DVT and VTE Management Policy

Transcription

1 This document has been reviewed in line with the Policy Alignment Process for Liverpool Community Health NHS Trust Services. It is a valid Mersey Care document, however due to organisational change this FRONT COVER has been added so the reader is aware of any changes to their role or to terminology which has now been superseded. When reading this document please take account of the changes highlighted in Part B and C of this form. Part A Information about this Document Policy Name DVT and VTE Management Policy Policy Type Board Approved (Trust-wide) Trust-wide Divisional / Team / Locality Action No Change Minor Change Major Change New Policy No Longer Needed Approval As Mersey Care s Executive Director / Lead for this document, I confirm that this document: a) complies with the latest statutory / regulatory requirements, b) complies with the latest national guidance, c) has been updated to reflect the requirements of clinicians and officers, and d) has been updated to reflect any local contractual requirements Signature: Date: Part B Changes in Terminology (used with Minor Change, Major Changes & New Policy only) Terminology used in this Document New terminology when reading this Document Part C Additional Information Added (to be used with Major Changes only) Section / Paragraph No Outline of the information that has been added to this document especially where it may change what staff need to do Part D Rationale (to be used with New Policy & Policy No Longer Required only) Please explain why this new document needs to be adopted or why this document is no longer required Part E Oversight Arrangements (to be used with New Policy only) Accountable Director Recommending Committee Approving Committee Next Review Date LCH Policy Alignment Process Form 1 1

2 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 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 2

3 Fairness, Respect, Equality Dignity, and Autonomy 3

4 Policy for the Referral Diagnosis and Treatment of New Venous Thromboembolism (VTE)/Deep Venous Thrombosis (DVT) within Liverpool Community Health (LCH) Adult services 4

5 Version Number 1 Reference Number Ratified by Date of Approval: (Original Version) Name of originator/author Approving Body / Committee Date issued: (Current Version) Review date: (Current Version) Target audience Name of Lead Director / Managing Director Changes / Alterations Made To Previous Version (including date of changes) 131 Clinical Standards Group 27 th February 2018 Clinical Nurse Manager and Nurse Clinician Clinical Standards Group February 2018 February 2020 LCH Patient Services Deputy Director of Nursing This is a combination of both the Policy for the Diagnosis and Treatment of New Venous Thromboembolism (VTE) within Liverpool Community Health (LCH) Adult Services and the Clinical Policy for the Management of a DVT in Patients who attend Liverpool Walk-In Centres. Key individuals involved in developing the document Name Designation Liz Norris Clinical Nurse Manager Margaret Carran Nurse Clinician Ambulatory Care and Diagnostics Tracey Carver Clinical Lead, South Locality This document was circulated to the following individuals for consultation Name Alan Martin Designation Call handler/referral Management Advisor 5

6 Contents Section Page 1 Introduction 4 2 Policy Statement 5 3 Status 5 4 Purpose 5 5 Scope 6 6 Duties 6 7 Definitions 8 8 Policy 9 9 Training Implementation Monitoring Equality Analysis Linked areas / Information Relevant Legislation / Statutory requirements References & Bibliography 16 Appendix 1 GP/Health professional referral pathway 17 SPC DVT criteria Appendix 2 18 DVT suspected LCH WIC flow chart Appendix 3 19 Appendix 4 Two level DVT WELLS 20 Appendix 5 SOP undertaking D-Dimer 21 Appendix 6 Ultrasound referral pathway 24 Appendix 7 Ultrasound request form 25 Appendix 8 Ultrasound patient information sheet 26 Appendix 9 DVT referral checklist 27 Appendix 10 NICE/RLBGUH Algorithm for diagnosis and management DVT 28 Appendix 11 LBGUHT AMU outpatient management and algorithm for DVT 29 6

