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Page 1 of 25 131a - Venous Thromboembolism (VTE) Risk Assessment Policy for Mersey Care Ward 35 V1 – June 19

COMMUNITY SERVICES DIVISION CLINICAL WARD BASED POLICY DOCUMENT

Venous Thromboembolism (VTE) Risk Assessment Policy for Mersey Care Ward 35

Policy Number: 131a Scope of this Document: Multidisciplinary Healthcare Team

involved in Patient Care on Ward 35 Recommending Committee:

VTE Harm Free Group

Approving Committee: Clinical Policies & Procedures Group Date Ratified: June 2019 Next Review Date (by): May 2020

(Formally extended to August 20202) Version Number: Version 1 - 2019 Lead Executive Director: Executive Director of Nursing and

Operations Lead Author(s): Ward Manager and ANP - Ward 35

ICRAS Clinical Support Manager

COMMUNITY SERVICES DIVISION CLINICAL WARD

BASED POLICY DOCUMENT

2019 – Version 1

Striving for perfect care for the people we serve


COMMUNITY SERVICES DIVISION CLINICAL WARD BASED POLICY DOCUMENT

Venous Thromboembolism (VTE) Risk Assessment Policy for Mersey Care Ward 35

Further information about this document: Document name Venous Thromboembolism (VTE) Risk Assessment Policy for

Mersey Care Ward 35 (131a)

Document summary

This policy is intended to assist with the reduction in fatal and non-fatal pulmonary emboli and reduce the incidence of deep

vein thrombosis in patients admitted to bed based services within of Mersey Care, through the effective use of thrombo-

prophylaxis.

Author(s)

Contact(s) for further information about this document

Orginal Authors - Nurse Clinician in the Bed Based Intermediate Care and Ward Manager for V4

Updated by MCFT VTE Harm Free Group Email: [email protected]

Published by

Copies of this document are available from the Author(s) and

via the trust’s website

Mersey Care NHS Foundation Trust V7 Building

Kings Business Park Prescot

Merseyside L34 1PJ

Trust’s Website www.merseycare.nhs.uk

To be read in conjunction with

Overarching Medicines Policy – 89 DVT and VTE Management Policy – 131

Injection Policy – 136 Trustwide Infection Prevention and Control Policy – IC01

Trustwide Consent to Treatment Policy – SD06 This document can be made available in a range of alternative formats including

various languages, large print and braille etc

Copyright © Mersey Care NHS Trust, 2015. All Rights Reserved

Version Control:

Version History:

Version 1 Ratified by Clinical Policies Group 18 June 2019

mailto:[email protected]

http://www.merseycare.nhs.uk/


SUPPORTING STATEMENTS

this document should be read in conjunction with the following statements:

SAFEGUARDING IS EVERYBODY’S BUSINESS

All Mersey Care NHS Foundation Trust employees have a statutory duty to safeguard and promote the welfare of children and adults, including: • being alert to the possibility of child / adult abuse and neglect through their observation of abuse, or

by professional judgement made as a result of information gathered about the child / adult; • knowing how to deal with a disclosure or allegation of child /adult abuse; • undertaking training as appropriate for their role and keeping themselves updated; • being aware of and following the local policies and procedures they need to follow if they have a child

/ adult concern; • ensuring appropriate advice and support is accessed either from managers, Safeguarding

Ambassadors or the trust’s safeguarding team; • participating in multi-agency working to safeguard the child or adult (if appropriate to your role); • ensuring contemporaneous records are kept at all times and record keeping is in strict adherence to

Mersey Care NHS Foundation Trust policy and procedures and professional guidelines. Roles, responsibilities and accountabilities, will differ depending on the post you hold within the organisation;

• ensuring that all staff and their managers discuss and record any safeguarding issues that arise at each supervision session

EQUALITY AND HUMAN RIGHTS

Mersey Care NHS Foundation Trust recognises that some sections of society experience prejudice and discrimination. The Equality Act 2010 specifically recognises the protected characteristics of age, disability, gender, race, religion or belief, sexual orientation and transgender. The Equality Act also requires regard to socio-economic factors including pregnancy /maternity and marriage/civil partnership.

The trust is committed to equality of opportunity and anti-discriminatory practice both in the provision of services and in our role as a major employer. The trust believes that all people have the right to be treated with dignity and respect and is committed to the elimination of unfair and unlawful discriminatory practices.

Mersey Care NHS Foundation Trust also is aware of its legal duties under the Human Rights Act 1998. Section 6 of the Human Rights Act requires all public authorities to uphold and promote Human Rights in everything they do. It is unlawful for a public authority to perform any act which contravenes the Human Rights Act.

Mersey Care NHS Foundation Trust is committed to carrying out its functions and service delivery in line the with a Human Rights based approach and the FREDA principles of Fairness, Respect, Equality Dignity, and Autonomy


Contents

1. Purpose and Rationale 5

2. Outcome Focused Aims and Objectives 5

3. Scope 5

4. Definitions 6

5. Duties 6

6. Process 7

7. Consultation 13

8. Training and Support 13

9. Monitoring 13

10. Equality and Human Rights Analysis 14

11. Appendices 17

Section Page No


1. PURPOSE AND RATIONALE 1.1 This policy is intended to assist with the reduction in fatal and non-fatal pulmonary emboli

and reduce the incidence of deep vein thrombosis in patients admitted to bed based services within of Mersey Care, through the effective use of thrombo-prophylaxis.

