A1. All surgical VTE prevention guidelines are included in the trust policy attached.

Response sent by email 19 December 2016 St Helier Hospital Wrythe Lane Carshalton Surrey SM5 1AA Tel: 020 8296 2000 Direct dial tel: 020 8296 4992 Re: Freedom of Information request - Ref: FOI 3736 Thank you for your recent request for information under the Freedom of Information (FOI) Act. Set out below is your original request followed by the Trust's response. This is a request under the Freedom of Information Act. Q1. I request that a copy of the following documents be provided to me: Trust Guidelines for Venous Thromboembolism (VTE) Prophylaxis in Surgical Patients. I would like you to include all surgical specialities at your trust, and specific guidelines you have for extended VTE prophylaxis in patients undergoing surgical procedures. A1. All surgical VTE prevention guidelines are included in the trust policy attached. Q2. In addition, I would like to know the approximate number of Colorectal resections performed at your trust in each year. A2. Please see table below: Year No. of Colorectal resections 2013-14 207 2014-15 188 2015-16 204 If you have any queries about this letter, please contact the Freedom of Information office. Please remember to quote the reference number above in any future communications. If you are unhappy with the way in which your Freedom of Information request has been handled and wish to raise any concerns, please contact Meg Stevens, Head of Governance, at the address above or by email (meg.stevens@esth.nhs.uk). Should you still be dissatisfied with the outcome, you are entitled to contact the Information Commissioner at: Information Commissioner s Office (ICO), Wycliffe House, Water Lane, Wilmslow, Cheshire SK9 5AF. Yours sincerely Great care to every patient, every day Patient Advice and Liaison Service (PALS) 020 8296 2508 Main Switchboard 020 8296 2000 Chairman Laurence Newman Chief Executive Daniel Elkeles

Teresa O Brien Freedom of Information Manager Corporate Affairs Epsom and St Helier University Hospitals NHS Trust T: 020 8296 4992 E: teresa.obrien@esth.nhs.uk W: www.epsom-sthelier.nhs.uk/ Great care to every patient, every day Patient Advice and Liaison Service (PALS) 020 8296 2508 Main Switchboard 020 8296 2000 Chairman Laurence Newman Chief Executive Daniel Elkeles

Policy for the Prevention of Venous Thromboembolism in Adult Patients Admitted to Hospital Version: Version 3 Ratified by: Clinical Governance Committee Date ratified: 15 May 2015 Name of originator/policy author: Stella Appiahcubi, Consultant Haematologist Name of responsible Trust Executive Committee committee/individual: Date issued: V1.5 July 2011 V 3 May 2014 Review date: May 2016 Target audience: Registered Nurses and Doctors AMENDMENTS (No more than three per policy version) DATE Change of author 15 May 2015 1

Document Title: Prevention of Venous Thromboembolism Error! Bookmark not defined. 1 INTRODUCTION... 4 2 BACKGROUND... 4 3 AIM, PURPOSE AND SCOPE... 4 4 HOSPITAL THROMBOSIS COMMITTEE... 5 5 PROCESS FOR IDENTIFYING PATIENTS AT RISK OF VTE... 5 5.1 RISK ASSESSMENT OF VTE AND BLEEDING... 5 5.2 DAY SURGERY UNITS... 5 5.3 ELECTIVE ORTHOPAEDIC CENTRE (EOC)... 5 5.4 OBSTETRIC PATIENTS... 5 5.5 LOW RISK COHORTS... 6 5.6 LOWER LIMB INJURY OUTPATIENTS... 7 6 PROPHYLACTIC TREATMENT FOR PATIENTS AT HIGH RISK OF VTE... 7 6.1 GENERAL MEASURES ALL PATIENTS... 7 6.2 GENERAL MEASURES FOR ELECTIVE SURGERY PATIENTS... 7 6.3 PALLIATIVE CARE PATIENTS... 8 7 MECHANICAL THROMBOPROPHYLAXIS... 8 7.1 ANTI-EMBOLISM STOCKINGS... 8 7.2 SEQUENTIAL COMPRESSION DEVICES... 9 8 PHARMACOLOGICAL THROMBOPROPHYLAXIS... 9 9 PATIENT INFORMATION... 10 9.1 ON ADMISSION, PATIENTS SHOULD BE GIVEN THE TRUST INFORMATION LEAFLET PREVENTING VENOUS THROMBOEMBOLISM: A GUIDE FOR PATIENTS AT THE TIME OF INITIAL VTE RISK ASSESSMENT. WARD SISTERS ARE RESPONSIBLE FOR ORDERING COPIES OF THIS LEAFLET FROM THE MEDICAL ILLUSTRATION DEPARTMENT.... 10 9.2 ALL PATIENTS SHOULD BE GIVEN VERBAL INFORMATION ON THE FOLLOWING:... 10 10 PROCEDURE TO BE FOLLOWED IF VENOUS THROMBOEMBOLISM IS SUSPECTED... 11 11 MANAGEMENT OF THE PATIENT ONCE A POSITIVE DIAGNOSIS OF VTE HAS BEEN MADE... 11 12 IDENTIFICATION AND INVESTIGATION OF CASES OF HOSPITAL ASSOCIATED THROMBOSIS... 11 13 DISCHARGE FROM HOSPITAL... 12 14 IMPLEMENTATION... 13 14.1 DISSEMINATION OF POLICY... 13 14.2 EDUCATION AND TRAINING... 14 14.3 MONITORING ARRANGEMENTS... 14 14.4 REVIEW POLICY... 14 14.5 EQUALITY IMPACT ASSESSMENT... 14 15 REFERENCES... 14 15.1 ASSOCIATED TRUST DOCUMENTS... 14 2