7 Introduction Venous Thrombolytic Embolism (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 (DVT). or the pelvis; The thrombus may dislodge from its site of origin to travel in the blood - a phenomenon called embolism the most serious of which is a pulmonary embolism (PE) when it lodges in a blood vessel (artery) in the lung it can cause damage to the lung if the clot is large enough it could stops blood flow to the lung which can be deadly DVT has a annual incidence is about 1 in 1000 people only about a third of people with a clinical suspicion of DVT have the condition. National institute of health care and excellence have a pathway for diagnosis and subsequent management in primary secondary and tertiary care This document sets out Liverpool Community Health`s (LCH) system for diagnosis of suspected Venous Thromboembolism (VTE) and treatment of patients for whom VTE is confirmed. This policy provides a robust framework to ensure a consistent approach across LCH and also supports our statutory duties as set out in the NHS Constitution (2012). Liverpool Walk-In Centers (LWIC) is a nurse led service that leads on the DVT Service provided by Liverpool Community Health NHS Trust (LCH) in collaboration with the Royal Liverpool and Broadgreen University Hospital Trust (RLBUHT) have a pathway in place for all patients who are registered with a Liverpool GP. This service aims to provide same day assessments, investigation and diagnosis or exclusion of a DVT for patients on a daily basis from, 8am-19:30pm The service is also available at weekends and on Bank Holidays. However, the ultrasound service is not available during these periods but treatment will be provided for patients who are suspected to have a DVT. 7

8 2. Policy Statement This policy is intended to assist with the reduction in fatal pulmonary emboli by a providing a standardised and evidence based approach into the timely identification of a suspected VTE and early identification and management of suspected DVT 3. Status This is a clinical policy document for use within Liverpool Community Health NHS Trust (LCH). 4. Purpose The purpose of this Policy is to ensure the risk to patient safety is reduced through adherence to national VTE prevention strategy, ensuring compliance to NICE guidance. Implementation of this policy will ensure that: All patients under the care of LCH services, presenting with signs and symptoms of a possible VTE will be investigated in a timely manner. All patients who have a suspected DVT will be managed according to current NICE guidance and clinical evidence base. Assists with the reduction in fatal VTE Provide comprehensive guidance to all Nurse Practitioners working within this policy That appropriate referral pathways and process are in place in order to facilitate early recognition and identification of a potential lower limb DVT The is collaborative working with the Royal Liverpool and Broadgreen University Hospital Trust Acute Medical Unit (AMU) to investigate patients with suspected DVT of the leg Supports the reduction of access to secondary care emergency services and provide a comprehensive service for patients in the Liverpool community Healthcare professionals, both temporary and permanent, are expected to take the policy fully into account when exercising their clinical judgment. However, this policy does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation 8

9 with the patient and/or guardian /carer. 5. Scope This policy applies to all the staffing groups involved in patients care across LCH. Community Matrons General Practitioners, Nurse Practitioners, Advanced Nurse Practitioner Intensive Community Care Team (ICCT) Walk in Centres 6. Duties 6.1 Duties within LCH The following general (statutory) duties apply: All LCH staff are responsible for co-operating with the development and implementation of Trust policies as part of their normal duties and responsibilities. All other personnel will be expected to comply with the requirements of all relevant Trust policies applicable to their area of operation. 6.2 Role of Chief Executive The Chief Executive is ultimately responsible for the content of all organisation wide procedural documents and their implementation 6.3 Role of General Practitioner/Advanced Nurse Practitioner/Community Matron within community settings The general practitioners, advanced nurse practitioners and community matron within community settings are responsible for; Performing a clinical assessment of all patients presenting or being referred, with symptoms of VTE/DVT. Referring the patient through Single Point of Contact to the appropriate health care service for investigation. The appropriate service may be secondary care 9

10 or the walk in centre, and will be sign-posted by the Single Point of Contact (SPC). Reviewing the patient if a diagnosis of DVT is excluded, for possible alternative conditions/diagnosis. 6.4 Role of Nursing Lead for community settings The Nursing Lead 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 6.5 Role of the Single Point of Contact The Single Point of Contact is responsible for :- Facilitating the clinical triage of patient referrals into the appropriate primary or secondary healthcare facility. Applying criteria on the suitability for the patient to be managed within the WIC s (Appendix 2) 6.6 Role of Harm Free Lead for VTE The Nursing Lead 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 6.7 Service Manager and Clinical Nurse Managers for Liverpool Walk-In Centres. Are responsible for the implementation of the policy and service delivery of the initial diagnostic testing and further management pathway That all staff involved in the delivery of the DVT pathway will be made aware of this policy on commencement to post and as part of their LWIC s local induction process 10