2. OUTCOME FOCUSED AIMS AND OBJECTIVES

2.1 Approximately 25,000 people in England each year, die from venous thromboembolism (VTE) contracted in hospital. Up to 40% of patients undergoing major surgery do not receive effective prophylaxis (House of Commons Health Committee (2005). In addition, 40% of medical patients who are eligible for preventative treatment do not received effective prophylaxis. It is estimated that the total cost both direct and indirect to the UK of managing VTE is an estimated £640 million (House of Commons Health Committee 2005).

2.2 VTE is a condition in which a blood clot (a 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 encompasses a range of clinical presentations. Venous thrombosis is often asymptomatic; less frequently it causes pain and swelling in the leg. Part or all of the thrombus can come free and travel to the lung as a potentially fatal pulmonary embolism. Symptomatic venous thrombosis carries a considerable burden of morbidity, sometimes over a long term because of chronic venous insufficiency. This in turn can cause venous ulceration and development of a post-thrombotic limb (characterised by chronic pain, swelling and skin changes). 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).

2.3 In March 2018 the National Institute for Health and Clinical Excellence (NICE) launched an updated guideline “Venous thrombo-embolism in over 16s: Reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism (ng89). This document sets out Mersey Care system for Venous Thromboembolism (VTE) Prevention for patients over 18 years of age being cared for within the in-patient areas of this organisation. Patients less than 18 years of age considered at high risk of developing VTE should be assessed and treated on individual clinical need. This policy provides a robust framework to ensure a consistent approach across the in-patient areas of Mersey Care and also supports our statutory duties as set out in the NHS Constitution (2012).

3. SCOPE 3.1 This policy applies to all the multidisciplinary healthcare team involved in patients care

within Ward 35 which is part of Mersey Care Community Services Division.


4. DEFINITIONS

Venous thromboembolism (VTE) Venous thrombosis is a condition in which a blood clot (thrombus) forms in a vein in any part of the venous system. The thrombus can reduce blood flow through the affected vein, causing pain and swelling. Venous thrombosis most commonly occurs in the ‘deep veins’ in the legs, thighs, or pelvis. This is known as a deep vein thrombosis (DVT). When a part or all of the thrombus in the deep vein breaks off from the site where it is created and travels through the venous system. This is known as an embolism. A dislodged thrombus that travels to the lung is known as a pulmonary embolism (PE). However, deep vein thrombosis (DVT) and PE are the most common manifestations of venous thrombosis. DVT and PE are known as venous thromboembolism (VTE).

VTE Thromboprophylaxis The treatment to prevent blood clots forming

in veins through chemical or mechanical interventions.

NICE The National Institute of Health & Clinical Excellence (NICE) is an independent organisation that assesses and decides which drugs and treatments are cost effective and are available on the NHS in England and Wales.

Bed Based Services Bed based services are facilities where patients are admitted for health care assessment and intervention for a minimum of twenty four hours.

5. DUTIES

Role of Chief Executive

5.1 The Chief Executive is ultimately responsible for the content of all organisation wide procedural documents and their implementation.

Role of Medical Staff/ Nurse Clinician/Advanced Nurse Practitioner

5.2 The medical staff and advanced nurse practitioners involved in the patient`s admission are responsible for:

• Ensuring that patients are risk assessed on admission, 24 hours after admission, and according to any changes in the patient`s clinical condition.

• Ensuring that appropriate pharmacological and/or mechanical prophylaxis is prescribed.


• Ensuring that decisions made in relation to preventative treatment for VTE are documented in the patient`s clinical record

Role of Admitting Nurse

5.3 The admitting nurses are responsible for:

• Ensuring that the VTE risk assessment, an example is shown in Appendix A, is completed on admission and reviewed within 24 hours of the patient`s admission or if the patients condition changes.

• Ensuring that the outcome is documented in the patient`s notes

Role of Nursing Staff

5.4 The nursing staff are responsible for:

• Administering pharmacological prophylaxis, where prescribed, in line with the Mersey Care Medicines Policy

• In line with the outcome of the VTE risk assessment, undertaking an initial assessment to determine whether patients are deemed suitable for anti-embolic stockings and recording this using appropriate documentation.

• Measuring and fitting anti-embolic stockings where it is assessed to be appropriate.

• Assessing and documenting the ongoing care of patients who have anti-embolic stockings or pharmacological prophylaxis prescribed.

Role of Pharmacists

Exception

5.5 The Pharmacists are normally responsible for:

• Checking pharmacological prophylaxis is appropriately prescribed and administered

• Ensuring discrepancies are recorded in the patient`s clinical record with the prescriber and or/medical staff.

