CONFIRMED DEEP VEIN THROMBOSIS - Walsall CCG · Web view2016/02/04 · The diagnosis of deep vein thrombosis in symptomatic out patients and the potential for clinical assessment

Name: NHS/Hospital No:

CONFIRMED DEEP VEIN THROMBOSISPATIENT CARE RECORDS – SUBJECT TO CALDICOTT GUIDELINES

This document forms the specialist assessment of the single assessment process

Instructions for use of document:All entries must be made in black inkAll entries must be signed and dated

To be used as for all patients with an actual diagnosis of deep vein thrombosis Applicable fields must be completed or a variance reason given for non- completion. This document is to be used in conjunction with suspected deep vein thrombosis pathway as

appropriate following confirmed diagnosis All persons contributing to this pathway must complete sign in sheet Referrals received after 1800 hrs will be seen in clinic for assessment next day unless prior

discussion with nurse in charge. Please NOTE only patients where GP completes home visits will be seen in their own home (clinically housebound)All patients should be encouraged to attend clinic

Any questions on completing this document please contact the Clinical Intervention Team on 0845 113 0761

Referrals to be signed by Doctor then scanned and e-mailed to#[email protected]

Guidelines to be read in conjunction with this document:

Scottish Intercollegiate Guidelines Network (SIGN)

Walsall hospitals guidelines on DVT – can be found on the intranet.

British committee for standards in Haematology (2004) The diagnosis of deep vein thrombosis in symptomatic out patients and the potential for clinical assessment and D-Dimer assays to reduce the need for diagnostic imaging. British Journal of Haematology., p124, p15-25

www.stjohnsmercy.org/mmg/mmghealthinfo/adults/deepveinthrombosis.asp

Institute for clinical systems improvement (2010) [ONLINE] Available from:http://www.icsi.org/venous_thromboembolism/venous_thromboembolism_4.html

Record Of Care – Sign In SheetDate Name Sign Date Name Sign

Confirmed DVT/Version 4/February 2016 Page 1 of 17

Pt Name………………………………………Date of birth………………………………….Address………………………………………………………………………………………..Date of presentation……………………….

http://www.icsi.org/venous_thromboembolism/venous_thromboembolism_4.html

http://www.stjohnsmercy.org/mmg/mmghealthinfo/adults/deepveinthrombosis.asp

Name: NHS/Hospital No:Exclusion criteria for Community Management

Tick if present□ Active bleeding e.g. Intracerebral bleed within last 6 months. GI bleed

within 1 month.

□ Symptoms suggestive of Pulmonary Embolism

□ Known haematological disorder Blood disorders i.e. abnormal clotting, Haemophilia, platelets less than 130

□ Systemically unwell requiring hospital admission

□ Actual or potential for violence towards NHS staff. Patients with no fixed abode, no telephone to enable contact. Patient does not have Walsall GP

□ Pregnancy – women of childbearing age must have had pregnancy excluded prior to referral

CAUTIONS WHEN REFERRING FOR OUT PATIENT MANAGEMENT

□ Drug and alcohol abuse – must be identified to CIT on referral

□ Liver/renal failure

□ Sensitivity to Warfarin / prothrombin time prolonged

□ Malignant disease undergoing chemotherapy

If the patient has any medical or social exclusion factors he/she will require hospital assessment please refer as appropriate.

Patients with cautions can potentially be managed as an out patient, factors including staff safety, client compliance and increased clinical risk. The prior factors should be assessed by the GP and Clinical Intervention Team together before reaching a decision for safe management

Clinical Intervention Team DVT checklistYES NO Comments

Authorisation section completed including Dose of Clexane and length of treatment by GPExclusion criteria checked and patient is suitable for the pathway?Target Range identified /specified?Patient has yellow anti-coagulation booklet? Confirmed DVT – CIT to

request prescription from G.P. Will not apply if USS inconclusive

Patient has MEDICATION including warfarin (1mg and 3mg tablets) from GPPatient has DVT information booklet?Patient has relevant contact phone numbers?

DATE PRINT SIGN


Name: NHS/Hospital No:G.P. Tel

Consultant

Discharging Ward/ Unit

Affix pt label

Clinical Intervention Team DVT discharge checklist & referral form(From Hospital to CIT)

YES NO CommentsAuthorisation section completed including Dose of Clexane and length of treatmentExclusion criteria checked and patient is suitable for the pathway?Target Range identified /specified?Patient has yellow anti-coagulation booklet? Will not apply if USS not yet

completed – CIT to obtain prescription from G.P.

