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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:  PAT/T 44 v.4 – Venous Thromboembolism (VTE) – Prevention and Treatment of VTE in Patients Admitted to Hospital

 

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Author/reviewer: (this version)

Pankaj Chaturvedi –Trust Lead for VTE Treatment

Stuti Kaul – Consultant Haematologist

Lee Wilson – Consultant Pharmacist

Date written/revised:

February 2019

Approved by:

Patient Safety Review Group

Date of approval:

April 2019

Date issued:

19 August 2021

Next review date:

April 2022

Target audience:

Trust wide

 

 

 

 

 

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 5

 

19 August

2021

Amendment

  • Within subsection 4.1 Prevention – link to the Guidance for VTE Prophylaxis, has been replaced.
  • Appendix 6 – Guidance for VTE Prophylaxis, has been replaced with the guidelines as updated in March 2021.

 

Cindy Storer

 

  

Version 4

15 January

2020

Significantly revised – please read in full.

Ben Kumar

Stuti Kaul

Lee Wilson

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

 

 

 

 

            

Contents

 

Page No.

1           INTRODUCTION ............................................................................................................................... 4 2        PURPOSE ......................................................................................................................................... 4

2.1  Prevention ............................................................................................................................... 4

2.2 Treatment ............................................................................................................................... 5

3           DUTIES AND RESPONSIBILITIES ....................................................................................................... 5 4        PROCEDURE .................................................................................................................................... 6

4.1 Prevention ............................................................................................................................... 6

4.2 Treatment ............................................................................................................................... 6

5           TRAINING/SUPPORT ........................................................................................................................ 7 6        MONITORING COMPLIANCE ........................................................................................................... 9 7        GLOSSARY OF DEFINITIONS .......................................................................................................... 10 8      EQUALITY IMPACT ASSESSMENT .................................................................................................. 11 9      ASSOCIATED TRUST PROCEDURAL DOCUMENTS ......................................................................... 12 10       DATA PROTECTION........................................................................................................................ 12 11   REFERENCES .................................................................................................................................. 12 APPENDIX 1 – Generic – VTE Risk Assessment ..................................................................................... 13 APPENDIX 2 – VTE Risk Assessment in Pregnancy ................................................................................ 15 APPENDIX 3 – Lower Limb POP Risk Assessment ................................................................................. 17 APPENDIX 4 – How to complete the VTE Risk Assessment  .................................................................. 17 APPENDIX 5 – Management of VTE Risk in Stroke Patients: Decision Tree .......................................... 19 APPENDIX 6 – Guidance for VTE prophylaxis ........................................................................................ 20 APPENDIX 7 – Preventing blood clots while you’re in hospital ............................................................ 23 APPENDIX 8 – DVT & PE IPOC ............................................................................................................... 27 APPENDIX 9 – DVT PIL ........................................................................................................................... 43 APPENDIX 10 – PE PIL ............................................................................................................................ 47 APPENDIX 11 – EQUALITY IMPACT ASSESSMENT - PART 1 INITIAL SCREENING ................................... 51

 

                    

 

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. Investigation and 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

for each individual patient and the decision will be informed by available published evidence. Following this the relevant pharmacological and/or mechanical prophylaxis should be prescribed.

(Appendix 7) should be given to all inpatients and day case patients >16 years of age

 

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 (VTE) IPOC. (Appendix 8)

The DVT & PE (VTE) IPOC contains the following sections

  1. Clinical Assessment including DVT (in Non-Pregnant and Pregnant Patients) and PE (in Non-Pregnant and Pregnant Patients) – see also Maternity Service Guidance 20.
  2. Post Diagnosis VTE checklists
  3. Daltepain and DOAC Prescribing and Dosing tablets in DVT/PE

 

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 Teaching Hospitals NHS Foundation Trust for those indications for which it is licensed.  Fondaparinux sodium should be used in individuals who are allergic to heparin.

4.1

Prevention  

4.2

Treatment  

 

 

PATIENTS LACKING CAPACITY

 

Sometimes it will be necessary to provide care and treatment to patients who lack the capacity to make decisions related to the content of this policy. In these instances staff must treat the patient in accordance with the Mental Capacity Act 2005 (MCA 2005).

 

 

 

 

There is no single definition of Best Interest.  Best   Interest is determined on an individual basis. All factors relevant to the decision must be taken into account, family and friends should be consulted, and the decision should be in the Best interest of the individual. Please see S5 of the MCA code of practice for further information.

 

5

TRAINING/SUPPORT

 

 

Staff Function

Training Needs

How Delivered

1

Staff who have general (nonspecific) role in delivery of

care to patients

General Awareness

Posters/leaflets/

Trust publicity

2

Staff who deliver care to patients

 

General Awareness 

Fitting of Antiembolism Stockings (AES)

On-going care of patient wearing 

Antiembolism Stockings (AES)

As above PLUS

Local Induction

 

3

Registered Staff who deliver care to patients

(Inc AHP’s)

General Awareness 

VTE disease process

Measuring and fitting of Antiembolism Stockings (AES)

Contraindications to GCS

On-going care of patient wearing Antiembolism Stockings (AES)

Indications and fitting of Flowton

Intermittent Pneumatic Compression (IPC) sleeves 

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 Antiembolism Stockings (AES)

Alternative methods of Mechanical compression.