However within Mersey Care staff work to a Local Agreement (Add Appendix B)

Role of Ward Manager/Matron

5.6 The Ward Manager/Matron is responsible for:

• Dissemination of this policy

• Ensuring staff are kept up to date in any training needs associated with this policy

• Ensuring that nursing staff comply with this policy

6 PROCESS

Admission Assessment

6.1 All patients admitted to bed based services must be assessed for their risk of developing a venous thromboembolism (VTE). This assessment is performed by completing the Mersey


Care VTE risk assessment form. WITHOUT EXCEPTION ALL PATIENTS whether “stepped up” from the community or “stepped down” from the acute sector/secondary care are to have this assessment completed on admission by nursing staff of the Bed Based Unit.

6.2 This policy does not include patients who are bed/wheelchair bound through chronic ill

health or palliative care within their usual place of residence; this includes residential/care homes.

6.3 For those patients discharged from secondary care to their usual place of residence, an

assumption will be made that secondary care have performed a VTE risk assessment and administered appropriate prophylaxis.

VTE Risk Assessment 6.4 The responsibility for completing the VTE risk assessment lies with those staff completing

the initial clinical assessment. This includes; • Nurse practitioners.

• Advanced Nurse Practitioners.

• GP/Medical Staff

6.5 The VTE risk assessment must also be repeated 24 hours after admission and if there is any change in the patients’ clinical status or mobility. Responsibility for completion of the risk assessment at twenty four hours and subsequent risk assessments lies with the registered nurses allocated to undertake the patients day to day care needs at that moment in time.

Completing the VTE risk assessment form (Appendix A); 6.6 Attach patient identification label to the VTE risk assessment form or complete by hand

(Black ink) with the patients details. Ensure the ward and date of completion is also documented.

6.7 Assess all patients admitted to bed based intermediate care for level of mobility, relative to

their normal state (tick one box). Significantly reduced mobility is defined as; bed bound, unable to walk unaided or likely to spend a substantial proportion of the day in bed or in a chair; and is a significant change from the patients’ usual state of mobility.

6.8 For all medical patients who are NOT expected to have significantly reduced mobility

relative to normal state are not regarded as at increased risk of VTE, and therefore further risk assessment is not required.

6.9 All surgical patients, and all medical patients with significantly reduced mobility, should be

considered for further risk assessment. Patients, who have been transferred from secondary care and have had surgery during their admission to secondary care, should be identified as surgical patients.

6.10 Further risk assessment requires review of the patient-related factors shown on the

assessment sheet against thrombosis risk, ticking each box that applies (more than one box can be ticked). Any tick for thrombosis risk should prompt the healthcare professional to consider appropriate thromboprophylaxis according to NICE guidance issued in 2018 -


https://www.nice.org.uk/guidance/ng89 ensuring that there are no contra-indications. The thrombosis risk factors identified are not exhaustive. Healthcare professionals may consider additional risks in individual patients and offer thromboprophylaxis as appropriate.

6.11 Following review of thrombosis risk, review the patient-related factors shown against

bleeding risk and tick each box that applies (more than one box can be ticked). Any tick should prompt clinical staff to consider if bleeding risk is sufficient to preclude pharmacological intervention.

6.12 Within twenty four hours of admission and following any changes in their clinical situation,

all patients should be reassessed for their bleeding and thrombosis risk. This is to ensure that the methods of VTE prophylaxis being used are suitable, that VTE prophylaxis is being used correctly and to identify adverse events resulting from VTE prophylaxis. Document this and any subsequent re-assessments within the multi-disciplinary notes. If the thrombosis or bleeding risk changes during the admission the thromboprophylaxis must be reviewed and adjusted as appropriate.

VTE Prophylaxis 6.13 Take into account risk of bleeding and of co-morbidities such as arterial thrombosis:

• If the risk of VTE outweighs the risk of bleeding, consider offering pharmacological

thromboprophylaxis according to the reason for admission. • If the risk of bleeding outweighs the risk of VTE offer anti embolic stockings if no

contraindications. • If no risk of VTE no prophylaxis is indicated.

6.14 Patients who already take antiplatelet therapy to treat other conditions:

• Do not regard aspirin or anti-platelet agents as adequate prophylaxis for VTE. • Consider offering additional mechanical or pharmacological VTE prophylaxis if patient is at

risk of VTE.

6.15 Patients who already take anti-coagulants to treat other conditions: • Do not offer additional pharmacological or mechanical thromboprophylaxis to patients who

are taking vitamin K antagonists and who are within their therapeutic range, providing anticoagulant therapy is continued.

• Do not offer additional pharmacological or mechanical thromboprophylaxis to patients who are having therapeutic anticoagulant therapy with heparin (e.g. treatment dose Dalteparin) or direct oral anticoagulants (eg dabigatran, apixaban, rivaroxaban or edoxaban).