11 6.8 Nurse Practitioners Liverpool WIC Those practitioners within WIC that offer DVT Are responsible in ensuring they have undertaken and update the relevant training Follow the relvent processess/pathways and procedures in place appopriate to patients presenting with suspected VTE/DVT Perform clinical assessment as outlined within this policy 7.Definitions Deep Vein Thrombosis (DVT) is a formation of a thrombus (blood clot) in a deep vein, usually of the lower limbs. Blood flow in the vein is partially or completely obstructed. Patient Group Direction (PGD) for supply / administration of medication within a clinical pathway for management of a suspected DVT. Wells Score is a risk predicter score for the possibility of DVT. D-Dimer is a type of blood test that may determine the presence of a DVT but can be raised in other conditions that cause abnormal clot formation and breakdown. Ultrasound Scan: Doppler ultrasound scan is a test that uses reflected sound waves to evaluate blood as it flows through a blood vessel. DVT Pathway is a guide on the patient s journey from the GP to Old Swan Walk-In Centre from diagnosis to possible treatment. Provoked VTE: A provoked VTE is a clot that develops in a patient with an antecedent (within 3 months) and transient major clinical risk factor for VTE for example surgery, trauma, significant immobility (bedbound, unable to walk unaided or likely to spend a substantial proportion of the day in bed or in a chair), pregnancy or puerperium or in a patient who is having hormonal therapy (oral contraceptive or hormone replacement therapy). Unprovoked VTE: An unprovoked VTE is a clot that develops in a patient with:-no antecedent major clinical risk factor for VTE (see 'Provoked deep vein thrombosis or pulmonary embolism' above) who is not having 11

12 hormonal therapy (oral contraceptive or hormone replacement therapy) or Active cancer, thrombophilia or a family history of VTE, because these are underlying risks that remain constant in the patient Policy 8. Recognizing VTE VTE occurs with a broad range of clinical symptoms from asymptomatic calf vein thrombosis to life-threatening, acute, massive PE. Classically DVT produces pain and oedema in the affected limb. However, patients can show no symptoms, conversely they maybe unilateral or bilateral. Patients with PE also rarely present with the classical symptoms of abrupt onset pleuritic chest pain, shortness of breath and hypoxia. In fact studies of patients having died from PE, often show complaints of nagging symptoms for weeks prior to death. Consider the possibility of VTE in a person with any of the clinical features, particularly if they also have a risk factor and an alternative diagnosis is unlikely. Clinical features of deep vein thrombosis may include; Pain and swelling Tenderness Changes to skin colour and temperature Vein distension Clinical features of pulmonary embolism may include: New or worsening breathlessness, particularly if it was sudden in onset. Tachypnoea (respiratory rate of 20 breaths or more per minute). Chest pain, which may be pleuritic, or retrosternal and angina-like. Tachycardia (heart rate greater than 100 beats per minute). Haemoptysis. Syncope. Hypotension (systolic blood pressure less than 90 mmhg). Crepitation s. Cough or fever may also be present but are too non-specific to be helpful. 12

13 Risk factors for the development of VTE include (list not fully inclusive); Venous stasis Hypercoagulable states Immobilisation, due to hospitalisation, stroke, paresis or paralysis Surgery and trauma, particularly to lower extremities and pelvis, in the last three months Pregnancy Oral contraceptives and oestrogen replacement Malignancy, especially lung cancer Hereditary factors resulting in a hypercoagulable state Acute medical illness Drug abuse (intravenous drugs) Haemolytic anaemias Heparin associated thrombocytopenia Varicose veins Travel of 4 hours or more in the past month Current or past history of thrombophlebitis Smoking Previous history of VTE 8.1 Procedure to be followed if VTE suspected within Community Services All patients presenting with signs and symptoms of venous thromboembolism (Clinical or worsening signs of suspected PE as above 999) should be referred to an Advanced Nurse Practitioner/Community Matron /General Practitioner in order to: Take a full clinical history and clinical examination with the aim of detecting underlying conditions contributing to the development of thrombosis and assessing suitability for antithrombotic therapy. Assess if provoked or unprovoked in order to identify if further investigations needed Clinical assessment should also consider likely alternative diagnosis. 13