Patient has TTO’s including warfarin (1mg and 3mg tablets) with them to take home?Patient has DVT information booklet?Patient has relevant contact phone numbers?First visit date………………….Bloods: FBC / U&E / LFT / Other…………………… to be repeated on (date)……………………Please note: INR will be done by CIT daily until patient therapeutic and stable on warfarin unless otherwise instructedCIT: liaise with GP re abnormal results

HOSPITAL USE ONLY

N.B.This section MUST be signed by a responsible practitioner authorising hospital discharge

Referral to DVT Clinical Intervention Team (CIT)

I agree that this patient may be transferred to the care of the Clinical Intervention Team (CIT) and authorise medication to be given following the Warfarin Dosing Protocol.The Warfarin protocol must be used.DIAGNOSIS:Target Range:DOSE OF CLEXANE:DOSE OF WARFARIN (as at discharge):INR ON DISCHARGE:

Print Name:………………………………..… Date:……………………………..

Signature:…………………………………….



Deep Vein Thrombosis Integrated care pathway flowchart for confirmed DVT management within the community.


Confirmed DVT on US scan

Evaluate inclusion/exclusion criteria for DVT care pathway

1.Complete assessment for suitability for warfarin

2. Inform GP / Dr on call of scan results3. obtain permission to commence warfarin

and obtain a prescription4.Take bloods FBC UE LFT and order any

further diagnostics

Do not commence DVT ICP

Liaise i/c GP to develop further management plan .Continue

clexane until plan

ICT will visit pt daily Follow Warfarin dosing schedule. Stop clexane when INR is within therapeutic range for 2 consecutive days.Monitor observationsReinforce education programme Measure for Bs class 3 stockings where contraindications not evident

Inclusion

Commence clexane and initial dose of warfarin once agreed by GP / Dr

in accordance with dosing protocol Offer education

programmeConsider lower dose in

high risk / elderly patients

Exclusion / Not

suitability to warfarin

Patient clinical need

increases – Refer to G.P. – Phone 999 if

condition warrants

Inform Snr CIT nurseRefer to

pathology dep’t manor hospital who will arrange referral to Warfarin clinic for maintenance therapy. Page

Complete audit form.

Name: NHS/Hospital No:Protocol for Initiation of Warfarin – Days 1 to 4 – Standard InitiationIf patient already on Warfarin dosing advice to be sought from anticoagulation nurse specialist

Day INR Warfarin Dose

Clinical considerations

1 1.0 - 1.4 10mg ONLY if the prothrombin time is within normal range and SENSITIVITY to warfarin is unlikely. INR should be Measured before the first dose is given on Day1. N: B Consider lower starting dose for warfarin where Patient sensitivity may be increased e.g. Abnormal LFT’s, impaired renal function, CCF. Age (elderly), frail, Low BMI, drug interactions.IF IN DOUBT REFER FOR SPECIALIST ADVICE - 01922 656488

1 Baseline 10mg1 >1.4 Refer for specialist advice

2

< 1.8 10mg

1.8 1mg

>1.8 0.5mg

Daily bloods for INR are required for at least the first four days of initiation. (Anti-coagulation effect takes between 48 and 72 hours to fully develop)

3

< 2.0 10mg

Check next INR Day 4

2.0 – 2.1 5mg2.2 – 2.3 4.5mg2.4 – 2.5 4mg2.6 – 2.7 3.5mg2.8 – 2.9 3mg3.0 – 3.1 2.5mg3.2 – 3.3 2mg3.4 1.5mg3.5 1mg3.6 – 4.0 0.5mg> 4.0 0mg

Predicted maintenance doseThe dose given on day 4 is a broad indicator as to the required maintenance doseSecond day of therapeutic range STOP ClexaneReference maintenance range: Usual therapeutic range: INR 2.0 – 3.0Higher therapeutic range may be indicated for:

Prosthetic heart valve Recurrent DVT/PE whilst on Warfarin

4

< 1.4 (12mg) Please see loading schedule 1 (table 3) from Day 4 below -

1.4 8mg

Check next INR Day 6 (if in range continue with dose or use table 6 or 7)

1.5 7.5mg1.6 – 1.7 7mg1.8 6.5mg1.9 6mg

2.0 – 2.1 5.5mgCheck next INR Day 5 (if in range refer to anticoag)2.2 – 2.3 5mg

2.4 – 2.6 4.5mg2.7 – 3.0 4mg

3.1 – 3.5 3.5mg Check next INR Day 6 (if INR in range continue with dose or use table 6 or 7)3.6 – 4.0 3mg

4.1 – 4.5 Omit day 4 Check next INR Day 5 and then daily;Once INR < 3.5 restart Warfarin at 3mg

