Document Details Reducing the Risk of Venous ... · Reducing the Risk of Venous Thromboembolism Policy ... this is called deep vein thrombosis. The thrombus may dislodge from its

0 Reducing risk of VTE Policy ndash May 2017 Datix Ref 1544-36862

Document Details

Title Reducing the Risk of Venous Thromboembolism Policy

Trust Ref No 1544-36862

Local Ref (optional) NA

Main points the document covers

This policy is intended to support clinical staff at Shropshire Community Health NHS Trust to carry out a risk assessment of patients admitted to the wards and prescribes appropriate prophylaxis to reduce the risk of venous thromboembolism (VTE)

Who is the document aimed at

All staff caring for Community Hospital Inpatients (including day case patients)

Author Andrew Thomas Amanda Tuckwell David Young

Approval process

Approved by (CommitteeDirector)

Clinical Policies Group notified to Quality and Safety Operational Group

Approval Date 31052017

Initial Equality Impact Screening

Yes

Full Equality Impact Assessment

No

Lead Director Director of Nursing and Operations

Category Clinical

Sub Category Medicines

Review date 31st May 2019

Distribution

Who the policy will be distributed to

Inpatient Medical and Nursing staff in Community Hospitals

Method Policy alert Heads of Department GP meetings and ward meetings Quality and Safety Group notification

Document Links

Required by CQC No

Required by NHSLA Yes

Other Nice Guidelines (Jan 2010) CG92

Amendments History

No Date Amendment

1 February 2017 Review including update assessment form and patient leaflet

2 November 2015 Replace VTE risk assessment form

3 October 2013 Review to Include NICE Quality Standard 29

4


Reducing the Risk of Venous Thromboembolism Policy CONTENTS

Chapter Page

1 Introduction 2

2 Purpose 2

3 Definitions 2

4 Duties 3

5 Assessing the Risks of VTE and Bleeding 3

6 Reducing the Risk of VTE 4

7 Patient Information and Discharge Planning 5

8 Choice of VTE Prophylaxis 6

9 Procedure if VTE is Suspected 10

10 Procedure if VTE is Confirmed 10

11 Consultation and Approval Process 11

12 Advice and Training 11

13 Monitoring Compliance 13

14 References amp NICE Guidance 16

15 Associated Documents 16

16 Appendices

Appendix 1 Risk Assessment Document 17 Appendix 2 Care Pathway ndash Medical Patients 19 Appendix 3 Care Pathway ndash Stroke Patients 20 Appendix 4 Care Pathway ndash Oncology Patients 21 Appendix 5 Care Pathway ndash End of Life Patients 22 Appendix 6 Care Pathway ndash Day Surgery Patients 23 Appendix 7 Care Pathway - Lower Limb Plaster Casts 24 Appendix 8 Patient Guide 25 Appendix 9 Care Pathway ndash VTE Risk Assessment Pathway 27


1 Introduction

An estimated 25000 people in the UK die from preventable hospital-acquired venous

thromboembolism (VTE) every year Treatment of non-fatal symptomatic VTE and

related long term morbidities is associated with considerable cost to the health

service

The Guidance in this policy has been produced in line with National Institute of

Clinical guidelines (NICE) CG92 a full version of which can be found at

httpguidanceniceorgukCG92

Additionally the policy has been reviewed to ensure that it complies with NICE

Quality Standard 29 ndash Quality Standard for diagnosis and management of venous

thromboembolic diseases (March 2013) which may be found at

guidanceniceorgukqs29

2 Purpose

This policy is intended to support clinical staff at Shropshire Community Health Trust

(SCHT) to carry out a risk assessment of patients admitted to community hospitals as

inpatients including day case surgery wards and prescribe appropriate prophylaxis to

reduce the risk of VTE

3 Definitions

31 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 ndash Which is

known as an embolism VTE encompasses a range of clinical presentations

4 Duties

41 The Chief Executive

The Chief Executive or chief Executive Officer has overall responsibility for

maintaining staff and patient safety and is responsible for the governance and patient

safety programmes within the organisation

42 Directors

Directors of Services are responsible for ensuring the safe and effective delivery of

services they manage this includes securing and directing resources to support the

implementation of this policy They are also responsible for ensuring process is in

place to effectively manage patient falls and that the organization is compliant with

3

the Care Quality Commission (CQC) and National Health Service Litigation Authority

(NHSLA)

43 Line Managers and Service Leads

Managers will ensure that a system is in place within the services they are

responsible for for the implementation of this policy and for monitoring its

effectiveness

This will include

Clinical audit where they are required by this policy

Provision of and attendance at staff training where indicated by the

Mandatory Training

Provision of equipment where this is required

Reviewing VTE related incidents where it is appropriate to do so either

Individually or collectively and identifying where changes could be made to

improve patient care

44 Team Leaders

Team Leaders must ensure team members have access to policy guidelines This

would include education and supervision to ensure safe practice

45 All Staff

All staff must ensure that they comply with the arrangements in place to implement

and maintain this policy within the areas they work

This will include

Attendance at training

Completing assessments partaking in audit as required

5 Assessing the Risks of VTE and Bleeding

Venous thrombosis pulmonary embolism deep vein thrombosis is often

asymptomatic less frequently it causes pain and swelling in the leg Part or all of the

thrombus can come free or break 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

4 Reducing the risk of VTE Policy May 2017

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 andor procedure for which the

patient is admitted and on any predisposing risk factors (such as age obesity and

concomitant conditions) The Department of Health recognizes that VTE is an

important problem in hospitals and has advised doctors and nurses that everyone

admitted to hospital should have a risk assessment completed The risk assessment

will identify patients that are at risk and would benefit from prophylactic treatment

51 Assess all patients within 24 hours of admission to identify those who are at increased risk of VTE

The initial risk assessment should be carried out by medical staff using the

assessment tool (appendix 1) Appendices 2 ndash 7 detail the thought processes and

clinical reasoning which should be followed depending on the patientrsquos medical

status to help in the decision making process outlined in the risk assessment

(Appendix 1)

511 Medical patients are considered to be at increased risk of VTE if they

Have had or are expected to have mobility reduced for 3 days or more

Are expected to have ongoing reduced mobility relative to their normal state and

Have one or more of the risk factors listed in the assessment tool see appendix 9

512 Surgical patients are considered to be at increased risk of VTE if they

Have a surgical procedure with a total anesthetic time and surgical time of more

than 90 minutes or 60 minutes if the surgery involves the pelvis or lower limb

Have acute surgical admission with inflammatory or intra-abdominal condition

Are expected to have significant reduction in mobility


52 Assess all patients for risk of bleeding before offering pharmacological VTE

prophylaxis

Do not offer pharmacological VTE prophylaxis to patients with any of the risk

factors for bleeding listed in the assessment tool unless the risk of VTE outweighs

the risk of bleeding


6 Reducing the Risk of VTE

61 Encourage patients to mobilise as soon as possible

62 Offer pharmacological VTE prophylaxis to general medical patients assessed to be at

increased risk of VTE

621 The Local Health Economy uses Tinzaparin as the Low Molecular Weight Heparin

(LMWH) of choice LMWH should not be used in acute stroke except under certain

clinical circumstances and following discussions with the consultant

622 Unfractionated Heparin (UFH) may be preferable for patients with renal failure or

a reduced dose of Tinzaparin ndash see British National Formulary for guidance

63 Start pharmacological VTE prophylaxis as soon as possible after risk assessment

has been completed Continue until the medical practitioner assesses the patient is

no longer at increased risk of VTE See Care Pathway (Appendix 9)