15.2 SUPPORTING REFERENCES & BIBLIOGRAPHY... 15 16 APPENDICES THE FOLLOWING APPENDICES HAVE BEEN ATTACHED ON THE FOLLOWING PAGES TO SUPPORT THIS DOCUMENT:... 15 APPENDIX 1: RISK ASSESSMENT FOR VTE AND THROMBOPROPHYLAXIS GUIDELINE... 16 APPENDIX 2: RISK ASSESSMENT FOR VTE AND THROMBOPROPHYLAXIS GUIDELINE FOR LOWER LIMB TRAUMA... 19 APPENDIX 3: CONTRA-INDICATIONS TO ANTI - EMBOLIC STOCKINGS.... 22 APPENDIX 4: PATIENT CARE PATHWAY FOR USE OF ANTI - EMBOLIC STOCKINGS. 23 APPENDIX 5: ANTI - EMBOLIC STOCKINGS INTEGRATED CARE PATHWAY... 25 APPENDIX 6: ELECTIVE ORTHOPAEDIC CENTRE (EOC) RIVAROXABAN PROTOCOL FOR VTE.... 26 APPENDIX 7: RCA PROCESS MAP... 27 APPENDIX 8: ARRANGEMENTS FOR MONITORING COMPLIANCE WITH THIS POLICY... 28 APPENDIX 9: EQUALITY IMPACT ASSESSMENT FORM... 30 IN ORDER TO CARRY OUT AN EFFECTIVE IMPACT ASSESSMENT IT IS IMPORTANT TO EXAMINE ALL AVAILABLE DATA AND RESEARCH SO THAT ANY ADVERSE IMPACT ON DISABILITY CAN BE PROPERLY ASSESSED.... 30 3

1 Introduction 1.1 This policy sets out the framework for the prevention and management of venous thromboembolism (VTE) in adult patients admitted to hospital. It is based on the recommendations NICE has made to the NHS in Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital (NICE clinical guideline 92). 1.2 The policy does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. 2 Background 2.1 Before the publication of NICE clinical guideline 92 it was estimated that 25,000 people in the UK died from preventable hospital-acquired venous thromboembolism every year. 2.2 VTE is a condition in which a blood clot (a thrombus) is formed in a vein. It most commonly occurs in the deep veins of the legs; this is called deep vein thrombosis (DVT). The thrombus may dislodge from its site of origin to travel in the blood a phenomenon called embolism. 2.3 VTE encompasses a range of clinical presentations. Venous thromboembolism is often asymptomatic; less frequently it causes pain and swelling in the leg. Part or all of the thrombus can come free and travel to the lung as a potentially fatal pulmonary embolism (PE). 2.4 Symptomatic venous thrombosis carries a considerable burden of morbidity, sometimes over a long term because of chronic venous insufficiency. This in turn can cause venous ulceration and development of a post-thrombotic limb (characterised by chronic pain, swelling and skin changes). 2.5 The risk of developing VTE depends on the condition and/or procedure for which the patient is admitted and on any predisposing risk factors (such as age, obesity and concomitant conditions). 3 Aim, Purpose and Scope 3.1 This policy is intended to reduce morbidity and mortality from VTE in adult (aged 18 years and over) patients admitted to hospital by giving guidance on best practice in VTE risk assessment, thromboprophylaxis and the management of VTE. It is applicable Trust wide and relevant to all staff groups that have a duty of care to adult in-patients. 3.2 For obstetric patients please refer to the Trust Guidelines for prophylaxis and treatment of thromboembolism during pregnancy ESH/MAT/CNST/ST3HRC/00809. 4

4 Hospital Thrombosis Committee 4.1 A Hospital Thrombosis Committee should be in place as recommended by the Department of Health, comprising representatives from Medicine, Surgery, Obstetrics, Orthopaedics, Pharmacy and Haematology. The remit of the Thrombosis Committee is to: Promote best practice through local policies based on national guidelines. Lead multiprofessional audit of the use of thromboprophylaxis. Promote education and training. Report quarterly to the Clinical Governance Committee. 5 Process for identifying patients at risk of VTE 5.1 Risk Assessment of VTE and Bleeding All adult patients aged 18 years and above (except those day cases who belong to one of the low risk cohorts see below) admitted to hospital either as in-patients or as day case procedures should undergo a full venous thromboembolism risk assessment using the electronic version of the Trust Risk assessment for venous thromboembolism (VTE) on icm Clinical Manager (Appendix 1). Instructions for using the electronic form are given on the Trust intranet (Clinical Systems/Clinical Manager (icm) Training/VTE Risk Assessment User Guide). The risk assessment can be completed on paper forms available on the G drive in G\All staff\downtime forms if icm is unavailable. The risk assessment should be performed by the admitting doctor within 6 hrs of admission as an integral part of the clerking-in process. A new assessment should be performed and documented on icm Clinical Manager whenever the clinical situation changes. 5.2 Day Surgery Units Day surgery units may use paper assessment forms if no access to icm is available. If a paper assessment is completed this will need to be recorded as such on icm, by administrative or nursing staff. The electronic version of the assessment is preferred. 5.3 Elective Orthopaedic Centre (EOC) All EOC patients are to be risk assessed for VTE and bleeding on the Bluespier computer programme. Initial assessments are completed in the pre-operative assessment clinic. Patients are then to be assessed post surgery in the Postoperative Acute Care Unit (PACU). 5.4 Obstetric Patients All pregnant patients should be risk assessed for risk of VTE and bleeding at booking, within 6 hours of any hospital admission and after delivery. This should be completed on icm, using the electronic maternity assessment form. Instructions for using the electronic form are 5

given on the Trust intranet (Clinical Systems/Clinical Manager (icm) Training/VTE Maternity Risk Assessment User Guide). 5.5 Low Risk Cohorts The following patients are considered as a group to be at low risk of VTE and therefore do not need a VTE risk assessment on admission: Day Cases Haemodialysis Endoscopy Chemotherapy (and related treatments e.g. bisphosphonates) Blood transfusion Iron infusion Immunoglobulin infusion Ophthalmological procedures with local anaesthetic/regional/sedation and not full general anaesthetic Non-cancer ENT surgery lasting less than 90 minutes with local anaesthetic/regional/sedation and not full general anaesthetic Non-cancer plastic surgery lasting less than 90 minutes with local anaesthetic/regional/ sedation and not full general anaesthetic Non-cancer dental and maxillo-facial surgery lasting less than 90 minutes with local anaesthetic/regional/sedation and not full general anaesthetic Other similar minor procedures lasting less than 90 minutes with local anaesthetic/regional/sedation and not full general anaesthetic to be signed off by the medical director Acute Admissions Patients seen in A&E observation wards or clinical assessment units who are admitted for less than 12 hours Patients seen in Maternity Units who are admitted for less than 4 hours 6