14 Patients with suspected VTE should be referred through the Single Point of Contact to either Liverpool Walk in or Secondary Care (Appendix 1). LCH only have pathway in place for the diagnosis and management of VTE in lower limbs (DVT) in place and if VTE is suspected elsewhere they should be admitted into secondary care for further assessment 8.2 Procedure to be followed if patient is referred into or presents with suspected DVT into Liverpool WIC A DVT Pathway has been put in place in collaboration with the RLBUHT and SPC for all patients who have a GP registered in the Liverpool area. The pathway provides same day assessments, investigation and diagnosis or exclusion of a DVT for patients with a Liverpool GP attending LWIC on a daily basis from. 8am-19:30pm The service is also available at weekends and on Bank Holidays. However, the ultrasound service is not available during these periods but treatment will be provided for patients who are suspected to have a DVT Process The nursing staff will assess the patient and plan care according to the DVT pathway /Flowchart Appendix 3. The staff will take a blood sample for a D-dimer according to the DVT pathway following the WIC DVT standard operating procedure (Appendix 5 ). Negative D-Dimer D Dimer is negative there is no indication of DVT if GP or practitioner assessing patient has a differential diagnosis, the patient will be managed as the differential diagnosis. If there is no differential dignosis the patient is referred back to the GP for further assessment. Postive D-Dimer If the D-dimer is positive staff should follow the DVT pathway (Appendix 3) on referrals to the RLBUHT Ultrasound Department. 14

15 All patients must be given a copy of the information sheet (Appendix 8 and a letter which provides them with the contact details of the Ultrasound Department appendix. D-dimer machine is changed every Tuesday on weekly basis by point of care RLBGUHT under a service level agreement If the D-Dimer is found not to be operational the practitioner will contact the point of care and a replacement will be sent. D-Dimer unavalible The following procedure applies: Inform AMU that the machine is unavailable; however, LWIC s will continue to provide a service. Review the Wells Score of the patient; if 1, the patient is referred to AMU. A blood sample is to be transferred to RLBUHT with the patient whenever feasible. The patient s blood sample is analysed by the laboratory and AMU will take over the care of the patient. If the Wells score is 2 or above, treat the patient and refer for next available ultrasound appointment. This is to prevent the ultrasound being blocked with potentially negative DVT patients. Ultrasound Ultrasound uses reflective sound waves to identify blood clots within the veins and all patients with postive D-Dimer will be sent for this assessment using the ultrasound referal pathway (Appendix 6 ) If the ultrasound is not available within 4 hours patients should be prescribed and administered with Dalteparin s/c via the Dalteparin PGD. If the patient attends a LWIC on a Friday and the ultra sound appointment is not available until the following Monday the patient will return daily with a 24 hour gap for Dalteparin via the PGD guidelines. The patient will be provided with all the relevant documentation to take to the Ultrasound Department. If the ultrasound is positive, the patient will be managed by the Acute Medical Unit (AMU) using LBGUHT AMU outpatient management and algorithm for DVT (appendix 11 ) this is based on the NICE pathway. 15

16 If the ultrasound is negative, the patient will be referred back to the GP with the result for follow up. Policy compliance will be measured against the local service plan using the DVT clinical audit tool (Appendix). The service will be continually audited, evaluated and developed accordingly on a monthly basis. 9.Training Requirements All Walk in Centre ANP staff and ANP staff working with adults will be made aware of this policy on commencement to post and as part of their LWIC s local induction process. Training Requirements for diagnosis/exclusion DVT within LCH WIC LWIC s training will consist of: Theory and Practice in relation to patients presenting with a suspected DVT within LWIC s Shadowing other health care professionals within Liverpool Walk-In Centres Self directed learning on presentation and management of patients within LWIC s with a suspected DVT D Dimmer traing provided by the RLBGUH Updated training will be provided by qualified nurses who have undertaken a period of extended training via a recognised institution and are deemed competent to teach others. 10. Implementation, Monitoring and Review The Clinical Lead of the VTE Harm free group is responsible for implementing this policy. This process has been delegated to the Services Managers within the community for the identified teams and service manager for LCH Walk-In Centres. 16