Patients Offered Prophylaxis 6.16 All patients offered thromboprophylaxis must be informed both verbally and in writing, of the

causes and risks of developing VTE, the risks and benefits of thromboprophylaxis, the correct use of thromboprophylaxis (i.e. anti-embolic stockings), and how to reduce the risks of VTE. If the patient refuses thromboprophylaxis this must be documented within the multi-disciplinary notes.

https://www.nice.org.uk/guidance/ng89


6.17 All patients whom have consented to thromboprophylaxis must not be allowed to become clinically dehydrated and must be mobilised (relative to their normal state) as soon as possible.

6.18 Any patients who do not wish to have porcine products in which pharmacological

prophylaxis is indicated can be offered fondaparinux as an alternative. Pharmacological Thromboprophylaxis 6.19 Low molecular weight heparin (LMWH) is the pharmacological thromboprophylaxis for

patients under the care of Mersey Care. (LMWH should not be used in acute stroke except under certain clinical circumstances. Patients following acute stroke will only be transferred to intermediate care during their re-enablement phase of recovery and should only be prescribed LMWH if discharged from the acute sector with LMWH, or they have a significant risk of VTE and they were prescribed LMWH during their acute admission and it is documented in the medical notes that LMWH is appropriate). Fondaparinux if indicated as an option to patients who do not wish to take porcine products for ethical and cultural reasons.

Types of Pharmacological Thromboprophylaxis and dosages 6.20 Types of Pharmacological Thromboprophylaxis and their dosages are: • Dalteparin (Fragmin): 5000 units once daily via subcutaneous injection for patients with

moderate or no renal impairment (eGFR > 30ml/ min/1.73m2)

• Dalteparin (Fragmin): 2500 units once daily via subcutaneous injection for patients with severe renal failure (eGFR < 30ml/ min/1.73m2).

• Enoxaparin (Clexane) 40 mg once daily via subcutaneous injection for patients with moderate or no renal impairment (> 30ml/ min/1.73m2).

• Enoxaparin (Clexane) 20 mg once daily via subcutaneous injection for patients with severe renal impairment (15-30ml/ min/1.73m2).

• Doses of LMWH can also be reduced to renal doses in patients who are under weight (e.g. <50kg).

• Fondaparinux 2.5mg once daily via subcutaneous injection.

• Fondaparinux 1.5mg once daily via subcutaneous injection in patients for patients with renal impairment (eGFR 20-50 > 50ml/ min/1.73m2).

Patient Management 6.21 Patients with increased risk of bleeding and significant risk of VTE should be discussed with

the GP responsible for the bed base/in patient setting. 6.22 Prior to initiation of pharmacological thromboprophylaxis, baseline platelet counts should be

checked. This should be repeated at days 5 and 10 and then once again between days 15-21 of treatment. If platelets drop by more than 30% of baseline, treatment should be stopped and discussed with the GP responsible for the bed base/in patient setting. Prior to initiation of pharmacological thromboprophylaxis, renal function should also be monitored and dose of LMWH reduced if appropriate.


6.23 Start pharmacological VTE prophylaxis as soon as possible after risk assessment has been completed. Continue until the patient is no longer at increased risk of VTE. N.B. Always refer to most recent British National Formulary before prescribing.

6.24 If major bleeding occurs discontinue LMWH immediately and ensure the service user is

reviewed by the senior clinician on duty with a consideration for the need to be transferred to the acute sector.

6.25 If VTE is suspected, patients must be escalated to Advanced Nurse Practitioner, Ward 35

GP or Medical emergency team out of hours. 6.26 Medical patients admitted to ward 35 and assessed as requiring VTE prophylaxis should be

given a minimum course of 7 days which should be continued in the community if discharged within this time.

6.27 Extended (28-35 days) thromboprophylaxis should be offered to patients after major cancer

surgery in the abdomen or pelvis, total hip or knee replacement or hip fracture. (N.B. LMWH is currently not licensed for use in medical patients beyond 14 days and therefore informed consent for off-label use should be obtained and documented.

• (1.4.1Cg 89 states “start pharmacological VTE prophylaxis if indicated within 14 hours of

risk assessment being completed. Continue until the patient is no longer at risk of VTE”) Mechanical Thromboprophylaxis 6.28 All patients who are risk assessed as requiring mechanical Thromboprophylaxis i.e. if at

high risk of VTE but also at high risk of bleeding, unless contraindicated should be fitted for anti-embolic stockings. Contraindications for anti-embolic stockings include:

• suspected or proven peripheral arterial disease • acute stroke • peripheral arterial bypass grafting • peripheral neuropathy or other causes of sensory impairment • local condition in which stockings may cause damage, such as fragile 'tissue • paper' skin, dermatitis, gangrene or recent skin graft • known allergy to material of manufacture • cardiac failure • severe leg oedema or pulmonary oedema from congestive heart failure • unusual leg size or shape • major limb deformity preventing correct fit.