7 Patient Information and Discharge Planning 71 Before starting VTE prophylaxis offer patients andor families or carers verbal and

written information (patient leaflet appendix 8) on

1 The risks and possible consequences of VTE

2 The importance of VTE prophylaxis and its possible side effects

3 The correct use of VTE prophylaxis (for example anti-embolism stockings)

4 How patients can reduce their risk of VTE (such as keeping well hydrated and

if possible exercising and becoming more mobile)

72 As part of the discharge plan offer patients andor families or carers verbal and


1 The signs and symptoms of deep vein thrombosis and pulmonary embolism

2 The correct and recommended duration of VTE prophylaxis at home if

discharged with prophylaxis

3 The importance of using VTE prophylaxis correctly and continuing treatment

for the recommended duration if discharged with prophylaxis

4 The signs and symptoms of adverse events related to VTE prophylaxis if


5 The importance of seeking help and who to contact if they have any

problems using the prophylaxis if discharged with prophylaxis


6 The importance of seeking medical help and who to contact if deep vein

thrombosis pulmonary embolism or another adverse event is suspected

73 Patients who are discharged on Tinzaparin should be given Tinzaparin pack which

includes a sharps box and information leaflet detailing why they are on this

medication and how to use it Patients will be offered training to self-inject or for

their carers to administer if this is not possible support can be given by community

services either to support self-administering or administer

74 Patient-centered treatment and care should take into account patientsrsquo individual

needs and preferences Good communication is essential supported by evidence-

based information to allow patients to reach informed decisions about their care

8 Choice of VTE Prophylaxis

81 Base the choice of mechanical VTE prophylaxis on clinical condition surgical

procedure and patient preference The only option currently available at Community

Hospitals is the anti-embolism stockings (thigh or knee length)

NICE guidance (2013) states that patients with proximal VTE should be offered

below knee graduated compression stockings within three weeks of diagnosis and

advised to use them for 2 years on the affected side The timeframe of three weeks

allows for swelling to reduce in order for stockings to be fitted

82 Anti-Embolism Stockings

821 Do not offer anti-embolism stockings to patients with

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

lsquotissue paperrsquo skin dermatitis gangrene or recent skin graft

Known allergy to material of manufacture

Severe leg oedema or pulmonary oedema from congestive heart

failure

Unusual leg size or shape

Major limb deformity preventing correct fit


822 Use caution and clinical judgment when applying anti-embolism stockings over

venous ulcers or wounds

Measure legs and use correct stocking size according to manufacturerrsquos instruction

Staff who fit stockings should be trained by senior staff in their use and should show

patients how to use them

If oedema or postoperative swelling develops ensure legs are re-measured and

stockings refitted

If arterial disease suspected seek medical 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 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 (see appendix 8

patient guide)

Monitor use of anti-embolism stockings and offer assistance if they are not being

worn correctly

83 Pharmacological VTE Prophylaxis and treatment 831 The choice and dose of pharmacological VTE prophylaxis should be decided on

an individual patient basis and synthetic alternatives to Heparin can be considered

for patients not wanting to use Heparin of animal origin In general the Community

Hospitals drug of choice is Tinzaparin which reflects the drug of choice of the

Local Health Economy

All patients should have the following investigations prior to commencing any form

of anticoagulation

Full Blood Count


Clotting Screen

Urea amp Electrolytes

Liver Function Tests

However this may not be possible if admitted at a weekend Therefore a review of most recent bloods is acceptable with these bloods being taken or as soon a feasibly possible

If no abnormality is detected then Heparin therapy can be started

832 Contraindications for Heparin Therapy

History of Heparin Induced Thrombocytopenia

Significant hepatic impairment

Active gastric or duodenal ulceration or oesophagus varices

Hemophilia and other inherited bleeding disordersmajor bleeding disorders

Thrombocytopenia with plateletslt50

Recent cerebral hemorrhage

Severe hypertension

Recent neurosurgery or eye surgery

Acute bacterial endocarditis

Sensitivity to any low molecular weight Heparin

833 Guidance for dosage of Tinzaparin for VTE can be found in the British National

Formulary (BNF) This is located in all inpatient areas

Patients may develop bruises and sometimes small hard lumps under the surface of

the injection site However if patients develop extensive bruising that spreads

around the body injections should be withheld and a doctor should be informed

immediately

There is also a possibility that the patient may develop Heparin Induced

Thrombocytopenia (HIT) Platelet counts should be monitored as per British

National Formulary Guidance

84 Heparin Induced Thrombocytopenia (HIT)

HIT usually presents itself between 5 and 14 days after starting therapy

This should be considered if platelet count falls below normal range or to less than

50 of baseline platelet count


If HIT is suspected refer as emergency to hematology

If patient develops thrombocytopenia skin reaction or new thrombosis within 14 days

of starting therapy HIT should be considered

Refer as emergency to hematology for assessment

Patients should also be monitored for hyperkalemia especially at risk patients with

diabetes chronic renal failure previously raised potassium levels or taking

medications that are potassium sparing or potassium supplements

85 Therapeutic treatment of VTE with Tinzaparin Tinzaparin is also used for the treatment for Venous Thromboembolism however the

dose is different to that used for prophylaxis and is given at 175 unitskg by

subcutaneous injection once daily until oral anticoagulation established (BNF No 66

September 2013 and Summary of Product Characteristics wwwmedicinesorguk)

It is very important that the dose is calculated accurately based on a recent patient

weight and not estimated

Patients may then be discharged on warfarin or where warfarin is not tolerated or

ineffective one of the newer anticoagulants where clinically indicated (Heart and

Stroke Network guidelines)

Whilst a patient is being stabilised on warfarin and whilst the international normalised

ratio (INR) is not in range a patient can be maintained on Tinzaparin until a

therapeutic INR is reached However lsquobridgingrsquo with Tinzaparin where the INR is

below the target range is outside the licence

86 Concurrent anticoagulant or antiplatelet use

Patients that are on aspirin or other anti-platelet agents are not regarded as having

appropriate prophylaxis for VTE

Do not offer additional pharmacological or mechanical VTE prophylaxis to patients

who are already taking vitamin K antagonists such as warfarin who are within

therapeutic range providing anticoagulation is continued


who are already having full anticoagulant therapy such as Tinzaparin at treatment

dose


9 Procedure to be followed if VTE Suspected

Nurse referral to medical staff for urgent medical review within 4 hours

People with suspected VTE should have all diagnostic investigations completed

within 24 hours of first clinical assessment which include completion of the

Wells probability scoreDVT pathway

If a patient is suspected of having a Pulmonary Embolism or if patientrsquos condition is

compromised ie vital signs have deteriorated or Early Warning Score is raised (see