Contraindications to Dalteparin, DOACs, Warfarin and Aspirin

Prescribing Dalteparin, DOACs, Warfarin and Aspirin

On going care of patients on Dalteparin,

DOACS, Warfarin and Aspirin

As above PLUS

Local Induction.

 

 

6.                 MONITORING COMPLIANCE WITH THE PROCEDURAL DOCUMENT

6

MONITORING COMPLIANCE

 

Criteria

Monitoring

Who

Frequency

How reviewed

All patients admitted to the

Trust as

Inpatients or Daycases will have a

VTE Risk

Assessment

Annual 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 division

Annual rolling programme

Report sent to division for recommendations and action plans.

Action plans and recommendations reviewed by VTE Group

Compliance with annual programme monitored

by Audit & Effectiveness

Forum

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

Cases identified via Datix system, 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 division, VTE 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 VTE Group

Lead

Annual

Report reviewed by VTE Group and results disseminated to Trust via Clinical Directors

            

 

7

GLOSSARY OF DEFINITIONS

 

  -VE         

Negative

  +VE        

Positive

  AES        

Anti-Embolism Stockings

  AHS       

Allied Health Professional

  AM        

Morning

  ANP       

Advanced Nurse Practitioner

  BD         

Twice Daily

  BMI       

Body Max Index

  BP          

Blood Pressure

  BNF       

British National Formulary 

  Ca2+     

Calcium

  CrCl       

Creatinine Clearance

CTPA 

CT Pulmonary/Angiogram

CT Scan

Computed Tomography Scan

  CXR       

Chest X-Ray

DOAC 

Direct Oral Anticoagulant

  DVT       

Deep vein Thrombosis

  ECG       

ElectroCardioGram

  ED          

Emergency Department

  SER        

Erythrocyte Sedimentation Rate

  EVE        

Evening

  FBC        

Full Blood Count

  GP         

General Practitioner

  INR        

International Normalised Radio

  IPOC      

Integrated Plan of Care

  IV           

Intravenous

  IVC        

Inferior Vena Cava

IVDU 

Intra Venous Drug misuse

  LFT         

Liver Function Tests

LMWH 

Low Molecular Weight Heparin

MSG        

Maternity Service Guideline

MDT        

Multi Disciplinary Team                          

NHSLA 

National Health Service Litigation Authority

NICE        

National Institute for Health and Care Excellence

OD           

Once Daily 

PE            

Pulmonary Embolism

PSA          

Prostate Specific Antigen

PT            

Prothrombin Time

Q Scan 

Perfusion Scan

ST             

Speciality Training

U&E         

Urea and Electrolytes

UFH   

UnFractionated Heparin

USS          

Ultrasound

VTE          

Venous ThromboEmbolism

8

EQUALITY IMPACT ASSESSMENT

 

       

 

The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are disadvantaged over others.  Our objectives and responsibilities relating to equality and diversity are outlined within our equality schemes.  When considering the needs and assessing the impact of a procedural document any discriminatory factors must be identified.   

 

An Equality Impact Assessment (EIA) has been conducted on this procedural document in line with the principles of the Equality Analysis 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.   (See Appendix 11)

 

 

 

 

 

9

ASSOCIATED TRUST PROCEDURAL DOCUMENTS

 

PAT/PA 19 - Mental Capacity Act 2005 Policy and Guidance, including Deprivation of Liberty Safeguards (DoLS)

CORP/EMP 4 – Fair Treatment for All Policy

CORP/EMP 27 - Equality Impact Assessment Policy

 

10

DATA PROTECTION

 

Any personal data processing associated with this policy will be carried out under ‘Current data protection legislation’ as in the Data Protection Act 2018 and the General Data Protection Regulation (GDPR) 2016. 

 

For further information on data processing carried out by the trust, please refer to our Privacy Notices and other information which you can find on the trust website: https://www.dbth.nhs.uk/about-us/our-publications/uk-data-protection-legislation-eugeneral-data-protection-regulation-gdpr/  

 

11

REFERENCES

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

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

  1. NICE Guideline 89: www.nice.org.uk/guidance/ng89  
  2. Guidelines on the use and monitoring of heparin (2006) British Journal of Haematology 133, 19 – 34
  3. NICE clinical guideline 144: https://www.nice.org.uk/guidance/CG144  
  4. Department of Constitutional Affairs 

        Mental Capacity Act (2005): Code of Practice, 2007  https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachm ent_data/file/497253/Mental-capacity-act-code-of-practice.pdf