17 10.2. The Clinical lead of the VTE harm free group is responsible for ensuring that this policy is reviewed and if necessary, revised in the light of legislative guidance, changes to current evidence or organisational change. This process has been delegated to the Service Managers within the community and the Walk-In Centres. Aspect of compliance or effectiveness being monitored Patients with symptoms of VTE are recognised immediately, undergo timely clinical assessment and appropriate investigation as Method of monitoring Audit operson/s responsible VTE Steering Group Monitoring Frequency Annually Results reviewed by Harm Care Steering Group Free Person/s responsible for completing actions Divisional Managers Staff completed training associated with this policy as per LCH TNA within Staff within locality LCH WIC providing D- Dimer results have yearly update training Monthly Reports Manager QA lead RLBGUH Will not renew bar code to access LDB Monthly Divisional Governance Groups QA lead D- dimer RLBGUH Rolling programme due to staff turnover and service need DVT lead LCH WIC Divisional Managers CNM LCH WIC The implementation of the policy will be undertaken by the Service Manager and Clinical Nurse Managers for Liverpool Walk-In Centres. Policy compliance will be measured by auditing the service delivery by the Clinical Nurse Managers for respective Liverpool Walk-In Centres using the LCH DVT clinical guidance audit tool (Appendix). This will take place on a monthly basis with a six monthly review. Action Plans will be monitored at the Walk-In Centres Clinical Network Meeting and the Adult Division Governance meetings This policy will be reviewed within 3 years unless practice changes in the interim. 17

18 This review of the policy was undertaken in collaboration with RLBUHT and approved through the policy approval process in place at RLBUHT. All relevant personnel will be informed of the changes to the policy via the Walk-In Centre and Adult Division Governance networks. The following people are on the distribution list for notification of policy changes: General Practitioners (GP s) Single point contact (UCD) Nurse Practitioners at Liverpool Walk-In Centres Medical/Nursing staff at AMU, RLBUHT Service lead for Liverpool Walk-In Centre All nurses are required to maintain contemporaneous records of patients care, which are unambiguous and legible in accordance with statutory NMC Code 2015: Professional standards and behaviour for nurses and midwives. Documentation will be provided by the Trust to assist the process. 11. Equality Analysis An Equality Analysis has been undertaken and retained by the author of this policy and the Equality and Diversity Lead of LCH. 12. Linked Areas/Information This policy should be read in conjunction with the following guidance documents of the Trust: Health and Safety Policies. Accident and Incident Reporting and Management Policy (Including Serious Untoward Incidents). CPR/Cardiopulmonary Resuscitation Policy Relevant Legislation/Statutory Requirements This policy should be read in conjunction with: Guidance documents from the NMC (Nursing and Midwifery Council) 18

19 All nursing staff should follow the Nursing and Midwifery Council Guidelines for thestandards of Medicines References NICE:- CG144 Venous thromboembolic diseases: two-level Wells score - templates for deep vein thrombosis and pulmonary embolism. Nice algorithm for DVT Management (Appendix 9). Guidelines for arranging ultrasound venous leg dopplers; RLBUHT Ultrasound Department. (Appendix 6 ) NMC Code

20 Appendix 1 General Practitioner /Health professional referral pathway General Practitioner contacts UCD via LCH Single Point of Contact on to make a referral to Old Swan Walk-In Centre for a D-dimer blood test. UCD referral advisor will ask a series of questions to include differential diagnosis, and arrange for the patient to attend Old Swan Walk-In Centre. Pregnant Suspected Pulmonary Embolism Intravenous drug user Not ambulant On anticoagulant Patients whose symptoms are in the lower limb: Thigh Calf Referral advisor will arrange a direct admission into the AMU. Referral advisor will arrange for the patient to attend Old Swan Walk-In Centre. 20

21 Appendix 2 Single Point of Contact (UCD) D.V.T. Criteria The following questions must be asked by the Referral Advisor: Is the patient an intravenous drug user? Is PE suspected? Is the patient pregnant? Is the patient on any anticoagulation? Is the patient ambulant (if a wheelchair user, can the patient stand unsupported) If the GP answers yes to any of the first 4 questions the patient needs to be referred to RLBUHT as a medical admission. If the GP answers yes to the last question but the patient cannot access the WIC they will also need to be referred to RLBUHT as a medical admission. If the patient meets the criteria, the GP will advise the patient to attend Old Swan Walk-In Centre. If the GP refuses, or the patient is not suitable, the response should be documented in the notes for follow up. The GP will be required to provide the following information to the Walk-In Centre either by fax or with the patient: GP letter List of current medication Past medical history if possible Differential diagnosis The Referral advisor will be required to print off a copy of the call and fax it to Old Swan Walk-In Centre on The Referral advisor will be required to contact the Walk-In Centre on to confirm receipt of the fax. If any further information is required or there are any queries please contact a nurse advisor 21