SCHT for Early Warning Score for Community Hospitals and Prisons policy) it

would usually be necessary to transfer patient immediately to Acute Hospital

Patients suspected of having a pulmonary embolism should have an interim

therapeutic dose of anticoagulation therapy if diagnostic investigations are expected

to take longer than one hour from the time of first clinical suspicion

If patientrsquos condition is stable commence therapeutic dose of Tinzaparin (see BNF)

unless contraindicated NICE Quality Standards state that people with a suspected

Deep Vein Thrombosis (DVT) are offered an interim therapeutic dose of

anticoagulation therapy if diagnostic investigations are expected to take longer than

four hours for the time of first clinical suspicion

Referral form made for appropriate diagnostic at Acute Hospital

Suspected Pulmonary Embolus = Computerised Tomography

Pulmonary Angiography (CTPA)

Suspected Deep Vein Thrombosis = Vascular USS (Ultra Sound Scan)

If both Pulmonary Embolus (PE) and Deep Vein Thrombosis (DVT)

suspected arrange both diagnostic tests

Confirm date and time of tests arrange transport and Nurse Escort

10 Procedure to be followed if VTE Confirmed

If VTE confirmed test results given to doctor full therapeutic anticoagulation

commenced as long as no contraindications Blood tests arranged to monitor

coagulation status and response to treatment Continue to monitor patientrsquos vital

signs to detect any deterioration in condition as directed in the National Early

Warning Score (NEWS) Guidance (See policy on The Deteriorating Patient)


Refer patient to the anticoagulant team at Shrewsbury and Telford Hospital

(SaTH) or local Acute Hospital via faxed referral formletter from clinician

NICE states that people with unprovoked DVT or PE who are not already known to

have cancer are offered timely investigations for cancer

People with active cancer and confirmed proximal DVT or PE are offered

anticoagulation therapy

People with provoked DVT or PE should not be offered testing for thrombophilia as

there is no benefit and is unnecessary for this group of patients

Provide patient and family with support education and reassurance Further

information to offer the patient with a confirmed VTE can be found on the NHS

Choices website

httpwwwnhsukconditionsdeep-vein thrombosis pagesintroductionaspx

11 Consultation

This policy has been developed by the Clinical Services Managers in consultation

with SCHT medical advisors and pharmacists by both individual meetings and

targeted questions a draft document circulation for comment over a one month

period to

Rachel Mole - Clinical Services Manager

Dr M Ganesh - Medical Director

Dr Emily Peer - Associate Medical Director

Rita OrsquoBrien - Chief Pharmacist

Elizabeth Watkins - Head of Infection Prevention Control

12 Dissemination and Implementation

121 Advice

Individual services medical staff and pharmacists act as a resource within their

clinical area and should be contacted in the first instance if appropriate

Further advice is available from the anticoagulation service at the local acute

provider at the Royal Shrewsbury Hospital who can be contacted via switchboard on

01743 261000


122 Implementation Training

Managers and service leads must ensure that all staff are familiar with this policy

through governance meetings Policy alerts Heads of Department meetings and

ward level meetings

All community Hospital registered nurses will be trained in reducing the risk of VTE

This e learning is mandatory Details of the training are provided in the SCHT

StatutoryMandatory Training Matrix issued by the Workforce Department

Any training requirements must be raised and addressed via appraisal or

supervision and a record of competencies kept for audit purposes It is the

responsibility of managers and service leads to ensure all staff fulfill their

mandatory training requirements in accordance with the Trust Training Needs

Analysis Refer to the Trust Mandatory (Risk Management) Training Policy and

Procedure

Further training needs may be identified through other management routes including

root cause analysis (RCA) review following an adverse VTE related incident or audit

findings

13 Monitoring Compliance

Element to be Monitored

Lead Tool Frequency Reporting Arrangements Acting on recommendations and Leads

Change in Practice and Lessons to be Shared

a Processrisk assessment for identifying patients at risk of venous thromboembolism

Medical Director Patient records audit

Annual The audit report will be submitted to the Quality and Safety Group The group is expected to read and interrogate the report to identify deficiencies in the system and act up on them

Any changes to the process will be identified as part of the audit and allocated to a relevant person(s) within a specified timeframe

Relevant clinical staff will be responsible for changes in the risk assessment Lessons will be shared with all the relevant stake holders

b Prophylatic

treatment regime for high risk patients

Chief Pharmacist Audit Annual An audit of the medical records of patients who have received prophylactic treatment will be carried out in all in-patient units and the audit report will be submitted to the Medicines Management Group The group is expected to read and interrogate the report to identify deficiencies in the system and act upon them

Any recommendations as part of the audit will be actioned by the appropriate clinical staff this will be monitored by the Chief Pharmacist

The Chief Pharmacist will be monitoring any changes in practice following due consultation Lessons will be shared with all the relevant stakeholders

Reducing risk of VTE Policy May 2017 13


Lead Tool Frequency Reporting Arrangements

Acting on Recommendations and Lead(s)


c Procedure

to be followed if venous thromboembolism is suspected


Annual An audit of medical records of patients who have been referred to Acute Secondary Care with suspected VTE will be carried out The audit report will be submitted to the Quality and Safety Group The group is expected to read and interrogate the report to identify deficiencies in the system and act upon them

The Medical Director will be monitoring any changes in practice following due consultation Lessons will be shared with all the relevant stakeholders

d Manage- ment of the patient once a positive diagnosis has been made


Annual An audit of medical records of patients who have been referred to Acute Care will be carried out The audit report will be submitted to the Quality and Safety Group The group is expected to read and interrogate the report to identify deficiencies in the system and act upon them

Any recommendations as part of the audit will be actioned by the appropriate clinical staff this will be monitored by the Medical Director







e Organis-

ationrsquos expectation in relation to staff training ndash as identified in the training needs analysis

Head of Workforce Development

Review Six Monthly Education training and Strategy Group and Health and Safety Committee The committees are expected to read and interrogate the report to identify deficiencies in the system and act upon them

Required actions will be identified and completed within a specified timeframe

Required changes to training arrangements will be identified and actioned within a specific timeframe The Head of Workforce DevelopmentRisk Management and Governance Lead will take each change forward where appropriate and lessons will be shared with all relevant stakeholders


14 References

NICE Guidance Venous Thromboembolism Reducing the Risk httpguidanceniceorgukCG92PublicinfopdfEnglish

NICE Quality Standard 29 Quality Standard for diagnosis and management of venous thromboembolic diseases (March 2013)

NPSA Alert Reducing treatment dose errors with low molecular weight Heparins httpwwwnrlsnpsanhsukresourcesentryid45=75208ampp=2

Policy for the Administration and Management of Patients on Anticoagulants BHRuT 2009

Keeling D Davison and Watson H British Society for Haematology 2006 133259- 269 Heparin induced Thrombocytopenia

NHS Choices wwwnhsukconditions

British National Formulary Number 66 September 2013 BMJ Group Tavistock Square London and Pharmaceutical Press Pharmaceutical Press is the publishing division of the Royal Pharmaceutical Society 1 Lambeth High Street London