6.29 Use caution and clinical judgement when applying anti-embolism stockings over venous

ulcers or wounds and on patients with diabetes mellitus. Measure legs and use correct stocking size. Staff who fit stockings should be trained in their use and should show patients how to use them (RCN 2010). If oedema or postoperative swelling develops, ensure legs are re-measured and stockings refitted. If arterial disease suspected, seek expert opinion before fitting stockings. Use stockings that provide graduated compression and produce a calf pressure of 14-15 mmHg. Encourage patients to wear the stockings day and night from admission until they no longer have significantly reduced mobility. Remove stockings daily for hygiene purposes and to inspect skin condition. Stockings must then be re-applied. If patient has significant reduction in mobility, poor skin integrity or sensory loss, inspect skin two or three times per day, particularly over heels and bony prominences. Discontinue use of stockings if there is marking, blistering or discolouration of skin, particularly over heels and bony prominences, or if patient has pain or discomfort. Show patients how to use anti-embolism stockings correctly and ensure they understand that this


will reduce their risk of developing VTE. Monitor use of anti-embolism stockings and offer assistance if they are not being worn correctly.

6.30 If patients are at high risk of VTE but both mechanical and pharmacological

thromboprophylaxis is contraindicated, discuss with the clinical director/general practitioner responsible for the bed base.

On Discharge 6.31 If patients remain at high risk of VTE on discharge, a further VTE risk assessment should

be carried out and the patient discharged on the appropriate VTE prophylaxis. Patients who have not reached their pre-admission mobility state or at a functional plateau and are unlikely to further improve, do not require continued pharmacological VTE prophylaxis on discharge. However, if patients are known to have an underlying medical condition that increases hypercoagulability (e.g. protein C, protein S, antithrombin III, or factor V Leiden deficiencies etc.), they must be assessed for the appropriateness of long-term anticoagulation.

6.32 For patients discharged on low molecular weight heparin a written request for initiation of a shared care agreement must be made with the patient’s general practitioner (Appendix D). This must include the following information:

• The relevant clinical details, including the patient’s baseline weight and renal function. • Details of the patient’s treatment to date. • Details of low-molecular weight heparin treatment, including reasons for choice of

treatment, dose and frequency and any other treatment or drugs that the patient is to receive.

• The date of the next outpatient appointment. • The duration of treatment. • Any continued monitoring requirements.

6.33 The general practitioner must reply to request for shared care within 14 days as part of the

Discharge Treatment Plan.

6.34 Prior to discharge ensure systems are in place for daily administration of low-molecular weight heparin injections for the duration of treatment (e.g. patient trained to self-administer, district nursing service to administer).

6.35 Ensure the patient is discharged with an initial 4 weeks supply of treatment and sharps bins should be provided.

6.36 As part of the discharge plan, patients and/or their families or carers should be offered verbal and written information on:

• The signs and symptoms of deep vein thrombosis and pulmonary embolism. • The correct and recommended duration of use of VTE prophylaxis at home (if discharged with

prophylaxis). • The importance of using VTE prophylaxis correctly and continuing treatment for the

recommended duration (if discharged with prophylaxis). • The signs and symptoms of adverse events related to VTE prophylaxis (if discharged with

prophylaxis). • The importance of seeking help and who to contact if they have any problems using

prophylaxis (if discharged with prophylaxis). • The importance of seeking medical help and who to contact if deep vein thrombosis, pulmonary

embolism of another adverse event is suspected.


Exclusions 6.37 This policy excludes service uses that are pregnant, under 18 year olds, and those awaiting

surgery.

7 CONSULTATION

7.1 The following staff were consulted in the production and content of this policy:

• Operational Manager • Ward Manager • Medicine Management

8 TRAINING AND SUPPORT 8.1 All registered nurses and health care assistants will be trained in reducing the risk of VTE. This

training is mandatory and will be carried out every two years. Details of the training are provided on the learning and development pages on the Mersey Care intranet site.

9 MONITORING Aspect of compliance or effectiveness being monitored

Method of monitoring

Person/s Responsible

Monitoring Frequency

Results reviewed by

Person/s Responsible for completing actions

Patients are assessed as to their risk of VTE on admission to Ward 35 and prophylactic methods are commenced appropriately as per this policy

Patient written and electronic records Sample size of 5 sets of medical notes

Performance Intelligence

Annually Sefton Quality and governance group

Service Manager

Staff completed training associated with this policy as per local TNA

Monthly Reports to Manager

LDB Monthly Sefton Quality and governance group

Service Manager


10 EQUALITY AND HUMAN RIGHTS ANALYSIS Title: 131a - Venous Thromboembolism (VTE) Risk Assessment Policy for Mersey Care Ward 35

V1 – June 19

Area covered: Ward based Policy What are the intended outcomes of this work? This is a further Equality review of policy No new equality issues identified The policy seeks to minimise the risk of inpatients on Ward 35 developing a venous Thromboembolism Who will be affected? Service Users Evidence What evidence have you considered? Previous and proposed policy documents Disability (including learning disability) This Policy is available in alternative formats on request Sex This policy does not adversely impact on sex Race This policy should be available in other languages o request Age This policy is intended for service users over the age of 18 There are no other impacts on age Sexual orientation This policy does not adversely impact on sexual orientation Religion or belief https://www.bmj.com/content/348/bmj.g401 Pregnancy and maternity This policy does not adversely impact on pregnancy or maternity Carers This policy aims to protect all people accessing the Trust. Other identified groups No other groups identified Cross Cutting


This policy aims to protect all people accessing the Trust Human Rights Is there an impact?