22 Appendix 3 DVT Suspected Self-referral Patient presents at Old Swan Walk-In Centre Patient is triaged Referred from Community GP / Matron/ other WIC Nurse obtains a D-dimer blood test WELL s score completed Other causes excluded through general medical assessment, history and physical examination. Negative D-dimer <500 nanograms per millilitre Positive D-dimer >500 nanograms per millilitre Wells > 2 Wells score 1 point Refer patient for ultrasound next available appointment Is there a differential diagnosis Available within four hours Not available within four hours but Appt on same day follow anticoagulant PGD Not available within four hours or on same day follow anticoagulant PGD Yes No Discharged home with advice on management and treatment of differential diagnosis if possible /and or refer back to GP letter sent Discharged home reassure patient Make appointment with referring health professional 22 Patient discharged to ultrasound Patient given written information on Ultrasound attendance Ultrasound referral letter WIC Re-attendance DVT information leaflet

23 Appendix 4 Two-Level WELLS DVT score Patient s Details Surname Date of Birth First names Address Telephone number ID Number GP Contact number GP Address NB.** If patient has only one leg, practioners need to score as +1 in these areas Clinical Risk Stratification Clinical Feature Points Patient Score Active cancer (treatment on-going, within 6 months, or palliative) Paralysis, paresis or recent plaster immobilisation of the lower extremities. Recently bedridden for 3 days or more or major surgery within 12 weeks requiring general or regional anesthesia. Localised tenderness along the distribution of the deep venous system. Entire leg swollen. 1 Calf swelling at least 3 cm larger than asymptomatic side. ** 1 Pitting oedema confined to the symptomatic leg. ** 1 Collateral superficial veins (non-varicose) 1 Previously documented DVT An alternative diagnosis is at least as likely as DVT. 2 Clinical probability simplified score DVT likely 2 points or more DVT unlikely 1 point or less Please Note: Alternate diagnosis is at least as likely: e.g. Ruptured Baker s cyst, superficial thrombophlebitis, cellulitis, chronic venous insufficiency or calf injury. Wells Score (2003) (two level) In 2003 a further component, previously documented DVT, was added to the original Wells Score. Additionally, the duration of risk after surgery was increased from 4 weeks to 12 weeks2. This gives a possible score range of 2 to 9. This version reduced the number of risk categories from three to two: likely (2 points or more) and unlikely (less than 2 points). 23

24 Appendix 5 Standard operating procedure undertaking D-Dimer Standard operating procedure for undertaking a D-Dimer within LCH Walk in centre SOP number: Version Number: 1 Effective Date: 11/06/2017 Review Date: June 2018 Author: Liz Norris, Clinical Nurse Manager and Margaret Carran, Nurse Clinician Authorisation: Name/Position: Signature: Date: Purpose and Objective: 1. To support clinical staff working within Liverpool Community Health (LCH) Walk in Centres in undertaking a d-dimer blood test when a patient presents with suspected DVT using the Roche Cobas H232 machine. 2. To ensure that the staffs undertaking a D-Dimer follow the correct procedure and are trained appropriately. Introduction A D Dimer is undertaken as part of the assessment and Management of patients presenting within Liverpool community Health (LCH) Walk in centres with suspected deep venous thrombosis (DVT) The following documentation include the training, assessment and processes used for the diagnosis treatment and management of patients presenting with suspected DVT and should be read in conjunction with the process outlined below. Policies/WICs/Deep_Vein_Thrombosis.pdf Procedures/PGDs/WIC/035%20Dalteparin%20for%20Management%20of%2 0DVT%20PGD%20V4%20extended%20until%2030th%20June% pdf 24

25 Procedure:- patient presenting following booking in at reception Responsibility Triage 2 Nurse Practitioner Triage 2 nurse Triage 2 nurse Individual Nurse practitioner in triage 2 to use Personal identification swipe card Triage 2nurse Triage 2 nurse Triage 2 nurse Nurse practitioner Triage 2 Activity Identifies the patient suspected of having a DVT from computer system. The patient is called into Triage room 2. Patient details checked Blood is obtained from patient Collected in orange heparinised tube This is the only sample that is used in the Roche Cobas H232 machine The wording on the bottle is Li-Heparin LH/2.6 ml Write patient details onto the bottle A Roche pipette is used to draw sample from the The Li-Heparin orange tube up to the blue line POCT bar code identification card is swiped onto the Roche Cobas machine Machine is activated The Patients NHS or computer system number is entered, when indicated by the machine the D-Dimer strip is inserted. Add patient details onto paper record. When the machine indicates, the Blood from the pipette is applied onto the test strip. Test takes 8-12 minutes Continue with patient triage. Undertakes B/P pulse.respiratory rate and document the results in the patient s notes Brief history entered in to triage Applet. If department quite patient can stay with nurse for the assessment to be fully completed. If department busy the Patient is sent back to the waiting area. When the D Dimer result is ready enter result into the patients computer notes and onto the paper records if the same nurse is undertaking all the sampling they do not need to sign out of the Cobas machine If different nurse is undertaking next patient sampling, they must ensure that the previous 25