15 Associated Documents

Shropshire Community Health NHS Trust Medicines Policy

Shropshire Community Health NHS Trust Early Warning Score for Community hospitals

and prisons policy

Shropshire Community Health NHS Trust Mandatory (Risk Management) Training

Policy and Procedures

Shropshire Community Health NHS Trust Consent to Examination and Treatment Policy

16 Appendices

1 Appendix 1 ndash VTE Risk Assessment Document

2 Appendix 2 ndash Care Pathway ndash Medical Patients

3 Appendix 3 - Care Pathway ndash Stroke Patients

4 Appendix 4 ndash Care Pathway ndash Oncology Patients

5 Appendix 5 ndash Care Pathway ndash Patients in End of Life Care

6 Appendix 6 ndash Care Pathway ndash Day Surgery

7 Appendix 7 ndash Lower Limb Plaster Casts

8 Appendix 8 ndash Patient Guide

9 Appendix 9 ndash Care Pathway Risk Assessment


Venous Thromboembolism (VTE)

and Bleeding Risk Assessment


1 = Admission assessment to be conducted by a Doctor within 4 hours for direct admissions

2 = Post 24 hours assessment by Qualified Nursing Staff AND NOTIFY Doctor of any changes

3 = Thereafter if condition changes assessments to be conducted by a Doctor

Admission Date Time

STEP 1 Classify each patient into one of the 3 groups below ndash Tick appropriate box

Surgical patient Complete sequentially

STEP 2 3 and 4 Medical patient have had or expected to have a reduction of mobility of 3 days or more OR is acutely ill

Medical patient with normal mobility and without acute illness Go straight to STEP 4

STEP 2 Thrombosis risk ndash Review the patient and tick every box that applies 1 OA

2 24hrs

3 Change

Active cancer or cancer treatment

Age gt 60

Dehydration

Known Thrombophilias

Personal history or first degree relative with a history of VTE

One or more significant medical co-morbidities

(eg Heart disease respiratory pathologies acute infection inflammatory conditions)

Obesity (BMI gt 30kgm2)

Use of Hormone Replacement Therapy (HRT)

Use of oestrogen containing contraceptive therapy

Varicose veins with phlebitis

Significantly reduced mobility for 3 days or more

Hip or Knee replacement

Hip fracture

STEP 3 Bleeding Risk ndash Review the patient and tick every box that applies

1

OA 2

24hrs 3

Change

1 OA

2 24hrs

3 Change

Active bleeding or suspicion of bleeding Acquired bleeding disorders

Acute stroke Neurosurgery spinal surgery or eye surgery

Thrombocytopenia (platelets lt 75 x 109l ) Other procedure with high bleeding risk

Concurrent use of anticoagulants known to increase the risk of bleeding (such as warfarin with INR gt 2)

Untreated inherited bleeding disorders (such as haemophilia and Von Willebrandrsquos disease)

Uncontrolled systolic hypertension (230120mmHg or higher)

STEP 4 Decision Box - Assess Risks vs Benefits of prescribing Thromboprophylaxis

Note Prescribe all Medication on Drug Chart

Yes - Thromboprophylaxis indicated OR No - Thromboprophylaxis NOT required because

Contra-Indication Bleeding Risk

Other (please detail)

Anti-thromboembolism stockings indicated OR

Already on Anticoagulant

Warfarin NOAC LMWHUFH

Signature Name GMC No Date amp Time

1 On admission Assessment completed by

2 24 hour Assessment completed

3 Assessment on Condition Change

Patient Addressogram

Risk Assessment for Venous Thromboembolism (VTE)

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

httpwwwniceorgukguidanceCG92


Consider offering mechanical VTE Prophylaxis with

Anti-embolism stockings

(thigh or knee length)

Appendix 2

Care Pathway ndash Medical Patients

General Medical Patients

Does Risk of VTE outweigh risk of bleeding

Yes No

Is Pharmacological VTE prophylaxis Contraindicated

Does the patient have any bleeding risk factors

Yes

No

Has Patient Been

Admitted for Stroke Offer pharmacological

VTE prophylaxis Continue until patient no longer at increased risk of VTE

Yes

See Appendix 3

Consider offering mechanical VTE prophylaxis with



Reducing risk of VTE policy May 2017

Reassess risks of bleeding and VTE within 24 hours of admission and whenever clinical situation change

19

Appendix 3 Care Pathway - Stroke Patients

Patients admitted for stroke

Do not offer anti-embolism stockings for VTE prophylaxis

Does patient have major restriction of mobility previous NO history of VTE dehydration or co morbidity (such as malignant disease)

Reassess within 24 hours of admission and whenever clinical situation changes

YES

Haemorrhagic stroke excluded

Risk of bleeding (haemorrhagic transformation NO of stroke or bleeding into another site) low

Consider offering foot impulse or intermittent compression stockings until patient can have pharmacological VTE prophylaxis

YES

Consider offering prophylactic ndash dose LMWH (or UFH)

YES

When acute event over and patientrsquos condition stable

Some types of LMWH do not have UK marketing authorization for VTE prophylaxis in medical patients Prescribers should consult the summary of product characteristics for the individual LMWH Informed consent for off-label should be obtained and documents


NO

YES

Appendix 4

Care Pathway - Oncology Patients

Patients with cancer Patients with central catheters

Is patient having is patient ambulant oncological treatment and ambulant

Yes No Yes No

Do not VTE risk Do not routinely VTE risk routinely offer increased offer increased pharmacological pharmacological

or mechanical

VTE prophylaxis

Yes No Yes No

Offer continue until Consider offering patient no longer at LMWH (or UFH) increased risk of VTE



Appendix 5 Care Pathway ndash End of Life Patients

Patients in End of Life Care

If Patient has potentially reversible acute pathology

Consider offering LMWH (or UFH)

If Patient in terminal care or end-of-life care pathway do not routinely offer pharmacological or mechanical VTE prophylaxis

Review decisions about VTE prophylaxis daily taking into account potential risks and benefits and views of the patient family andor carers and multidisciplinary team


Appendix 6 Care Pathway ndash Day Surgery

Day Surgery

If VTE risk increased

Offer mechanical VTE prophylaxis

at admission

Continue until Mobility no longer

Significantly Reduced

If risk of major

Bleeding low

Add LMWH (or UFH)

Continue until mobility No longer significantly

Reduced (Generally 5-7 days)

Choose any one of

Anti-embolism stockings (thigh or knee length)


Appendix 7

Care Pathway ndash Lower Limb Plaster Casts

Patient having lower limb plaster cast

Assess risk of VTE


Consider offering LMWH (or UFH) after valuating risks and benefits and based on clinical discussion with patient

Continue until plaster cast removed


VTE Patient Leaflet

This leaflet explains more about blood clots which can form after illness and surgery

What are hospital-acquired blood clots A hospital-acquired blood clot may occur in a patient when they are in hospital and up to ninety days after a hospital admission There are two kinds

1 Deep vein thrombosis (DVT) A DVT is a blood clot (also known as a

thrombosis) that forms in a deep vein most commonly in your leg or pelvis It may cause no symptoms at all or it may cause swelling redness and pain

2 Pulmonary embolism (PE) If a clot becomes dislodged and passes through your

blood vessels it can reach your lungs this is called a PE Symptoms include coughing (with blood stained phlegm) chest pain and breathlessness Health professionals use the term venous thromboembolism (VTE) to cover both DVT and PE If you develop any of these symptoms either in hospital or after you go home please get medical advice immediately