How this right could be protected?

Right to life (Article 2) Not applicable

Right of freedom from inhuman and degrading treatment (Article 3)

This article is not engaged

Right to liberty (Article 5) This article is not engaged

Right to a fair trial (Article 6) This article is not engaged

Right to private and family life (Article 8)


Right of freedom of religion or belief (Article 9)


Right to freedom of expression Note: this does not include insulting language such as racism (Article 10)


Right freedom from discrimination (Article 14)


Engagement and Involvement detail any engagement and involvement that was completed inputting this together.


Summary of Analysis This highlights specific areas which indicate whether the whole of the document supports the trust to meet general duties of the Equality Act 2010 Eliminate discrimination, harassment and victimisation No evidence of the above in relation to this policy Advance equality of opportunity Not Applicable to this policy Promote good relations between groups Not Applicable to this policy What is the overall impact? No negative impact has been identified within this assessment Addressing the impact on equalities

Action planning for improvement

Detail in the action plan below the challenges and opportunities you have identified. Include here any or all of the following, based on your assessment • Plans already under way or in development to address the challenges and priorities

identified. • Arrangements for continued engagement of stakeholders. • Arrangements for continued monitoring and evaluating the policy for its impact on

different groups as the policy is implemented (or pilot activity progresses) • Arrangements for embedding findings of the assessment within the wider system,

OGDs, other agencies, local service providers and regulatory bodies • Arrangements for publishing the assessment and ensuring relevant colleagues are

informed of the results • Arrangements for making information accessible to staff, patients, service users and

the public • Arrangements to make sure the assessment contributes to reviews of DH strategic

equality objectives. For the record Name of persons who carried out this assessment:

Date assessment completed: Name of responsible Director: Date assessment was signed:


APPENDIX A – Mersey Care VTE Risk Assessment 1st Assessment…………2nd Assessment……………Other……………

MOBILITY – ALL PATIENTS (tick one box) Surgical patient Medical patient expected to

have ongoing reduced mobility relative to normal state

Medical patient NOT expected to have significantly reduced mobility relative to normal state*

Assess for thrombosis and bleeding risk below Risk assessment now complete *Patients thought to be at their normal mobility state / reached a functional plateau but are known to have an underlying medical condition that increases hypercoagulability (e.g. protein C, protein S, antithrombin III, or factor V Leiden deficiencies etc.), must be assessed for the appropriateness of long-term anticoagulation.

Thrombosis risk Patient related Admission related Active cancer or cancer treatment Significantly reduced mobility for 3 days or

more.

Age over 60 years Hip or knee replacement Dehydration Hip fracture Known thrombophilias Total anaesthetic + surgical time > 90 minutes Obesity (BMI over 30 kg/m2) Surgery involving pelvis or lower limb with total

anaesthetic + surgical time > 60 minutes

One or more significant medical co-morbidities (e.g. heart disease; metabolic, endocrine or respiratory pathologies: acute infectious diseases: inflammatory conditions)

Acute surgical admission with inflammatory or intra-abdominal condition

Personal history or first-degree relative with a history of venous thrombo-embolism

Critical care admission

Use of hormone replacement therapy Surgery with significant reduction in mobility Use of oestrogen-containing contraceptive therapy Varicose veins with phlebitis

Bleeding risk

Patient related Admission related Active bleeding Neurosurgery, spinal or eye surgery Acquired bleeding disorder (e.g. acute liver failure) Other procedure with high bleeding risk Concurrent use of anti-coagulants known to increase risk of bleeding (i.e. Warfarin with INR > 2)

Lumbar puncture/epidural/spinal anesthesia within next 12 hours

Lumbar puncture/epidural/spinal anaesthesia within previous 4 hours or expected within the next 12 hours?

Lumbar puncture/epidural/spinal anesthesia within the previous 4 hours

Acute stroke Thrombocytopenia (platelet count < 75 x 109/l) Uncontrolled systolic hypertension (≥ 230/120 mmHg)

Refer to Medical Staff for Advice

Untreated inherited bleeding disorders (i.e. haemophilia or Von Willebrand’s disease)

Ward Name Admission Date Date dob Time


All patients should be risk assessed on admission to hospital. Patients should be reassessed within 24 hours of admission and whenever the clinical situation changes. STEP ONE Assess all patients admitted to hospital for level of mobility (tick one box). All surgical patients, and all medical patients with significantly reduced mobility, should be considered for further risk assessment. STEP TWO Review the patient-related factors shown on the assessment sheet against thrombosis risk, ticking each box that applies (more than one box can be ticked). Any tick for thrombosis risk should prompt thromboprophylaxis according to NICE guidance. The risk factors identified are not exhaustive. Clinicians may consider additional risks in individual patients and offer thromboprophylaxis as appropriate. STEP THREE Review the patient-related factors shown against bleeding risk and tick each box that applies (more than one box can be ticked). Any tick should prompt clinical staff to consider if bleeding risk is sufficient to preclude pharmacological intervention. Guidance on thromboprophylaxis is available at: National Institute for Health and Clinical Excellence (2010) Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. NICE clinical guideline 92. London: National Institute for Health and Clinical Excellence.


