Venous Thromboembolism Policy

Venous Thromboembolism Policy Name of Policy Authors Dr Liz Grey-Davies, Consultant Haematologist and Titles: Julianne Rigby, VTE Prevention nurse Dr Christopher Tibbs, Medical Director Miss Renata Hutt, Consultant Obstetrician Nicola Ho-Yen, Deputy Chief Pharmacist Clinical Services Name of Review / Development Body: Ratification Body: Haemostasis &Thrombosis Committee Clinical Quality Risk Management Group Date of Ratification/ Effective from: October 2012 Review Date: October 2015 Reviewing Officer: Consultant Haematologist with Lead for Haemostasis and Thrombosis If this document is required in an alternative language or format, such as Braille, CD, audio, please contact the PALS Office Venous Thromboembolism Policy Version 2.1 Page 1 of 26

Date Nov 11 VERSION CONTROL SHEET Review Type (please tick) Version Author of Minor 1 Full No. Review amendment Review 1 G Robbins L Grey-Davies J Rigby C.Tibbs R Hutt Title of Author Cons. Haematologist Cons. Haematologist VTE Prevention nurse Medical Director Cons. Obstetrician Deputy Chief Pharmacist Date Ratified Nov 11 Ratification Body Clinical Quality Risk Management Group Page Numbers (where amended) Line Numbers (where amended) Details of change Inserted Deleted Dec 11 N Ho-Yen 1.1 L Grey-Davies N Ho-Yen Cons. Haematologist Deputy Chief Pharmacist Clinical Quality Risk Management Group Page 16 Appendix B Section 4.3 and 4.4 Page 22-23 Appendix D Dalteparin (Fragmin ) information Dalteparin (Fragmin ) information Enoxaparin (Clexane ) information Enoxaparin information July 12 Aug 2012 I De Silva Women s and children s lead pharmacist 1.2 Vanessa Watts Lead medication Risk Pharmacist 1.3 Nicola Ho-Yen Deputy Chief Pharmacist Clinical Quality Risk Management Group Clinical Quality Risk Management Group Page 31 Appendix E Table 9.1 Page 25 Appendix E Page 16 Appendix B Section 4.4 Page 23-24 Appendix D Rearranged Dalteparin section New Obstetric policy inserted Dalteparin (Fragmin ) information Dosing on wt and renal function amended Dalteparin (Fragmin ) information Dosing on wt and renal function amended Dalteparin (Fragmin ) information. Dalteparin (Fragmin ) information 1 Where there is a full review, amendment details are not required in the version control sheet. Venous Thromboembolism Policy Version 2.1 Page 2 of 26

Date Aug 2012 Review Type (please tick) 1 Minor Full amendment Review Version No. Author of Review 1.4 Elisabeth Grey-Davies Title of Author Consultant Haematologist Date Ratified Ratification Body Clinical Quality Risk Management Group Page Numbers (where amended) Page 8-9 Section 5.3 and 5.4 Line Numbers (where amended) Details of change Inserted Added link to Obstetric Policy for the Management of Suspected or Confirmed Deep Vein Thrombosis or Pulmonary Embolism Deleted Oct 2012 Aug 2015 2 Julianne Rigby VTE Nurse MAU 17.10.12 CGRMG 2.1 Elisabeth Grey- Davies Consultant Haematologist Page 12 Appendix A P19 Appendix C Added to day case cohort groups Updated VTE Risk Assessment form Nicola Ho-Yen Deputy Chief Pharmacist P4 Version number changed Page numbers updated following insertion of VTE RA form Venous Thromboembolism Policy Version 2.1 Page 3 of 26