Are blood clots common

Blood clots occur in the general population in about one in 1000 people every year You may have heard about DVT in people who have been on an aeroplane but you are much more likely to get a blood clot after going into Hospital In fact about two thirds of all blood clots occur during or after a stay in hospital The government recognises hospital-acquired blood clots are an important problem and has asked hospital doctors nurses and pharmacists to assess each patientrsquos risk If you are at risk your doctor or nurse will talk with you about what will be done to offer you protection against clots

Who is at risk Any unwell adult admitted to hospital is at risk ndash that is most adults Other factors that put people at greater risk include

A previous clot

A recent diagnosis of cancer

Certain lsquosticky bloodrsquo conditions such as antiphospholipid syndrome or Factor V Leiden

Being overweight

Being immobile

Oestrogen-containing contraceptives and hormone replacement

Having an operation

Significant injury or trauma


What can be done to reduce my risk

Preventing blood clots (anticoagulants)

Most patients at risk will be prescribed a small dose of an anticoagulant by injection Anticoagulants block the activity of clotting factors and prevent blood clots developing or getting worse

If you need to take this medication when you leave hospital you will be given more information and another information booklet The most common side-effect is bruising and or bleeding If you are concerned please contact your doctor (in hours) or ShropDoc (out of hours)

Stockings In hospital you might be measured and fitted with anti-embolism stockings for your legs You should be shown how to wear them and told to report any new pain or discomfort in your feet or legs to a health professional Your stockings will be removed for a short time every day so that you can have a wash and check for any skin problems

Inflatable sleeves

The clinical team may ask you to wear calf or foot pumps special inflatable sleeves around your legs or feet while you are in bed or sat in a chair These will inflate automatically and provide pressure at regular intervals increasing blood flow out of your legs

What can I do to help

When in hospital

Keep moving or walking and get out of bed as soon as you can

Drink plenty of fluids to keep hydrated

Ask you nurse or physiotherapist for more information

What happens when I go home

If you need to continue anticoagulation injections at home your nursing team will teach you how to do this If you have any concerns make sure you speak to a nurse before you leave

If you develop any signs or symptoms of a clot at home then seek medical advice immediately either from your General Practitioner (GP) or your nearest hospitalrsquos emergency department

Until you return to your usual level of activity you may need to wear anti-embolism stockings after you go home Your nurse will tell you how to put them on and what you should check your skin for


B

a

l a

n c e

r i s k s

l

B a

Appendix 9

VTE Risk Assessment Pathway

Patient admitted to

Community Hospital

Assess VTE risk within 4 hours (direct admission) using the risk assessment tool (appendix 1)

Assess bleeding risk

Balance risks of VTE and bleeding

Offer VTE prophylaxis if appropriate Do not offer pharmacological VTE prophylaxis if patient has any risk

factor for bleeding and risk of bleeding outweighs risk of VTE

Reassess risks of VTE and bleeding within 24 hours of admission and whenever clinical situation changes

For all patients

bull Do not allow patients to become dehydrated unless clinically indicated

bull Encourage patients to mobilise as soon as possible

bull Do not regard aspirin or other antiplatelet agents as adequate prophylaxis for VTE



Reducing the Risk of Venous Thromboembolism Policy CONTENTS

Chapter Page

1 Introduction 2

2 Purpose 2

3 Definitions 2

4 Duties 3

5 Assessing the Risks of VTE and Bleeding 3

6 Reducing the Risk of VTE 4

7 Patient Information and Discharge Planning 5

8 Choice of VTE Prophylaxis 6

9 Procedure if VTE is Suspected 10

10 Procedure if VTE is Confirmed 10

11 Consultation and Approval Process 11

12 Advice and Training 11

13 Monitoring Compliance 13

14 References amp NICE Guidance 16

15 Associated Documents 16

16 Appendices

Appendix 1 Risk Assessment Document 17 Appendix 2 Care Pathway ndash Medical Patients 19 Appendix 3 Care Pathway ndash Stroke Patients 20 Appendix 4 Care Pathway ndash Oncology Patients 21 Appendix 5 Care Pathway ndash End of Life Patients 22 Appendix 6 Care Pathway ndash Day Surgery Patients 23 Appendix 7 Care Pathway - Lower Limb Plaster Casts 24 Appendix 8 Patient Guide 25 Appendix 9 Care Pathway ndash VTE Risk Assessment Pathway 27


1 Introduction




service








2 Purpose





3 Definitions





4 Duties





42 Directors





3


(NHSLA)




effectiveness

This will include



Mandatory Training





44 Team Leaders



45 All Staff



This will include









insufficiency This















(Appendix 1)












prophylaxis

























































Acute stroke







failure










stockings refitted



of 14-15 mmHg










patient guide)


worn correctly







of anticoagulation

Full Blood Count


Clotting Screen












Severe hypertension









immediately





































dose











































Choices website


11 Consultation




period to







121 Advice





01743 261000





ward level meetings









Procedure



findings










b Prophylatic










c Procedure















e Organis-







14 References











and prisons policy




16 Appendices

















Admission Date Time






2 24hrs

3 Change


Age gt 60

Dehydration











Hip fracture


1

OA 2

24hrs 3

Change

1 OA

2 24hrs

3 Change























changes

STEP ONE




STEP TWO




guidance



STEP THREE















Appendix 2




Yes No



Yes

No

Has Patient Been



Yes

See Appendix 3






19






YES




YES


YES




NO

YES

Appendix 4




Yes No Yes No


or mechanical

VTE prophylaxis

Yes No Yes No












Day Surgery



at admission



If risk of major

Bleeding low

Add LMWH (or UFH)



Choose any one of



Appendix 7



Assess risk of VTE





VTE Patient Leaflet










A previous clot



Being overweight

Being immobile


Having an operation








Inflatable sleeves



When in hospital









B

a

l a

n c e

r i s k s

l

B a

Appendix 9


Patient admitted to

Community Hospital







For all patients






1 Introduction




service








2 Purpose





3 Definitions





4 Duties





42 Directors





3


(NHSLA)




effectiveness

This will include



Mandatory Training





44 Team Leaders



45 All Staff



This will include









insufficiency This















(Appendix 1)












prophylaxis

























































Acute stroke







failure










stockings refitted



of 14-15 mmHg










patient guide)


worn correctly







of anticoagulation

Full Blood Count


Clotting Screen












Severe hypertension









immediately





































dose











































Choices website


11 Consultation




period to







121 Advice





01743 261000





ward level meetings









Procedure



findings










b Prophylatic










c Procedure















e Organis-







14 References











and prisons policy




16 Appendices

















Admission Date Time






2 24hrs

3 Change


Age gt 60

Dehydration











Hip fracture


1

OA 2

24hrs 3

Change

1 OA

2 24hrs

3 Change























changes

STEP ONE




STEP TWO




guidance



STEP THREE















Appendix 2




Yes No



Yes

No

Has Patient Been



Yes

See Appendix 3






19






YES




YES


YES




NO

YES

Appendix 4




Yes No Yes No


or mechanical

VTE prophylaxis

Yes No Yes No












Day Surgery



at admission



If risk of major

Bleeding low

Add LMWH (or UFH)