> 4.5 Omit for 2 days i.e. day 4 and day 5

Check next INR Day 6 then daily;Once INR < 3.5 restart Warfarin at 3mg


Name: NHS/Hospital No:WARFARIN LOADING SCHEDULE FOR HIGH RISK PATIENTS

This warfarin loading schedule should be considered for patients ▪ with high risk factors such as congestive heart failure, liver disease, intercurrent illness ▪ taking other drugs known to potentiate warfarin ▪ over 75 years of age

NB. These patients are more likely to encounter problems with warfarin. A review of risk: benefit ration of anticoagulation should be considered

Day INR Warfarin dose Follow up

1 <1.4 10mg Next INR Day 2

2 <1.8 5mgNext INR Day 31.8-2.0 1mg

2.1-2.5 Omit>2.5 Omit Seek medical advice

3 <2.0 5mg

Next INR Day 42..0 - 2.5 4mg2.6 – 2.9 3mg3.0 – 3.2 2mg3.3 – 3.5 1mg>3.5 Omit

4 <1.4 9mg Check INR Day 6 If INR in range continue same dose - follow

up by GP If INR not in range see Table 6 or 7 for

suggested dose

1.4 -1.5 7mg1.6 – 1.7 6mg1.8 – 1.9 5mg

2.0 – 2.3 4mg Check INR Day 5 If INR in range continue same dose - follow


suggested dose

2.4 – 3.0 3mg

3.1 – 3.2 2mg Check INR Day 6 If INR in range continue same dose - follow


suggested dose

3.3 – 3.5 1mg

3.6 – 4.0 Omit Check INR Day 5 If INR in range continue same dose - follow


suggested dose>4.0 Omit 2 days Check next INR Day 6

See Table 6 or 7 for suggested dose

UNDER-ANTICOAGULATED PATIENTS – (TABLE 6)Confirmed DVT/Version 4/February 2016 Page 6 of 17


Table 6 shows suggested % increase in daily Warfarin dose. The dose should be rounded up to nearest 0.5mg-tablets should not be broken e.g. if suggested dose 1.5mg daily give 2mg/1mg alternate days starting with higher dose i.e. 2mg

INR Target INR Increase dose by % *suggested reduced dose for medically unstable patients

< 1.0 – 1.2 2.53.03.5

30%35%40%

15%20%25%

1.3 – 1.5 2.53.03.5

25%30%35%

10%15%20%

1.6 – 1.9 2.53.03.5

20%25%30%

5%10%15%

2.0 – 2.4 3.03.5

20%25%

5%10%

2.5 – 2.9 3.03.5

10%20%

N/A5%

3.0 – 3.4 3.5 10% N/A

* If the patient is medically unstable i.e. requiring frequent changes in medication or management 15% can be subtracted from the suggested dose increase change i.e.20% would be 5% Repeat INR 2-3 days later (it will take at least 2 days for any change in dose to have full effect) or sooner if clinically indicated e.g. active bleeding or medically unstable, in which case check the next day


Name: NHS/Hospital No:Management of over-anticoagulated patient - (TABLE 7 )

Table 7 shows suggested % decrease in daily Warfarin dose. The dose should be rounded down to nearest 0.5mg-tablets should not be broken e.g. if suggested dose 1.5mg daily give 1mg/2mg alternate days starting with lower dose of 1mg.

Target INR 2.5 ( 2 – 3 )

INR Omit Warfarin days Repeat INR Suggested % dose reduction once Warfarin restarted*

3.1 – 3.5 0 At 2 days unless clinically indicated e.g. active bleeding or medically unstable

15


20

4.1 – 5.0 1 day At 2 days unless clinically indicated e.g. active bleeding or medically unstable

25

5.1 – 6.0 At least 1 Daily restart Warfarin once INR < 5 25


>8.0 See Table 8 Daily; ward and medical staff must be informed and involved in management

50

Target INR 3.0 (2.5 – 3.5)


15


20



>8.0 Seek Specialist Advice 50Target INR 3.5 ( 3 – 4 )

4.1 – 5.0 0; unless patient medically unstable when omit dose

At 2 days unless clinically indicated e.g. active bleeding or medically unstable

15


20


>8.0 Seek Specialist Advice 50

Warfarin loading schedule 1 from day 4 only to be used for patients with INR<1.4 on day 4 (Table 3)