5.6 Lower Limb Injury Outpatients Outpatients seen in A&E or Fracture Clinic with lower limb injury may be at risk of VTE. A risk assessment should be carried out by the A&E extended nurse practitioner or doctor using a paper form of the Trust Venous Thromboembolism Risk Assessment and Thromboprophylaxis Guideline for Lower Limb Trauma (Appendix 2). The completed form should be photocopied and kept with the patient s other A&E documents so that it is available when the patient is seen in the Fracture Clinic. 6 Prophylactic treatment for patients at high risk of VTE Patients identified by the risk assessment as being at high risk of VTE should have prophylactic treatment prescribed according to the Thromboprophylaxis Guideline (Appendix 1). The icm VTE Risk Assessment will automatically provide the doctor with instructions for appropriate treatment according to the patient s risk. For details of prophylactic treatment see sections 7 and 8. 6.1 General Measures All Patients Do not allow patients to become dehydrated unless clinically indicated. Encourage patients to mobilise as soon as possible. Do not regard aspirin or other antiplatelet agents as adequate prophylaxis for VTE. Consider offering temporary inferior vena caval filters to patients who are at very high risk of VTE (such as patients with a recent VTE event or active malignancy) if mechanical and pharmacological VTE prophylaxis contraindicated. 6.2 General Measures for Elective Surgery Patients 6.2.1 Oral contraceptives and HRT Advise women to consider stopping oestrogen-containing contraceptives or HRT 4 weeks before surgery. 6.2.2 Pre-existing antiplatelet therapy Assess risks and benefits of stopping pre-existing antiplatelet therapy 1 week before surgery. Consider involving the multidisciplinary team in assessment. 6.2.3 Anaesthesia Consider regional anaesthesia, in addition to other methods of VTE prophylaxis, as it carries a lower risk of VTE than general anaesthesia. Take into account patient preference, suitability for regional anaesthesia and any other planned method of VTE prophylaxis. If regional anaesthesia is used, plan the timing of pharmacological prophylaxis to minimise risk of epidural haematoma. If antiplatelet or anticoagulant agents are being used or their use is planned, refer to the Trust Epidural Analgesia Policy, Procedures and Guidelines ESH/POL/10308/CLI for guidance about safety and timing of these agents in relation to regional anaesthesia. 7

Do not routinely offer pharmacological or mechanical VTE prophylaxis to patients having surgery with local anaesthesia by local infiltration with no limitation of mobility. 6.3 Palliative Care Patients Consider offering pharmacological VTE prophylaxis to patients in palliative care who have potentially reversible acute pathology. Take into account potential risks and benefits and the views of the patient and their family and/or carers. Do not routinely offer pharmacological or mechanical VTE prophylaxis to patients admitted for terminal care or those commenced on an end-of-life care pathway. Review decisions about VTE prophylaxis for patients in palliative care daily, taking into account the views of the patient, their family and/or carers and the multidisciplinary team. 7 Mechanical Thromboprophylaxis All surgical patients assessed to be high risk for VTE should be fitted with anti-embolism (TED) stockings and/or sequential compression devices unless these are contraindicated (Appendix 1). Medical patients assessed to be high risk for VTE but with significant bleeding risk should be fitted with anti-embolism (TED) stockings and/or sequential compression devices unless these are contraindicated (Appendix 1). Do not use anti-embolism stockings in patients admitted with stroke; consider thigh-length sequential compression devices in stroke patients instead. 7.1 Anti-embolism Stockings A registered nurse should assess the patient s suitability for mechanical prophylaxis (Appendix 3). If mechanical prophylaxis is contraindicated this should be documented and the medical/surgical team should be informed. Do not offer anti-embolism stockings to patients with: o suspected or proven arterial disease o peripheral arterial bypass grafting o peripheral neuropathy or other cause of sensory impairment o local conditions in which stockings may cause damage, such as fragile tissue paper skin, dermatitis, gangrene or recent skin graft o known allergy to material of manufacture o cardiac failure o severe leg oedema or pulmonary oedema from congestive cardiac failure o unusual leg size or shape o major limb deformity preventing correct fit o Use caution and clinical judgement when applying antiembolism stockings over venous ulcers or wounds 8

Measure legs and use correct stocking size. Staff who fit stockings should be trained in their use and should show patients how to use them. (Appendix 4, Care Pathway) If oedema or postoperative swelling develops, ensure legs are remeasured and stockings refitted. If arterial disease suspected, seek expert opinion before fitting stockings. Use stockings that provide graduated compression and produce a calf pressure of 14-15 mmhg. Encourage patients to wear the stockings day and night from admission until they no longer have significantly reduced mobility. Remove stockings daily for hygiene purposes and to inspect skin condition. 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. If suitable, offer intermittent pneumatic compression or foot impulse devices as alternative. (Appendix 5). Show patients how to use anti-embolism stockings correctly and ensure they understand that this will reduce their risk of developing VTE. Monitor use of anti-embolism stockings and offer assistance if they are not being worn correctly. Ensure patients who require continuing the stockings on discharge from hospital are able to remove and replace them, or have someone available who will be able to do this for them. 7.2 Sequential Compression Devices Sequential compression/intermittent pneumatic compression devices may be used as alternatives or in addition to anti-embolic stockings. This may be used for stroke patients Do not offer these devices to patients with a known allergy to the material of manufacture and also avoid in patients with suspected or confirmed DVT. Encourage patients on the ward who have these devices to use them for as much of the time as is possible and practical, both when in bed and sitting in a chair. 8 Pharmacological Thromboprophylaxis 8.1 All patients should be assessed for risk of bleeding prior to offering pharmacological VTE prophylaxis. Pharmacological VTE prophylaxis should not be prescribed in patients with any risk factors for bleeding, unless the risk of VTE outweighs the risk of bleeding. 9