Choose any one of



Appendix 7



Assess risk of VTE





VTE Patient Leaflet










A previous clot



Being overweight

Being immobile


Having an operation








Inflatable sleeves



When in hospital









B

a

l a

n c e

r i s k s

l

B a

Appendix 9


Patient admitted to

Community Hospital







For all patients





3


(NHSLA)




effectiveness

This will include



Mandatory Training





44 Team Leaders



45 All Staff



This will include









insufficiency This















(Appendix 1)












prophylaxis

























































Acute stroke







failure










stockings refitted



of 14-15 mmHg










patient guide)


worn correctly







of anticoagulation

Full Blood Count


Clotting Screen












Severe hypertension









immediately





































dose











































Choices website


11 Consultation




period to







121 Advice





01743 261000





ward level meetings









Procedure



findings










b Prophylatic










c Procedure















e Organis-







14 References











and prisons policy




16 Appendices

















Admission Date Time






2 24hrs

3 Change


Age gt 60

Dehydration











Hip fracture


1

OA 2

24hrs 3

Change

1 OA

2 24hrs

3 Change























changes

STEP ONE




STEP TWO




guidance



STEP THREE















Appendix 2




Yes No



Yes

No

Has Patient Been



Yes

See Appendix 3






19






YES




YES


YES




NO

YES

Appendix 4




Yes No Yes No


or mechanical

VTE prophylaxis

Yes No Yes No












Day Surgery



at admission



If risk of major

Bleeding low

Add LMWH (or UFH)



Choose any one of



Appendix 7



Assess risk of VTE





VTE Patient Leaflet










A previous clot



Being overweight

Being immobile


Having an operation








Inflatable sleeves



When in hospital









B

a

l a

n c e

r i s k s

l

B a

Appendix 9


Patient admitted to

Community Hospital







For all patients



















(Appendix 1)












prophylaxis

























































Acute stroke







failure










stockings refitted



of 14-15 mmHg










patient guide)


worn correctly







of anticoagulation

Full Blood Count


Clotting Screen












Severe hypertension









immediately





































dose











































Choices website


11 Consultation




period to







121 Advice





01743 261000





ward level meetings









Procedure



findings










b Prophylatic










c Procedure















e Organis-







14 References











and prisons policy




16 Appendices

















Admission Date Time






2 24hrs

3 Change


Age gt 60

Dehydration











Hip fracture


1

OA 2

24hrs 3

Change

1 OA

2 24hrs

3 Change























changes

STEP ONE




STEP TWO




guidance



STEP THREE















Appendix 2




Yes No



Yes

No

Has Patient Been



Yes

See Appendix 3






19






YES




YES


YES




NO

YES

Appendix 4




Yes No Yes No


or mechanical

VTE prophylaxis

Yes No Yes No












Day Surgery



at admission



If risk of major

Bleeding low

Add LMWH (or UFH)



Choose any one of



Appendix 7



Assess risk of VTE





VTE Patient Leaflet










A previous clot



Being overweight

Being immobile


Having an operation








Inflatable sleeves



When in hospital









B

a

l a

n c e

r i s k s

l

B a

Appendix 9


Patient admitted to

Community Hospital







For all patients


























































Acute stroke







failure










stockings refitted



of 14-15 mmHg










patient guide)


worn correctly







of anticoagulation

Full Blood Count


Clotting Screen












Severe hypertension









immediately





































dose











































Choices website


11 Consultation




period to







121 Advice





01743 261000





ward level meetings









Procedure



findings










b Prophylatic










c Procedure















e Organis-







14 References











and prisons policy




16 Appendices

















Admission Date Time






2 24hrs

3 Change


Age gt 60

Dehydration











Hip fracture


1

OA 2

24hrs 3

Change

1 OA

2 24hrs

3 Change























changes

STEP ONE




STEP TWO




guidance



STEP THREE















Appendix 2




Yes No



Yes

No

Has Patient Been



Yes

See Appendix 3






19






YES




YES


YES




NO

YES

Appendix 4




Yes No Yes No


or mechanical

VTE prophylaxis

Yes No Yes No












Day Surgery



at admission



If risk of major

Bleeding low

Add LMWH (or UFH)



Choose any one of



Appendix 7



Assess risk of VTE





VTE Patient Leaflet










A previous clot



Being overweight

Being immobile


Having an operation








Inflatable sleeves



When in hospital









B

a

l a

n c e

r i s k s

l

B a

Appendix 9


Patient admitted to

Community Hospital







For all patients



























Acute stroke







failure










stockings refitted



of 14-15 mmHg










patient guide)


worn correctly







of anticoagulation

Full Blood Count


Clotting Screen












Severe hypertension









immediately





































dose











































Choices website


11 Consultation




period to







121 Advice





01743 261000





ward level meetings









Procedure



findings










b Prophylatic










c Procedure















e Organis-







14 References











and prisons policy




16 Appendices

















Admission Date Time






2 24hrs

3 Change


Age gt 60

Dehydration











Hip fracture


1

OA 2

24hrs 3

Change

1 OA

2 24hrs

3 Change























changes

STEP ONE




STEP TWO




guidance



STEP THREE















Appendix 2




Yes No



Yes

No

Has Patient Been



Yes

See Appendix 3






19






YES




YES


YES




NO

YES

Appendix 4




Yes No Yes No


or mechanical

VTE prophylaxis

Yes No Yes No












Day Surgery



at admission



If risk of major

Bleeding low

Add LMWH (or UFH)



Choose any one of



Appendix 7



Assess risk of VTE





VTE Patient Leaflet










A previous clot



Being overweight

Being immobile


Having an operation








Inflatable sleeves



When in hospital









B

a

l a

n c e

r i s k s

l

B a

Appendix 9


Patient admitted to

Community Hospital







For all patients












stockings refitted



of 14-15 mmHg










patient guide)


worn correctly







of anticoagulation

Full Blood Count


Clotting Screen












Severe hypertension









immediately





































dose











































Choices website


11 Consultation




period to







121 Advice





01743 261000





ward level meetings









Procedure



findings










b Prophylatic










c Procedure















e Organis-







14 References











and prisons policy




16 Appendices

















Admission Date Time






2 24hrs

3 Change


Age gt 60

Dehydration











Hip fracture


1

OA 2

24hrs 3

Change

1 OA

2 24hrs

3 Change























changes

STEP ONE




STEP TWO




guidance



STEP THREE















Appendix 2




Yes No



Yes

No

Has Patient Been



Yes

See Appendix 3






19






YES




YES


YES




NO

YES

Appendix 4




Yes No Yes No


or mechanical

VTE prophylaxis

Yes No Yes No












Day Surgery



at admission



If risk of major

Bleeding low

Add LMWH (or UFH)