Day INR Warfarin dose Follow up

4 <1.4 12mg for 2 days Check INR Day 6

6 >2.0 <3.0<2.0

12mg14mg for 2 days

Check INR Day 8-10; if >3.0 see Table 7Next INR Day 8

8 >2.0 <3.0<2.0

14mg16mg for 2 days

Check INR Day 10-12; if >3.0 see Table 7Next INR Day 10

10 >2.0 <3.0<2.0

16mgSee table 6 for suggested dose

Check INR Day 12-14; if >3.0 see Table 7



ICT TREATMENT RECORD

DAY DATE/TIME CONSENT GAINED: Y / N

Warfarin: INR: Dose:

Enoxaparin Dose: Batch Number: Expiry Date:

SOB YES / NO Chest Pain YES / NO

BP Pulse Sats Resps

Comments:

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Name: NHS/Hospital No:Warfarin: INR: Dose:



BP Pulse Sats Resps

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BP Pulse Sats Resps

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Name: NHS/Hospital No:Warfarin: INR: Dose:



BP Pulse Sats Resps

Comments:

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BP Pulse Sats Resps

Comments:

Signature: Print:



Dear Dr ………………………..

Thank you for your referral to the Clinical Intervention Team.

The patient …………………………………………. has been diagnosed with a Deep Vein Thrombosis (DVT) to their ……………..leg.

Please consider prescribing your patient support hosiery in line with current guidelines to prevent “

post thrombotic syndrome”. We would suggest “graduated compression hosiery Class 3 “

below knee, 1 stocking to be worn on the affected leg for 2 years post DVT. Prescription to be

renewed every 6/12. Patients are advised to observe their feet for any signs of discolouration to

their toes then to remove stockings if this should occur. Should class 3 hoisery not be tolerated we

would suggest lowering class strength. We have taken the appropriate measurements for your

information.


CALFMEASUREMENT CM

ANKLEMEASUREMENT CM

FOOT LENGTH CM

PATIENTS PREFFERED COLOUR CHOICEOPEN / CLOSED TOE PREFFERED

Name: NHS/Hospital No:This patient has been on the DVT Care pathway and has been treated for a DVT by the Clinical Intervention Team (CIT). Please include scan result, and GP Summary, fax referral to Specialist Nurses for Anti-coagulation / DVT on 01922 656488.

ANTICOAGULANT CLINIC REFERRALFrom Clinical Intervention Team (CIT) to Pathology Department, Manor Hospital.

NHS number : CONSULTANT:NAME: WARD/HOSPITAL/ ICT

ADDRESS:

POSTCODE:

GP’S NAME & ADDRESS:

TEL NO: GP’S TEL NO:Date of Birth:Current INR: ON:Warfarin dosage:Duration of Anti-coagulation required: Please circle

Other:

3 months 6 months 12 months Long term

Does the referring Consultant wish to review the patient prior to treatment completion? YES/NO/UNSPECIFIEDDoes patient require a thrombophilla screen on completion of treatment? YES/NO/UNSPECIFIED

Past medical history: (ATTACH GP SUMMARY AND SCAN RESULT)

Other medication: (ATTACH GP SUMMARY AND SCAN RESULT)

Preferred choice of clinic Please tick

The Keys Practice, Field Street, Willenhall Monday amDarlaston Health Centre, Pinfold St, Darlaston Tuesday amPinfold Health Centre, Field Road, Bloxwich Wednesday amWalsall Manor Hospital Thursday amThe Park View Centre, Chester Road North, Brownhills Friday amG.P. Practice based clinic (if available)Name: Sign: Date:

Please fax the completed referral to Specialist Nurses for Anti-coagulation/DVT on 01922 656488.



Audit Sheet (TEAR OFF) To be detached when completed and sent to Clinical Team Leader Intermediate Care, C/O

Hollybank House, Coltham Road, Willenhall

Integrated care pathway: DVT

Patient name: NHS no:

Milestones / outcomes Met Code if not met

1 Commenced on confirmed DVT pathway within 24hrs of positive scan result

2 Face to face contact by CIT within 24 hours of receipt of result.

3 Clinically stable throughout care episode, hospital readmission not required

4 Target range INR reached on two consecutive days by day 5.

5 Appointment at Anti-coagulation clinic within one week of discharge from CIT.

This audit form completed by: Date:

Variance Codes - Please use these codes to document variances from this pathway.

CODE VARIANCE TYPE CODE VARIANCE TYPE

A Client Condition E System Hospital related

B Client/Carers decision F System Community related

C Clinician Decision G Clinical Incident

D Clinician Availability H Other

Variance & action taken. Page in ICP& initial

CODE


Documents

CONFIRMED DEEP VEIN THROMBOSIS - Walsall CCG · Web view2016/02/04 · The diagnosis of deep vein thrombosis in symptomatic out patients and the potential for clinical assessment