8.2 All surgical and medical patients assessed to be at high risk for VTE with low risk of bleeding should be prescribed pharmacological prophylaxis with dalteparin. Elective Orthopaedic Centre (EOC) patients may be prescribed rivaroxaban as an alternative to dalteparin (Appendix 6). EOC patients should receive dalteparin whilst in hospital and for 30 days post discharge; rivaroxaban for 30 days post discharge may be used as an alternative for EOC patients with previous history of VTE who are not on long term warfarin. 8.3 The full blood count and renal function should be checked prior to pharmacological prophylaxis. Dalteparin and unfractionated heparin are contraindicated if the platelet count is less than 75 x 109/l. Unfractionated heparin rather than dalteparin should be used for patients with egfr <30mls/min. The platelet count should be checked at least every few days in all inpatients on unfractionated heparin. If the platelet count falls by >30% of baseline values, the possibility of heparin-induced thrombocytopenia should be considered and haematology advice sought. 8.4 Obese patients need careful consideration with regards to pharmacological thromboprophylaxis. Please consult the haematology or VTE teams for advice. Monitoring of anti-xa levels may be used to guide dosing. This should be discussed with the coagulation laboratory and blood samples should be taken into citrate 4 hours following the last dose of dalteparin. Prophylactic anti-xa levels should be within the range 0.2-0.4 anti-xa units/ml. The dosing guide in Table 1. is based on the limited evidence available. Table 1. Guide to prophylactic dose of dalteparin according to body weight Weight <50kg 50-99kg 100-150kg >150kg Dalteparin 2500 units daily 5000 units daily 5000 units BD 7500 BD 9 Patient Information 9.1 On admission, patients should be given the Trust information leaflet Preventing venous thromboembolism: a guide for patients at the time of initial VTE risk assessment. Ward sisters are responsible for ordering copies of this leaflet from the Medical Illustration Department. 9.2 All patients should be given verbal information on the following: The risks and possible consequences of developing a blood clot whilst in hospital The signs and symptoms of DVT and PE. The correct use of prophylaxis in hospital and at home. The importance of seeking medical attention if deep vein thrombosis, pulmonary embolism is suspected after discharge from hospital. 10

10 Procedure to be followed if venous thromboembolism is suspected If an inpatient already receiving thromboprophylaxis is suspected to have a DVT or PE they should be treated with therapeutic dose dalteparin or unfractionated heparin and the appropriate radiological investigations should be arranged (either duplex Doppler scan of the lower limb or CT pulmonary angiogram or V/Q scan). Refer to the Common Medical Emergencies Guidelines on the Medicines Resource site of the intranet. Suspected cases of hospital associated thrombosis (see 12 below) should be reported to the VTE nurses. 11 Management of the patient once a positive diagnosis of VTE has been made If a DVT or PE is confirmed the patient should be loaded with warfarin (unless contraindicated). Refer to section 6.0 in Anticoagulation in adult patients: clinical protocol for secondary care. 12 Identification and Investigation of Cases of Hospital Associated Thrombosis A hospital associated thrombosis (HAT), either DVT or PE, is defined as occurring during a hospital admission (noting that the admission may have been as a day case) or within 90 days following discharge from hospital. The VTE nurses should be informed of all suspected cases of HAT; they will also identify cases via the Anticoagulant Clinic, Bereavement Office and Radiology. The VTE nurses will complete an incident form for each HAT case and send this to Clinical Risk who will enter the case on Datix. Clinical Risk will contact the head of nursing in the relevant directorate to request that a root cause analysis (RCA) is carried out and is returned within 20 working days in draft form to the VTE Clinical Lead. The VTE Clinical Lead is responsible for reviewing and signing off the RCA before returning it within 10 working days to the directorate head of nursing and Clinical Risk so that it can be closed on Datix and reviewed in the directorate governance meeting. The directorate governance committee must ensure that any actions are completed and any actions/recommendations from the RCA will be collated by the VTE nurses. Actions/recommendations from all RCAs will be reported quarterly to the Thrombosis Committee and twice a year to the Trust Clinical Governance Committee and the VTE nurses will be responsible for communicating lessons learnt from the RCAs to Trust clinical staff. (Appendix 8: VTE 2013/14 CQUIN RCA Process Map). If the HAT is considered to have been caused by admission to another hospital trust, the VTE nurses will be responsible for informing that trust so that root cause analysis can still be performed. 11

13 Discharge from Hospital 13.1 The nurse responsible for discharging the patient should check that they have been given the Trust information leaflet Preventing venous thromboembolism: a guide for patients and verbal information on VTE. 13.2 Patients having orthopaedic surgery for hip fracture, hip replacement or knee replacement (Appendix 1) should have their VTE prophylaxis continued for 30 days post discharge. EOC patients should receive dalteparin whilst in hospital and for 30 days post discharge; rivaroxaban for 30 days post discharge may be used as an alternative for EOC patients with previous history of VTE who are not on long term warfarin. 13.3 Patients having major cancer surgery in the abdomen or pelvis should have their VTE prophylaxis continued for 28 days after surgery. 12