Choose any one of



Appendix 7



Assess risk of VTE





VTE Patient Leaflet










A previous clot



Being overweight

Being immobile


Having an operation








Inflatable sleeves



When in hospital









B

a

l a

n c e

r i s k s

l

B a

Appendix 9


Patient admitted to

Community Hospital







For all patients






Clotting Screen












Severe hypertension









immediately





































dose











































Choices website


11 Consultation




period to







121 Advice





01743 261000





ward level meetings









Procedure



findings










b Prophylatic










c Procedure















e Organis-







14 References











and prisons policy




16 Appendices

















Admission Date Time






2 24hrs

3 Change


Age gt 60

Dehydration











Hip fracture


1

OA 2

24hrs 3

Change

1 OA

2 24hrs

3 Change























changes

STEP ONE




STEP TWO




guidance



STEP THREE















Appendix 2




Yes No



Yes

No

Has Patient Been



Yes

See Appendix 3






19






YES




YES


YES




NO

YES

Appendix 4




Yes No Yes No


or mechanical

VTE prophylaxis

Yes No Yes No












Day Surgery



at admission



If risk of major

Bleeding low

Add LMWH (or UFH)



Choose any one of



Appendix 7



Assess risk of VTE





VTE Patient Leaflet










A previous clot



Being overweight

Being immobile


Having an operation








Inflatable sleeves



When in hospital









B

a

l a

n c e

r i s k s

l

B a

Appendix 9


Patient admitted to

Community Hospital







For all patients


































dose











































Choices website


11 Consultation




period to







121 Advice





01743 261000





ward level meetings









Procedure



findings










b Prophylatic










c Procedure















e Organis-







14 References











and prisons policy




16 Appendices

















Admission Date Time






2 24hrs

3 Change


Age gt 60

Dehydration











Hip fracture


1

OA 2

24hrs 3

Change

1 OA

2 24hrs

3 Change























changes

STEP ONE




STEP TWO




guidance



STEP THREE















Appendix 2




Yes No



Yes

No

Has Patient Been



Yes

See Appendix 3






19






YES




YES


YES




NO

YES

Appendix 4




Yes No Yes No


or mechanical

VTE prophylaxis

Yes No Yes No












Day Surgery



at admission



If risk of major

Bleeding low

Add LMWH (or UFH)



Choose any one of



Appendix 7



Assess risk of VTE





VTE Patient Leaflet










A previous clot



Being overweight

Being immobile


Having an operation








Inflatable sleeves



When in hospital









B

a

l a

n c e

r i s k s

l

B a

Appendix 9


Patient admitted to

Community Hospital







For all patients















































Choices website


11 Consultation




period to







121 Advice





01743 261000





ward level meetings









Procedure



findings










b Prophylatic










c Procedure















e Organis-







14 References











and prisons policy




16 Appendices

















Admission Date Time






2 24hrs

3 Change


Age gt 60

Dehydration











Hip fracture


1

OA 2

24hrs 3

Change

1 OA

2 24hrs

3 Change























changes

STEP ONE




STEP TWO




guidance



STEP THREE















Appendix 2




Yes No



Yes

No

Has Patient Been



Yes

See Appendix 3






19






YES




YES


YES




NO

YES

Appendix 4




Yes No Yes No


or mechanical

VTE prophylaxis

Yes No Yes No












Day Surgery



at admission



If risk of major

Bleeding low

Add LMWH (or UFH)



Choose any one of



Appendix 7



Assess risk of VTE





VTE Patient Leaflet










A previous clot



Being overweight

Being immobile


Having an operation








Inflatable sleeves



When in hospital









B

a

l a

n c e

r i s k s

l

B a

Appendix 9


Patient admitted to

Community Hospital







For all patients
















Choices website


11 Consultation




period to







121 Advice





01743 261000





ward level meetings









Procedure



findings










b Prophylatic










c Procedure















e Organis-







14 References











and prisons policy




16 Appendices

















Admission Date Time






2 24hrs

3 Change


Age gt 60

Dehydration











Hip fracture


1

OA 2

24hrs 3

Change

1 OA

2 24hrs

3 Change























changes

STEP ONE




STEP TWO




guidance



STEP THREE















Appendix 2




Yes No



Yes

No

Has Patient Been



Yes

See Appendix 3






19






YES




YES


YES




NO

YES

Appendix 4




Yes No Yes No


or mechanical

VTE prophylaxis

Yes No Yes No












Day Surgery



at admission



If risk of major

Bleeding low

Add LMWH (or UFH)



Choose any one of



Appendix 7



Assess risk of VTE





VTE Patient Leaflet










A previous clot



Being overweight

Being immobile


Having an operation








Inflatable sleeves



When in hospital









B

a

l a

n c e

r i s k s

l

B a

Appendix 9


Patient admitted to

Community Hospital







For all patients









ward level meetings









Procedure



findings










b Prophylatic










c Procedure















e Organis-







14 References











and prisons policy




16 Appendices

















Admission Date Time






2 24hrs

3 Change


Age gt 60

Dehydration











Hip fracture


1

OA 2

24hrs 3

Change

1 OA

2 24hrs

3 Change























changes

STEP ONE




STEP TWO




guidance



STEP THREE















Appendix 2




Yes No



Yes

No

Has Patient Been



Yes

See Appendix 3






19






YES




YES


YES




NO

YES

Appendix 4




Yes No Yes No


or mechanical

VTE prophylaxis

Yes No Yes No












Day Surgery



at admission



If risk of major

Bleeding low

Add LMWH (or UFH)



Choose any one of



Appendix 7



Assess risk of VTE





VTE Patient Leaflet










A previous clot



Being overweight

Being immobile


Having an operation








Inflatable sleeves



When in hospital









B

a

l a

n c e

r i s k s

l

B a

Appendix 9


Patient admitted to

Community Hospital







For all patients














b Prophylatic










c Procedure















e Organis-







14 References











and prisons policy




16 Appendices

















Admission Date Time






2 24hrs

3 Change


Age gt 60

Dehydration











Hip fracture


1

OA 2

24hrs 3

Change

1 OA

2 24hrs

3 Change























changes

STEP ONE




STEP TWO




guidance



STEP THREE















Appendix 2




Yes No



Yes

No

Has Patient Been



Yes

See Appendix 3






19






YES




YES


YES




NO

YES

Appendix 4




Yes No Yes No


or mechanical

VTE prophylaxis

Yes No Yes No












Day Surgery



at admission



If risk of major

Bleeding low

Add LMWH (or UFH)



Choose any one of



Appendix 7



Assess risk of VTE





VTE Patient Leaflet










A previous clot



Being overweight

Being immobile


Having an operation








Inflatable sleeves



When in hospital









B

a

l a

n c e

r i s k s

l

B a

Appendix 9


Patient admitted to

Community Hospital







For all patients









c Procedure















e Organis-







14 References











and prisons policy




16 Appendices

















Admission Date Time






2 24hrs

3 Change


Age gt 60

Dehydration











Hip fracture


1

OA 2

24hrs 3

Change

1 OA

2 24hrs

3 Change























changes

STEP ONE




STEP TWO




guidance



STEP THREE















Appendix 2




Yes No



Yes

No

Has Patient Been



Yes

See Appendix 3






19






YES




YES


YES




NO

YES

Appendix 4




Yes No Yes No


or mechanical

VTE prophylaxis

Yes No Yes No












Day Surgery



at admission



If risk of major

Bleeding low

Add LMWH (or UFH)