APPENDIX B – Shared Care Agreement Aintree Hospitals NHS Foundation Trust, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Southport & Ormskirk Hospital NHS Trust, Liverpool Heart and Chest Hospital NHS Foundation Trust and NHS Sefton, Liverpool PCT and Knowsley PCT Drug: Low-molecular weight heparin Indication: Treatment of deep vein thrombosis and/or pulmonary embolism where oral anticoagulant therapy is unsuitable. Secondary prevention (prophylactic dose) in high-risk patients where oral anticoagulant therapy is unsuitable. This shared care agreement has been approved by North Mersey Area Medicines Management Committee. It outlines how management and prescribing of low-molecular weight heparin injection may be safely and effectively shared between the specialist and general practitioner (GP). It covers use of low molecular weight heparin at treatment doses for treatment of deep vein thrombosis and pulmonary embolism over a period of several months where oral anticoagulant therapy is unsuitable, including pregnancy. It also covers secondary prevention of deep vein thrombosis and pulmonary embolism in high-risk patients using prophylactic doses. It does not cover prophylactic administration used in connection with hospital admission, for example post-operatively, which if still required for a period after hospital discharge should be prescribed by the hospital team. The National Patient Safety Agency issued Rapid Response Report NPSA/2010/RRR014 “Reducing treatment dose errors with low molecular weight heparins” in July 2010, highlighting that dose should be based on weight and renal function, that this information and duration of treatment should be provided at transfers of care and that weight and renal function should be monitored periodically to ensure continued correct dosing. The report is located at; http://www.nrls.npsa.nhs.uk/resources/?entryid45=75208&p=3 RESPONSIBILITIES - Specialist responsibilities:

• Assessment of the need for low-molecular weight heparin treatment. • Discuss with the patient the benefits and side effects of treatment. • Baseline check of patient weight and renal function • Initiation of treatment and supply of initial 4 weeks of treatment, or until the patient’s

GP has commenced prescribing and monitoring if longer. • Initial monitoring of platelets and renal function on day 5 and between week 2 and 3

of treatment, until GP takes over monitoring. • Write to the GP requesting initiation of shared care for the patient, including the

following information: - relevant clinical details, including patient baseline weight and renal function - details of patients treatment to date - details of low-molecular weight heparin treatment, including reasons for

choice of treatment, dose and frequency and any other treatment or drugs that the patient is to receive

- date of next outpatient appointment • Specify the duration of treatment.


• Ensure systems are in place for daily administration of low-molecular weight heparin injections for the duration of treatment (e.g. patient trained to self-administer, district nursing service to administer).

• Advise GP on continued monitoring requirements. • Ensure the GP is kept informed of any changes in the patients’ treatment or clinical

circumstances and provide clear arrangements for back-up, advice, and support. • Ensure that the patient is stabilized on treatment prior to handover to the GP. • It is recognised that in certain clinical circumstances the GP may feel unable to take

clinical responsibility for prescribing and in such an event the responsibility for prescribing will remain with the specialist.

GP responsibilities:

• Reply to request for shared care as soon as practical. • Ensure that they have the information and knowledge to understand the therapeutic

issues relating to the patients’ clinical condition. • Continue the prescribing of low-molecular weight heparin to complete the course of

treatment as specified by the specialist. • Follow the specialist's guidance on any blood and weight monitoring required. • Report any abnormal results to the specialist promptly, and seek advice regarding

continuation of treatment. • Reporting adverse events or relevant changes to patients condition to specialist. • Reporting to and seeking advice from the specialist on any aspect of patient care

which is of concern to the GP and may affect treatment. Monitoring to be carried out by GP: Parameter Frequency Action Renal function Once per month Contact specialist for

advice if significant deterioration in creatinine (risk of eGFR<30ml/min), or hyperkalaemia develops. Dose reduction or anti-Factor Xa measurement may be necessary if eGFR<30ml/min

Platelets Once per month Mild thrombocytopenia is common. If platelets fall by 50% or more contact specialist for advice. Contact specialist for advice if necessary

Weight (does not apply to prophylactic dose)

Once per month significant change in weight >+/- 5kg as change in dose may be

* Heparin can cause hypoaldosteronism, which may result in an increase in plasma potassium.