13.4 Patients considered to be at very high risk on discharge for reasons other than the above should also be considered for extended thromboprophylaxis. The discharging consultant is responsible for deciding on the duration of treatment. 13.5 Patients receiving extended pharmacological thromboprophylaxis should have the full supply of dalteparin or unfractionated heparin supplied from the trust pharmacy and should be taught how to self-inject by the ward nursing staff. If the patient is unable to self-inject, arrangements must be made for the dalteparin or unfractionated heparin to be administered by a relative/carer or the District Nurses. If it is likely that thromboprophylaxis may continue for longer than 30 days post discharge, please refer the patient to the anticoagulant clinic who will supervise ongoing prescriptions of dalteparin. 13.6 Notify the patients GP if the patient is to be discharged home on pharmacological prophylaxis. 14 Implementation The Trust will demonstrate that this document has been issued, read and implemented as follows: 14.1 Dissemination of Policy A variety of dissemination methods are in place to make sure that all staff are aware of, have access to and comply with the Trust s Core Policies. These are: Summary list of all new documents published in the Trust Weekly News including a brief description of the document and it s intended core audience. Via clinical directors for cascade to all consultants. Via the Chief Pharmacist for cascade to pharmacy staff. Via the Deputy Director of Nursing for cascade to directorate Heads of Nursing, ward/department managers and nursing staff. This guidance will be held on the Document Management System on the Trust intranet which all staff are encouraged to use to gain access to controlled documents. Staff should always consult the intranet for the latest version of the document. This document may be printed and filed in ward / departmental areas. However where documents are printed and filed in this way, managers of those areas are responsible for ensuring that at all times, the up to date version only is on file. 13

14.2 Education and Training 14.2.1 Clinical directors and heads of nursing are responsible for ensuring that relevant staff members are familiar with the content of this document. 14.2.2 The prevention of venous thromboembolism is a NHSLA risk management standard (standard 4 - criterion 8). All clinical staff will receive induction training delivered by the Nurses. Mandatory training will be given annually to all clinical staff as detailed in the Training Needs Analysis and included in the Statutory and Mandatory Policy. 14.2.3 An E- Learning programme on venous thromboembolism is available at www.e-vte.org. This has been designed & provided by the Chief Medical Officer s VTE Implementation Working Group in Partnership with e-learning for Healthcare. 14.3 Monitoring Arrangements 14.3.1 Monitoring of compliance will be by clinical, nursing and pharmacy staff. Refer to Appendix 7 for arrangements for monitoring compliance. 14.4 Review Policy The policy will be reviewed in March 2015 or following the production of new evidence or National Guidelines. 14.5 Equality Impact Assessment 14.5.1 In order to comply with guidelines regarding carrying out an impact assessment regarding all Trust polices, refer to Appendix 8 for the Equality Impact Assessment Form. 15 References 15.1 Associated Trust Documents Guideline for prophylaxis and treatment of thromboembolism during pregnancy ESH/MAT/CNST/ST3HRC/00809 Anticoagulation in adult patients: clinical protocol for secondary care Epidural analgesia policy, procedures and guidelines ESH/POL/10308/CLI Common Medical Emergencies Guidelines 14

15.2 Supporting References & Bibliography Website of National VTE Exemplar Network http://www.vteprevention-nhsengland.org.uk/cgi-bin/kingsthrombosis/index.pl National Institute for Health and Clinical Excellence. Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. Clinical Guideline 92, January 2010. Available at: http://publications.nice.org.uk/venous-thromboembolism-reducing-the-riskcg92 National Institute for Health and Clinical Excellence. Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing. Clinical Guideline 144, June 2012. Available at: http://guidance.nice.org.uk/cg144 Watson H, Davidson S, Keeling D (2012). Guidelines on the diagnosis and management of heparin-induced thrombocytopenia: second edition. British Journal of Haematology, 2012 Volume 159, issue 5 pages 528-540 GEMNet guideline: Thromboprophylaxis in ambulatory care trauma patients requiring temporary limb immobilisation. October 2012 http://www.collegemergencymed.ac.uk/shop-floor/clinical%20guidelines 16 Appendices The following Appendices have been attached on the following pages to support this document: Appendix 1 Risk assessment for VTE and Thromboprophylaxis Guideline. Appendix 2 Venous Thromboembolism Risk Assessment and Thromboprophylaxis Guideline for Lower Limb Trauma Appendix 3 Contra - Indications to Anti Embolic Stockings. Appendix 4 Patient Care Pathway for the use of Anti Embolic Stockings Appendix 5 Anti Embolic Stockings Integrated Pathway. Appendix 6 Elective Orthopaedic Centre (EOC) Protocol for the introduction of VTE. Appendix 7 VTE 2013/14 CQUIN RCA Process Map Appendix 8 Arrangements for Monitoring Compliance with this Policy. 15

Appendix 1: Risk Assessment for VTE and Thromboprophylaxis Guideline RISK ASSESSMENT FOR VENOUS THROMBOEMBOLISM (VTE) AND THROMBOPROPHYLAXIS GUIDELINE All patients should be risk assessed within 6 hours of admission to hospital using the electronic risk assessment form within Clinical Manager (icm). 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 have further risk assessment. Pregnant patients should be referred to the Maternal Medicine Midwives or the Labour ward registrar via switchboard. STEP TWO Review the patient-related factors shown on the assessment form against thrombosis risk, ticking each box that applies (more than one box can be ticked). Clinicians may consider additional risk in individual patients. Any tick for thrombosis risk should prompt thromboprophylaxis according to the Trust s thromboprophylaxis guidelines. If no box is ticked for thrombosis risk, or if they are a medical patient with normal mobility the patient is at low risk of VTE (i.e. does not need thromboprophylaxis). 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. STEP FOUR Decide if patient is; High risk of VTE with Low Bleeding Risk High risk of VTE with Significant Bleeding Risk Low risk of VTE Prescribe thromboprophylaxis (pharmacological +/- mechanical) in accordance with Trust thromboprophylaxis guidelines. Ensure the patient has received information leaflet regarding VTE risk and thromboprophylaxis. Ensure the patient is reassessed within 24 hours and whenever clinical situation changes using the Risk Assessment Form within the Clinical Manager (icm). Adapted from Department of Health, VTE risk assessment template, Department of Health: London, March 2010. Hospital no: Surname: First name: DOB: 16