Choose any one of



Appendix 7



Assess risk of VTE





VTE Patient Leaflet










A previous clot



Being overweight

Being immobile


Having an operation








Inflatable sleeves



When in hospital









B

a

l a

n c e

r i s k s

l

B a

Appendix 9


Patient admitted to

Community Hospital







For all patients









e Organis-







14 References











and prisons policy




16 Appendices

















Admission Date Time






2 24hrs

3 Change


Age gt 60

Dehydration











Hip fracture


1

OA 2

24hrs 3

Change

1 OA

2 24hrs

3 Change























changes

STEP ONE




STEP TWO




guidance



STEP THREE















Appendix 2




Yes No



Yes

No

Has Patient Been



Yes

See Appendix 3






19






YES




YES


YES




NO

YES

Appendix 4




Yes No Yes No


or mechanical

VTE prophylaxis

Yes No Yes No












Day Surgery



at admission



If risk of major

Bleeding low

Add LMWH (or UFH)



Choose any one of



Appendix 7



Assess risk of VTE





VTE Patient Leaflet










A previous clot



Being overweight

Being immobile


Having an operation








Inflatable sleeves



When in hospital









B

a

l a

n c e

r i s k s

l

B a

Appendix 9


Patient admitted to

Community Hospital







For all patients





14 References











and prisons policy




16 Appendices

















Admission Date Time






2 24hrs

3 Change


Age gt 60

Dehydration











Hip fracture


1

OA 2

24hrs 3

Change

1 OA

2 24hrs

3 Change























changes

STEP ONE




STEP TWO




guidance



STEP THREE















Appendix 2




Yes No



Yes

No

Has Patient Been



Yes

See Appendix 3






19






YES




YES


YES




NO

YES

Appendix 4




Yes No Yes No


or mechanical

VTE prophylaxis

Yes No Yes No












Day Surgery



at admission



If risk of major

Bleeding low

Add LMWH (or UFH)



Choose any one of



Appendix 7



Assess risk of VTE





VTE Patient Leaflet










A previous clot



Being overweight

Being immobile


Having an operation








Inflatable sleeves



When in hospital









B

a

l a

n c e

r i s k s

l

B a

Appendix 9


Patient admitted to

Community Hospital







For all patients











Admission Date Time






2 24hrs

3 Change


Age gt 60

Dehydration











Hip fracture


1

OA 2

24hrs 3

Change

1 OA

2 24hrs

3 Change























changes

STEP ONE




STEP TWO




guidance



STEP THREE















Appendix 2




Yes No



Yes

No

Has Patient Been



Yes

See Appendix 3






19






YES




YES


YES




NO

YES

Appendix 4




Yes No Yes No


or mechanical

VTE prophylaxis

Yes No Yes No












Day Surgery



at admission



If risk of major

Bleeding low

Add LMWH (or UFH)



Choose any one of



Appendix 7



Assess risk of VTE





VTE Patient Leaflet










A previous clot



Being overweight

Being immobile


Having an operation








Inflatable sleeves



When in hospital









B

a

l a

n c e

r i s k s

l

B a

Appendix 9


Patient admitted to

Community Hospital







For all patients








changes

STEP ONE




STEP TWO




guidance



STEP THREE















Appendix 2




Yes No



Yes

No

Has Patient Been



Yes

See Appendix 3






19






YES




YES


YES




NO

YES

Appendix 4




Yes No Yes No


or mechanical

VTE prophylaxis

Yes No Yes No












Day Surgery



at admission



If risk of major

Bleeding low

Add LMWH (or UFH)



Choose any one of



Appendix 7



Assess risk of VTE





VTE Patient Leaflet










A previous clot



Being overweight

Being immobile


Having an operation








Inflatable sleeves



When in hospital









B

a

l a

n c e

r i s k s

l

B a

Appendix 9


Patient admitted to

Community Hospital







For all patients








Appendix 2




Yes No



Yes

No

Has Patient Been



Yes

See Appendix 3






19






YES




YES


YES




NO

YES

Appendix 4




Yes No Yes No


or mechanical

VTE prophylaxis

Yes No Yes No












Day Surgery



at admission



If risk of major

Bleeding low

Add LMWH (or UFH)



Choose any one of



Appendix 7



Assess risk of VTE





VTE Patient Leaflet










A previous clot



Being overweight

Being immobile


Having an operation








Inflatable sleeves



When in hospital









B

a

l a

n c e

r i s k s

l

B a

Appendix 9


Patient admitted to

Community Hospital







For all patients










YES




YES


YES




NO

YES

Appendix 4




Yes No Yes No


or mechanical

VTE prophylaxis

Yes No Yes No












Day Surgery



at admission



If risk of major

Bleeding low

Add LMWH (or UFH)



Choose any one of



Appendix 7



Assess risk of VTE





VTE Patient Leaflet










A previous clot



Being overweight

Being immobile


Having an operation








Inflatable sleeves



When in hospital









B

a

l a

n c e

r i s k s

l

B a

Appendix 9


Patient admitted to

Community Hospital







For all patients





Appendix 4




Yes No Yes No


or mechanical

VTE prophylaxis

Yes No Yes No












Day Surgery



at admission



If risk of major

Bleeding low

Add LMWH (or UFH)



Choose any one of



Appendix 7



Assess risk of VTE





VTE Patient Leaflet










A previous clot



Being overweight

Being immobile


Having an operation








Inflatable sleeves



When in hospital









B

a

l a

n c e

r i s k s

l

B a

Appendix 9


Patient admitted to

Community Hospital







For all patients













Day Surgery



at admission



If risk of major

Bleeding low

Add LMWH (or UFH)



Choose any one of



Appendix 7



Assess risk of VTE





VTE Patient Leaflet










A previous clot



Being overweight

Being immobile


Having an operation








Inflatable sleeves



When in hospital









B

a

l a

n c e

r i s k s

l

B a

Appendix 9


Patient admitted to

Community Hospital







For all patients






Day Surgery



at admission



If risk of major

Bleeding low

Add LMWH (or UFH)



Choose any one of



Appendix 7



Assess risk of VTE





VTE Patient Leaflet










A previous clot



Being overweight

Being immobile


Having an operation








Inflatable sleeves



When in hospital









B

a

l a

n c e

r i s k s

l

B a

Appendix 9


Patient admitted to

Community Hospital







For all patients





Appendix 7



Assess risk of VTE





VTE Patient Leaflet










A previous clot



Being overweight

Being immobile


Having an operation








Inflatable sleeves



When in hospital









B

a

l a

n c e

r i s k s

l

B a

Appendix 9


Patient admitted to

Community Hospital







For all patients





VTE Patient Leaflet










A previous clot



Being overweight

Being immobile


Having an operation








Inflatable sleeves



When in hospital









B

a

l a

n c e

r i s k s

l

B a

Appendix 9


Patient admitted to

Community Hospital







For all patients










Inflatable sleeves



When in hospital









B

a

l a

n c e

r i s k s

l

B a

Appendix 9


Patient admitted to

Community Hospital







For all patients





B

a

l a

n c e

r i s k s

l

B a

Appendix 9


Patient admitted to

Community Hospital







For all patients