26 Nurse practitioner nurse has signed out. This is to avoid the possibility of using their swipe when the machine is already activated. Thus registering their own details where the patients, details are entered If the patient was returned to the waiting area following a D Dimer and triage assessment Follow process of calling the patient into the consultation room. Undertake a full assessment and documentation Act on the results see supporting documentation above Training All nurses undertaking this procedure will have completed the in house training on DVT s. Reviewed the VTE/DVT policy on the trust intranet Undertaken training in both quality control and patient testing using the Cobas H 232 within the area of diagnostic in which they practice Be competent in undertaking assessment of patient including calculating the WELL Score 26

27 Appendix 6. Ultrasound Referral Pathway Patient referred for ultrasound at RLBUHT by Walk-In Centre staff member Discuss any anomalies with GP as required Confirm date and time of ultrasound with department on Appointment available to patient on the same day Appointment available on the next day or over a weekend/ Bank Holiday Patient provided with an appointment time and all relevant documentation If ultrasound is not available until next day, at the weekend or Bank Holiday: Negative ultrasound Positive ultrasound Patient advised to attend next available appointment and commenced on treatment as per PGD number 35 Patient will be managed according to the NICE guidelines/ RLBUHT DVT protocol and instructed to contact GP Patient will attend AMU for follow up Patient to return to LWIC daily for administration of dalteparin via PGD number 35 Patient given advice and information leaflet with all contact numbers. If able, the patient will be provided with the date and time of their ultrasound appointment 27

28 Appendix 7 Liverpool Walk-In Centres DVT Ultrasound Request Form Liverpool Walk-In Centre State Site: Surname: Address: Postcode: Telephone: GP: Forename: DOB: Marital Status: Address: Telephone: Postcode: Referral Details: Procedure: Ultrasound Lower Leg Left Right Diagnosis, History, Relevant Medication and Previous Surgery: Referrers Details: Name: Contact Number: Wells score D dimer result 28

29 Appendix.8 Ultrasound Patient Information Referral to Ultrasound Department Thank you for attending. Walk-In Centre today at the request of your GP. Following investigations it is necessary to refer you to the Ultrasound Department at the: Royal Liverpool and Broadgreen University Hospital, Prescott Street, Liverpool L7 8XP Telephone number: The Ultrasound Department is situated off the main corridor. Please ensure that you have a copy of your documents, which will be contained in a yellow file and given to you by a Nurse Practitioner. These are to be taken to the Ultrasound Department and handed in to the Radiographer. If you have any further queries then please do not hesitate to contact this Walk-In Centre on and ask to speak to a Nurse Practitioner. 29

30 Appendix 9 DVT referral checklist Please tick completed - and fax the following 1. Referral form and 2. Wells score sheet = fax to DVT ultrasound request form Patient details Referral details Diagnosis history Leg L/R D-Dimer result Signature on bottom of form 2. Wells sheet Completed two level wells score Wells scoring list Action All details fully filled in State history of presenting complaint With relevant medication Which leg? Only one leg to be scanned In referral details Legible Name of patient and date on top of form DO NOT take from GP notes Redo the wells Taking into account -2 for alternative diagnosis State wells score at the bottom of the form Completed Please include the following in the envelope and give to the patient Action Completed Patient notes Patient assessment noted Printed From EMIS DVT Ultrasound request form and wells score GP notes Referral to ultrasound department instructions Write telephone number on the envelope and department to visit i.e. ultrasound Failure to complete all forms as requested will result in patient not receiving an ultrasound Completed audit form For all patients who present and have a DVT assessment outcome and presentation irrelevant Complete and leave for Reception supervisor 30

31 Appendix 10 NICE Algorithm for DVT 31

32 Appendix 11 LBGUHT AMU outpatient management and algorithm for DVT 32