RISK ASSESSMENT FOR VENOUS THROMBOEMBOLISM (VTE) Mobility all patients (tick one box) Medical patients expected to have ongoing reduced Surgical Patients mobility relative to normal state Assess for thrombosis and bleeding risk below Tick Tick Tick Medical patients NOT expected to have significantly reduced mobility relative to normal state Assessment now complete Thrombosis risk Patient related Tick Admission related Tick Active cancer or cancer treatment Significantly reduced mobility for 3 days or more Age >60 Hip or knee replacement Dehydration Hip fracture Known thrombophilias Total anaesthetic + surgery time > 90 minutes Obesity (BMI>30kg/m 2 Surgery involving pelvis or lower limb with ) anaesthetic + surgery time > 60 minutes One or more significant medical comorbidities (eg heart disease; metabolic, endocrine or respiratory pathologies, acute infections, inflammatory conditions) Personal history/first degree relative with history of VTE Use of hormone replacement therapy Use of oestrogen-containg oral contraceptive therapy Varicose veins with phlebitis Pregnancy or <six weeks post partum (see NICE guideline for specific risk factors) Acute surgical admission with inflammatory or intra-abdominal condition Critical care admission Surgery with significant reduction in mobility Bleeding risk Patient related Tick Admission related Tick Active bleeding Neurosurgery, spinal surgery or eye surgery Acquired bleeding disorder (such as acute liver failure) Other procedure with high bleeding risk Concurrent use of anticoagulants known to Lumbar puncture/epidural/spinal anaesthesia increase risk of bleeding (such as warfarin with expected in the next 12 hours INR >2) Acute stroke Lumbar puncture/epidural/spinal anaesthesia within the previous 4 hours Platelets <75x10 9 /l, check on admission Uncontrolled hypertension (>230/120) Untreated inherited bleeding disorder (such as haemophilia and von Willebrand disease) Risk of VTE (tick box) High risk of VTE with low bleeding risk High risk of VTE with significant bleeding risk Low risk of VTE Preadmission assessment date: Name: Signed: Risk assessment must be confirmed on admission On admission, date/time: Name: Signed: THROMBOPROPHYLAXIS GUIDELINE 17

SURGICAL PATIENTS MEDICAL PATIENTS Risk of VTE Recommended Prophylaxis Recommended prophylaxis HIGH (with low risk of bleeding) Dalteparin 5000 units once daily s/c + TED stockings +/- Sequential compression device (SCD) + Early mobilisation Dalteparin 5000 units once daily s/c + Early mobilisation HIGH (with significant risk of bleeding) LOW TED stockings +/- Sequential compression device (SCD) + Early mobilisation Early mobilisation TED stockings +/- sequential compression device (SCD) + Early mobilisation (Do NOT use TED stockings in stroke patients) Early mobilisation NOTE. For Obstetric patients Please refer to Trust Guideline for thromboprophylaxis during pregnancy. CONTRAINDICATIONS: Dalteparin EGFR < 30 ml/min - use unfractionated heparin 5000 units BD s/c Active bleeding Thrombocytopenia (platelet count<50) Known bleeding disorder Previous Heparin Induced Thrombocytopenia or allergy to dalteparin On therapeutic anticoagulation Patient concerns regarding the use of animal products CONTRAINDICATIONS: TEDS/SCDs Severe peripheral vascular disease Severe dermatitis Leg oedema Leg deformity Peripheral neuropathy Recent skin graft Do not use SCDs in recent lower limb DVT (can use TEDS) Do not use TEDs in stroke patients Allergy to fabric Timing Epidural/ Spinal analgesia Duration Extremes of Body Weight Sequential compression device (SCD): Mechanical VTE prophylaxis should be offered on admission. Dalteparin should start 4-7 hours post op (providing haemostasis secured) and then at 6pm daily thereafter. In addition, dalteparin can be given the evening prior to surgery on consultant recommendations Placement or removal of catheter should be delayed for 12 hrs after administration of dalteparin and 8 hours after unfractionated heparin. Dalteparin should not be given sooner than 6 hrs after catheter removal Continue until mobility no longer significantly reduced. At least 10 days prophylaxis is recommended for all high risk orthopaedic patients. Extended prophylaxis (30 days post surgery) is recommended for elective hip replacement, elective knee replacement, hip fracture and other selected highrisk general surgery patients e.g. major cancer surgery of abdomen/pelvis Seek advice from Haematology if patient weighs <50kg or > 100kg. Consider in high-risk patients & those unable to receive Low Molecular Weight Heparin (LMWH) due to high bleeding risk 18

Appendix 2: Risk Assessment for VTE and Thromboprophylaxis Guideline for Lower Limb Trauma Venous Thromboembolism Risk Assessment and Thromboprophylaxis Guideline for Lower Limb Trauma To be completed by emergency nurse practitioner (ENP) or doctor for all patients over 16 years with: Isolated lower limb trauma, immobilised in lower limb cast/boot Above knee back slab/cricket pad splint and non-weight bearing Any form of lower limb immobilisation where the patient will be non-weight bearing PATIENT S NAME HOSPITAL NUMBER... DATE OF BIRTH CONSULTANT. RISK FACTOR TICK SCORE PATIENT FACTORS Age 50 years or above 1 Obese BMI 30 kg/m 2 (BMI = Weight in kg/height in metres 2 ) 2 CURRENT MEDICATION Hormone therapy (combined oral contraceptive pill, hormone replacement therapy, tamoxifen) MEDICAL HISTORY Past history of DVT or PE 3 Family history of DVT or PE in first degree relative (parents, 3 children, siblings) Varicose veins 1 Any serious medical condition (e.g. congestive cardiac failure, 1 chronic obstructive pulmonary disease, chronic kidney disease, inflammatory bowel disease, rheumatoid arthritis, intravenous drug use etc.) Major or abdominal surgery within last 6 weeks 2 Recent hospital admission with immobility ( within last 6 weeks 1 ) Active cancer 3 Pregnant or within 6 weeks of delivery 3 Complex lower limb surgery or pelvic fracture 3 Thrombophilia (e.g. Factor V Leiden, Protein C, Protein S or antithrombin deficiency) discuss with haematologist Haematological condition e.g. myeloproliferative disease discuss with haematologist for score TOTAL SCORE 2 3 ENP/Doctor SIGNATURE DATE PRINT NAME 19

