delivered

1

Staff who have general (none specific) role in delivery of care to patients

General Awareness

Posters/leaflets/

Trust publicity

2

Staff who deliver care to patients

 

General Awareness  

Fitting of Graduated Compression Stockings (GCS)

On-going care of patient wearing GCS

As above PLUS

Local Induction

3

Registered Staff who deliver care to patients

(Inc AHP’s)

General Awareness  

VTE disease process

Contraindications to GCS

Measuring and fitting of Graduated Compression Stockings (GCS)

On-going care of patient wearing GCS

Contraindications to dalteparin

Administration of dalteparin

As above PLUS

Local Induction

4

Medical staff  

General Awareness  

VTE disease process

Long term effects of VTE

Contraindications to GCS

Alternative methods of Mechanical compression.

Contraindications to dalteparin

Prescribing dalteparin

On going care of patients on dalteparin

As above PLUS

 

Induction.

 

Completion of  e-vte.org modules

(optional)

 

 

6.

MONITORING COMPLIANCE WITH THE PROCEDURAL DOCUMENT

 

 

Monitoring compliance

 

 

Criteria

Monitoring

Who

Frequency

How reviewed

 

All patients admitted to the

Trust as

Inpatients or Daycases will have a

VTE Risk

Assessment

Monthly audit using pre-defined proforma (specific to VTE Risk Assessment used), auditing 20 sets of casenotes of patients with a current stay

Each specialty,  lead by the

Clinical Audit Lead within the CSU

Monthly rolling programme

Report sent to CSU for recommendations and action plans.

Action plans and recommendations reviewed by VTE Prevention Group

Compliance with monthly programme monitored by CA&E

 

All patients with hospital acquired VTE (within 3 months of admission) to have a RCA undertaken

Casenotes are located and reviewed to identify if the VTE was avoidable

Feedback letters sent to Primary Clinician to complete.

Reviewed on an individual case basis

Each outcome is shared with CSU, VTE

Prevention Group and fed back to Trust via Medical Director.

 

Patients admitted with a VTE will have care according to the DVT & PE IPOC

Audit of compliance with the IPOC

Audit instigated by the Clinical Audit Lead for

Haematology

Annual

Report reviewed by VTE Treatment Group and results disseminated to

Trust via Clinical

Directors

 

7.

DEFINITIONS

 

CA&E  

Department of Clinical Audit and Effectiveness

 

 

CTPA  

Computed Tomographic Pulmonary Angiography

 

 

DVT       

Deep Vein Thrombosis

 

 

GCS       

Graduated Compression Stocking

 

 

GP          

General Practitioner

 

 

IPOC      

Integrated Pathway of Care

 

 

IVDU 

Intra-Venous Drug User

 

 

LMWH 

Low Molecular Weight heparin

 

 

NHS-LA

National Health Service – Litigation Authority

 

 

NICE      

National Institute for Health and Clinical Excellence

 

 

PE          

Pulmonary Embolism

 

 

UFH

 

Un-Fractionated Heparin

 

 

USS

 

Ultra-Sound Scan

 

 

VTE

 

Venous Thrombo-Embolism

 

8.

EQUALITY IMPACT ASSESSMENT

                       

 

An Equality Impact Assessment (EIA) has been conducted on this procedural document in line with the principles of the Equality Impact Assessment Policy (CORP/EMP 27) and the Fair Treatment for All Policy (CORP/EMP 4).

The purpose of the EIA is to minimise and if possible remove any disproportionate impact on employees on the grounds of race, sex, disability, age, sexual orientation or religious belief. No detriment was identified. There are now nine protected characteristics:

A copy of the EIA is available on request from the Human Resources Department.

 

9.

REFERENCES

 

  1. Prevention of Venous Thromboembolism in Hospitalised Patients (2007)

Chief Medical Officer’s report from the Independent Expert Working Group

 

  1. NICE clinical guideline 92: Venous thromboembolism, reducing the risk of venous thromboembolism in patients admitted to hospital (2010) http://guidance.nice.org.uk/CG92

 

  1. Guidelines on the use and monitoring of heparin (2006) British Journal of Haematology 133, 19 – 34

 

  1. NICE clinical guideline 144 (see above for title/links)