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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

• Patients (and relatives and carers as appropriate) should have the opportunity to be involved in decisions. 
• All inpatients and day-case patients >18 years must undergo a mandatory risk assessment for the prevention of VTE.
• The risk assessment must be completed by a doctor or nurse and filed in the medical notes. 
• The risk assessment should be undertaken on admission to hospital or at pre-operative assessment (if undergoing elective surgery), and again if the patient’s clinical condition changes.
• The clinical decision on how to manage the risk of venous thromboembolism will be based on an assessment of the risks of VTE against the risks of preventative treatment for each individual patient and the decision will be informed by available published evidence. Following this the pharmacological and mechanical prophylaxis should be prescribed.
• This guideline provides guidance for the prevention of VTE based on recommendations in NICE clinical guideline 92 and the Report of the Independent Expert Working Group on the prevention of VTE in hospitalised patients as described above.
• This guideline was developed in consultation with all clinical directorates and specialities to allow for speciality specific recommendations. 

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 Renal impairment Pregnancy (see also MSG 20) IVDUs Investigations for VTE associated with cancer Thrombophilia testing Mechanical interventions
3.	DUTIES AND RESPONSIBILITIES

 

• All relevant healthcare professionals should give patients verbal and written information on the following, as part of their discharge plan.

 The signs and symptoms of DVT and PE

 The correct use of prophylaxis at home

 The implications of not using the prophylaxis correctly.

• All relevant healthcare professionals should follow the DVT and PE IPOC when treating a patient with symptoms of VTE.
• Should clinical specialities subsequently wish to amend the specific guidance for the prevention of VTE in their speciality, application should be submitted to the VTE Treatment or Prophylaxis Group for consideration and if agreed, should be included as appendices to this guideline. 

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

• All patients (age 18 and over) need to be risk assessed on admission to identify those who are at increased risk of VTE using either; the Generic VTE Risk Assessment (see Appendix 1), Women’s VTE Risk Assessment (see Appendix 2) or if the patient has a lower limb cast in fracture clinic, the POP VTE Risk Assessment (see appendix 3).
• For guidance on completing the Generic VTE Risk Assessment, see Appendix 4
• For dosage recommendations for prescribing dalteparin,  please see Appendix 5
• Patients on Orthopaedic wards use the Generic VTE Risk Assessment, however further details on pharmacological thromboprophylaxis and extended prophylaxis can be found on the following

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

• For further guidance on VTE prevention and prophylaxis, please follow the link for NICE

Clinical Guideline 92 – Venous Thromboembolism: Reducing the Risk

• All patients admitted to hospital as an Inpatient or Daycase (including maternity and orthopaedic patients) must receive the Trust’s information leaflet “Preventing Blood Clots While You Are In Hospital” (WPR 30722) on admission to hospital. See Appendix

7.

4.2

Treatment

• All patients with symptoms of DVT or PE should be managed according to the DVT & PE IPOC (WPR 24522), see Appendix 8
• The algorithms in the Trust’s IPOC present the most concise summarisation of the treatment guidance.
• All patients with diagnosed VTE must receive a copy of either the “DVT Patient Information Leaflet” (See appendix 9) or the “PE Patient Information Leaflet” (see appendix 10)
• For further guidance on VTE treatment, please follow the link below:
• Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing  
• Formulary guidance and protocols on reversal of anticoagulation (including heparin, warfarin and rivaroxaban) can be found via:

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:

• • Age
  • Disability
  • Gender reassignment
  • Marriage and civil partnership
  • Pregnancy and maternity
  • Race – this include ethnic or national origins, colour and nationality
  • Religion or belief
  • Sex, and;
  • Sexual orientation

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)