SCORE RECOMMENDATION 0-2 Instruct patient to keep active, drink plenty of water and give them booklet 3 or Instruct patient to keep active, drink plenty of water and more give them booklet PLUS Consider dalteparin 5000 units once daily subcutaneous (s/c) pending orthopaedic review or full mobility (unless patient already on therapeutic anticoagulation) See overleaf for instructions regarding dalteparin FOR PATIENTS NEEDING DALTEPARIN (Score 3 or more): 1. Check FBC, U&E, LFTs, INR and APTTr in selected patients e.g. diabetes, chronic kidney disease, liver disease and patients on oral anticoagulation. 2. Check for contraindications to dalteparin: Estimated GFR less than 30ml/min prescribe unfractionated heparin 5000 units twice daily Active bleeding subcutaneous Thrombocytopenia (platelets < 50) Known bleeding disorder Previous Heparin Induced Thrombocytopenia or allergy to dalteparin On therapeutic anticoagulation Patient concerns regarding the use of animal products 3. If no contraindications: Prescribe dalteparin 5000 units once daily subcutaneous for 10 days (or to last until patient reviewed in Fracture Clinic) Dalteparin subcutaneous dose at extremes of weight: Body weight (kg) Prophylactic dalteparin dose (units) <50 50-100 101-150 >150 2500 units once daily 5000 units once daily 5000 units twice daily 7500 units twice daily Teach patient to self inject or arrange for district nurse Give patient Taking Care pack containing a sharps bin and patient information on dalteparin administration and sharps disposal Advise patient that dalteparin treatment will be reviewed in the Fracture Clinic For further information/advice, please contact: VTE Nurses on Bleep 059 (St Helier) or 060 (Epsom) 20

References GEMNet guideline: Thromboprophylaxis in ambulatory trauma patients requiring temporary limb immobilisation, October 2012. http://www.collemergencymed.ac.uk/shop-floor/clinical%20guidelines/ Website of National VTE Exemplar Network http://www.vteprevention-nhsengland.org.uk/cgi-bin/kingsthrombosis/index.pl Authors Dr Aziz Siddiqui, Consultant Accident and Emergency Medicine Agreed by Medicines Management Dr Katy Rice, Consultant Haematologist Committee August 2013 21

Appendix 3: Contra-Indications to Anti - Embolic Stockings. Insert patient sticker Hospital no: Surname: First name: DOB: Nursing staff must complete for ALL patients prescribed anti embolic stockings, and/or intermittent pneumatic devices/foot impulse devices and file in the patient s notes. If in doubt, it is essential that patient is assessed by the medical team before stockings/intermittent compression/foot impulse devices are given. Tick ALL relevant columns Patients Condition Peripheral vascular disease Peripheral neuropathy Cellulitis (initially patients will be unable to wear stockings until pain and inflammation is resolving.) Any local leg conditions with which the stockings would interfere e.g. dermatitis, gangrene, skin grafts, skin lesions, gout Leg oedema, pulmonary oedema from congestive cardiac failure (CCF) Extreme leg deformity Leg / foot ulceration Known allergies to contents of stockings Patient refuses to wear stockings (this refusal must be documented in notes) Ankle circumference >33cm Patient on noradrenaline (remove stockings) Patient given stockings/intermittent pneumatic device? No If not given for another reason, please state why: Signature of Assessor. Date/Time.... Designation.... 22

Appendix 4: Patient Care Pathway for use of Anti - Embolic Stockings. Insert patient sticker Hospital no: Surname: First name: DOB: Action Pre-Admission Patients should be provided with verbal and written information on the risk of blood clots in hospital. On Admission A venous thromboembolism risk assessment should be performed by the admitting doctor on every patient on admission. Check and remind the doctor that this should be done. Following the risk assessment, ascertain whether the patient should wear stockings, and/or intermittent pneumatic devices. Re-assess the patient as clinical condition changes. Identify if patient has any contraindications prior to application of stockings. Peripheral vascular disease Peripheral neuropathy Cellulitis Any local leg conditions with which the stockings would interfere e.g. dermatitis, gangrene, skin grafts, skin lesions, gout Leg oedema, pulmonary oedema from congestive cardiac failure (CCF) Extreme leg deformity Leg/foot ulceration Known allergies to contents of stockings Patient refuses to wear stockings (this refusal must be documented in notes) Ankle circumference >33cm Patient on noradrenaline NB: If any contra-indications in notes, complete and sign Contraindications to Anti-embolic Stockings form (Appendix 3) and refer to medical team. Inform the patient of the need to wear anti-embolic stockings and provide the information leaflet, plus advice re laundering. Measure the patient carefully in accordance with the manufacturer s instructions. Select the correct size for the patient according to the colour code. Document the ankle circumference and stocking size in the Stocking Pathway Plan All patients should be given clean stockings if they are to be in for longer than three days. Stockings should be sent home with relatives for laundering. Rationale To identify patients at risk of venous thromboembolic disease in order to ascertain appropriate management. To identify patients at risk of venous thromboembolic disease in order to ascertain appropriate management. Unless risk is categorised, prevention can be ineffective. Patient risk status may alter during their stay and current method of prevention may be ineffective. To reduce the risk of possible hazards associated with inappropriate application of stockings. Informing the patient, including written information, can improve patient compliance. Optimum therapeutic value is dependent upon well fitted hosiery. To make it easier for subsequent practitioners. Stockings should be changed every three days. 23