Monitoring is recommended during treatment in patients at increased risk of hyperkalaemia eg those with chronic renal failure, diabetes mellitus, raised plasma potassium, or taking potassium sparing drugs - see Summary of Product Characteristics (SPC). Back-up advice and support – Specialist: As per accompanying letter Contact details: As per accompanying letter SUPPORTING INFORMATION – Details of licensed indications: Low molecular weight heparins are licensed for treatment of venous thromboembolism while oral anticoagulant therapy is initiated and until INR has reached therapeutic range. Use in pregnancy is unlicensed but the SPC states that dalteparin has been assessed in pregnant women and no harmful effects are known with respect to the course of pregnancy and the health of the unborn and neonate, and dosages are given in the British National Formulary. Significant side effects: Common side effects are subcutaneous haematomas at injection site, and mild thrombocytopenia, which tends to resolve with continued use. Heparin induced thrombocytopenia (HIT) has also been observed. At recommended doses, bleeding occurs rarely. Transient, slight to moderate, elevations of liver transaminases have been observed but no clinical significance has been demonstrated. Refer to the SPC of the relevant low-molecular weight heparin for a full list of adverse effects. Significant drug interaction: May enhance the anticoagulant effect of anticoagulant/antiplatelet drugs eg aspirin, NSAIDs. Refer to BNF for full list of drug interactions Dosage and administration: Therapeutic doses of LMWH should be based on the patient's weight and renal function and administered by subcutaneous injection. Dose differs for each low-molecular weight heparin (see below and BNF) Doses in pregnancy and in patients with solid tumours differ, as recommended by the specialist (but also see BNF). - Dalteparin (“Fragmin”) Treatment dose: Syringe Strength Bodyweight Dalteparin Dose

Volume (ml) kg St/lb 7,500 units <46 <7/3 7,500 units daily 0.30 10,000 units 46-56 7/3-8/11 10,000 units daily 0.40 12,500 units 57-68 8/12-10/10 12,500 units daily 0.50 15,000 units 69-82 10/11-12/13 15,000 units daily 0.60 18,000 units 83 and over 13 and over 18,000 units daily 0.72 In patients who are at increased risk of bleeding, a dose of 100units/kg twice daily may be used (up to a maximum dose of 9,000 units twice a day) - note, this would require the use of other syringe strengths or the multidose vial Use of LMWH in patients whose creatinine clearance / eGFR is less than 30mL/min. No dose reduction is required with dalteparin although a dose of 100 units/kg sc twice daily may be used if the patient is at increased risk of bleeding (up to a maximum of 9,000 units twice a day).


Prophylactic dose: 2,500 – 5,000 units (as recommended by specialist) once daily. Available as 2,500unit and 5,000 unit syringes Enoxaparin 1.5mg/kg o.d. (“Clexane”) Treatment dose: USE ONLY 120mg or 150mg syringes- Each Graduation is 3mg Weight (Kg) Syringe Dose (mg) NB Dose for patients with Creatinine

Clearance less than 30mls/minute is 1mg/kg once daily Weight (kg) Syringe dose (mg)

50 75 50-52 51 51-52 78 53-55 54 53-54 81 56-58 57 55-56 84 59-61 60 57-58 87 62-64 63 59-60 90 65-67 66 61-62 93 68-70 69 63-64 96 71-73 72 65-66 99 74-76 75 67-68 102 77-79 78 69-70 105 80-82 81 71-72 108 83-85 84 73-74 111 86-88 87 75-76 114 89-91 90 77-78 117 92-94 93 79-80 120 95-97 96 81-82 123 98-100 99 83-84 126 101-103 102 85-86 129 104-106 105 87-88 132 107-109 108 89-90 135 110-112 111 91-92 138 113-115 114 93-94 141 116-118 117 95-96 144 119-121 120 97-98 147 122-124 123 99-100 150 125-127 126

101-102 153-use 2 SYRINGES

120mg+33mg

128-130 129


120mg +36mg


120mg +39mg


120mg+42mg


150mg+15mg


150mg+18mg

113-114 171-use 2


SYRINGES 150mg+21mg


150mg+24mg


150mg+27mg


150mg+30mg


150mg+33mg


150mg+36mg


150mg+39mg

Prophylactic dose: 20 – 40mg (as recommended by specialist) once daily (20mg daily in patients with creatinine clearance <30mls/min). Available as 20mg and 40mg syringes Additional information: This Shared Care Agreement should be read in conjunction with the SPC of the relevant low-molecular weight heparin. Approved: March 2011 Review date: January 201


APPENDIX C – Flowchart to illustrate the management of Patients on Ward 35 when a VTE is

suspected

Patient has Wells Score of 2 or over Clinical suspicion of a VTE

Contact physician of the day (bleep 5548) or transfer to

A&E via bed manager

Refer for ultrasound Doppler on Sigma and commence treatment dose of

anticoagulant as appropriate while waiting (See page 22 this Policy) Take blood for D-Dimer

D-Dimer results If received prior to scan

Review by GP/ANP Consider alternative

diagnosis

Await scan results

Is a GP/ANP On

Duty?

NO

YES

Positive Negative

Negative

Positive

If no further alternative diagnosis is met then re-scan within 7 days

Review by GP/ANP Continue treatment as per policy


APPENDIX D – Patient Information Leaflet Preventing hospital-associated blood clots

http://www.nnuh.nhs.uk/publication/download/preventing-clots-english/

http://www.nnuh.nhs.uk/publication/download/preventing-clots-english/

Documents

Venous Thromboembolism (VTE) Risk Assessment Policy for ...€¦ · Venous thromboembolism (VTE) Venous thrombosis is a condition in which a blood clot (thrombus) forms in a vein