Apply stockings, check limb 30 minutes after application for any tissue redness/damage and tissue perfusion. Every Shift At the beginning of each nursing shift the patients legs should be checked to ensure that their hosiery is in place correctly. (ie no wrinkles) Every Day Stockings should be worn 23.5 hours a day. The stockings may remain off for a maximum of thirty minutes in a 24 hour period. Intermittent pneumatic compression devices should be worn for as much time as practical whilst in bed or these can also be used in addition to stockings. Legs should be re-measured if there is any sign of oedema or swelling. If an increase in size is noted, this should be documented on Anti-embolic Stockings Integrated Care Pathway and hosiery re-prescribed. Please report any increase in size to medical staff. Stockings should be changed every day on patients who are MRSA positive. Every Three Days Clean stockings should be applied every three days or if soiled. On Discharge Patients whose mobility may be restricted or limited after discharge are at risk of DVT for up to four weeks post discharge. These patients should be given the stockings they are wearing plus an additional pair along with a patient information leaflet on discharge. NB: Orthopaedic patients undergoing hip surgery for fracture or hip replacement (see risk tool) require LMWH for four weeks post surgery. Education re self-administration prior to discharge or refer to District Nurse as appropriate If patient is unable to apply/remove stockings independently then either refer patient to district nurses or educate family member or carer. To identify any tissue ischaemia following application of stockings. To ensure they are not acting as a tourniquet anywhere as this will increase risk of DVT. To allow the patient to be washed and check circulation and sensation are adequate and that the skin over pressure points is intact. To ensure effective prophylaxis An increase in leg diameter of 5cm can double pressure applied by stockings. To ensure effective decolonisation. To maintain patient hygiene. To prevent DVT until patient is fully mobile. To ensure concordance of stockings. NOTE: After three days, stockings should not be thrown away. Consider sending home with patient s relatives for laundering as per manufacturer s instructions. 24

Appendix 5: Anti - Embolic Stockings Integrated Care Pathway At Risk Stockings checked twice daily Sign when completed. Date Am pm Anti Embolic Stockings Integrated Care Pathway Stockings Clean stockings Ankle Size Stocking removed for every third day Size 30 minutes daily Variance / Reason Action taken and result from action Signature and Designation Patient discharged Is the patient still at risk of DVT / PE on discharge? No If yes: Patient discharged with two pairs of stockings and an information leaflet? No Is patient able to apply and remove stockings independently? No If no: Refer to District Nurse or Carer No... Signature.... Designation.... Date 25

Appendix 6: Elective Orthopaedic Centre (EOC) Rivaroxaban Protocol for VTE. Outline 1. Venous thromboembolism (VTE) is a condition strongly associated with hip and knee joint arthroplasty. NICE 92 (venous thromboembolism, reducing the risk) gives clear direction how to achieve risk reduction. 2. Current Trust guidelines drawn up by the thrombosis prevention committee follow NICE 92 using subcutaneous dalteparin for chemo-prophylaxis following hip and knee replacement. Even though the majority of patients self-inject, those that do not cause considerable logistic problems for primary care especially over bank holiday weekends as EOC perform 50 to 60 joint replacements a week. 3. Rivaroxaban 10mg once daily has been approved by NICE as an alternative to Dalteparin. Rivaroxaban is to be reserved for needle averse and patients who are at higher than normal risk e.g. patients with a high BMI. This is in view of increased risk of surgical site bleeding. Plan 4. Education All EOC clinical staff using Bayer training package. This will also serve to heighten VTE awareness (updated version attached). During all presentations Rivaroxaban will be referred to by it generic rather than its trade name. 5. Prescribing of Rivaroxaban Will follow SMPC the 1st dose given 8 hours after the start of surgery provided haemostasis has been established, all subsequent daily doses will be given at 18.00. 6. Discharge All suitable patients will be discharged with their full supply of rivaroxaban: 30 days for TKR, 30 days for THR. They will have anticoagulant warning cards and drug information sheets in case of subsequent readmission to hospital. 7. Cost The cost of this will met by EOC and as adequate VTE risk assessment and prophylaxis is a CQUIN goal this will form part of all future commissioning negotiations. NICE 92 compliant alternative prophylaxis will be provided for those patients unable to use or who become sensitive to Rivaroxaban. The EOC 24hr PACU will act as an initial point of contact for any anticoagulant queries. 26

Appendix 7: RCA Process Map START VTE 2013/14 CQUIN RCA Process Map Identify all cases of VTE for the month (from Anti Coag, Wards, Bereavement Office, Radiology) END Recommendations/ actions from Level 3 RCAs and non compliance with process reported quarterly to Thrombosis Committee and twice a year to Trust Clinical Governance Committee Identify all cases that satisfy definition of HAT Level 3 Incident report created (for each patient identified as HAT) and sent to Clinical Risk Other Regular Reporting: Report CQUIN progress and non compliance monthly in QCIP Reports and Quarterly in Commissioners Reports Incident entered into Datix. Incident form and Request for RCA sent to Head of Nursing in relevant directorate Run RCA Reports direct from Datix to assist with monitoring / chasing Escalations: Escalation 1: Risk team escalates through internal process Escalation 2: Contact Hervey Wilcox & Hilary Hollis IR sent to responsible clinician (with Head of Nursing copied in) Return draft RCA to Risk, VTE Clinical Lead & VTE Nurses (within 20 working days) If breached, see Escalation 1 Forward RCA to VTE Clinical Lead for review and sign off Completed actions added to recommendations report Check whether actions have been completed by directorate teams (according to target implementation date(s) in RCA action plan) Review in directorate Clinical Governance meeting and ensure actions are completed RCA closed on Datix Review/amend & sign off RCA (within 10 working days). Send completed RCA to Head of Nursing in relevant directorate and to Clinical Risk If breached, see Escalation 2 Key: Done by VTE Nurses Done by Clinical Risk Team Done by Head(s) of Nursing Done by clinician responsible for RCA Done by VTE Clinical Lead Done by SI Team 27