CONTENTS VERSION CONTROL SHEET... 2 1. INTRODUCTION/BACKGROUND... 5 2. PURPOSE AND OBJECTIVES... 5 3. SCOPE... 5 4. DUTIES AND RESPONSIBILITIES... 6 4.1. Trust Board...6 4.2. Clinical Quality and Governance Committee...6 4.3. All Speciality Business Unit / Supporting Services Management Teams, including Deputy Directors of Operations (DDO s), Clinical Directors, Speciality Business Unit Managers and Matrons...6 4.4. Ward/Departmental Managers...6 4.5. Haemostasis & Thrombosis Committee...6 4.6. Trust Clinical Leads for VTE...6 4.7. Trust Employees...6 5. SUBJECT MATTER OF POLICY... 7 5.1. Risk Assessment for Identifying Patients at Risk of VTE...7 5.2. Prophylactic Treatment of High Risk Patients...7 5.3. Clinical Assessment and Investigation of Patients with Suspected VTE 7 5.4. Management of Patients Once a Positive Diagnosis has been Made...8 5.5. Root Cause Analysis (RCA)...8 5.6. Patient Information and Planning for Discharge...8 5.7. Mandatory VTE Related Data Collection...9 6. TRAINING... 9 7. IMPLEMENTATION... 9 8. MONITORING THE COMPLIANCE WITH AND EFFECTIVENESS OF THE POLICY... 9 9. REVIEW, RATIFICATION AND ARCHIVING... 10 10. DISSEMINATION AND PUBLICATION... 10 11. EQUALITY IMPACT ASSESSMENT... 11 12. ASSOCIATED DOCUMENTS... 11 13. REFERENCES... 11 APPENDIX A: LOW RISK COHORTS... 12 APPENDIX B: THROMBOPROPHYLAXIS IN ADULT (NON-OBSTETRIC) PATIENTS... 14 APPENDIX C: VTE ASSESSMENT TOOL (NON-OBSTETRIC)... 19 APPENDIX D: THROMBOPROPHYLAXIS GUIDELINE SUMMARY... 23 APPENDIX E: PATIENT INFORMATION... 25 Venous Thromboembolism Policy Version 2.1 Page 4 of 26

1. INTRODUCTION/BACKGROUND Venous thromboembolism (VTE) is a leading and preventable cause of death in hospitalised patients. An estimated 25,000 people in the UK die from preventable hospital-acquired VTE every year. Blood clots (thrombosis) forming in the deep veins of the lower limb or elsewhere (a Deep Vein Thrombosis (DVT)), may give rise to local symptoms and complications including long term deterioration in the venous circulation in the lower limb (chronic venous insufficiency). Part, or all, of a thrombus may come loose and travel to the lung where it is trapped giving rise to pulmonary embolism (PE). This can vary in severity from a totally asymptomatic event to a lifethreatening or fatal event. The House of Commons Select Committee Report on the Prevention of Venous Thromboembolism in Hospitalised Patients and The Venous Thromboembolism in Hospitalised Patients Expert Working Group have been tasked with addressing this issue. NICE Clinical Guideline 92 Reducing the risk of venous thromboembolism in patients admitted to hospital gives clear guidance regarding national standards. The appropriate use of thromboprophylaxis will reduce morbidity due to VTE, reduce mortality rates due to VTE and reduce the cost of treatment of VTE. The authors consulted with members of the haemostasis thrombosis committee, obstetric lead consultants and the clinical quality risk management group in the production of this policy which applies to all adult patients with the exception of obstetric patients (for whom there is a separate policy The Policy for Obstetric Thromboprophylaxis ). 2. PURPOSE AND OBJECTIVES The purpose of the Policy is to establish the overarching framework for the implementation of a high-quality and robust VTE prevention programme for the Trust. It will ensure a standardised approach to risk assessment of all patients being admitted to the trust to optimise clinical outcome. The strategy for risk assessment and prevention of VTE incorporates the current published Department of Health (DH) and National Institute for Clinical Excellence (NICE) guidelines The guidelines as applicable to the Royal Surrey County Hospital are in the appendices to this document and will be updated as appropriate to keep in line with national Policy and local factors. 3. SCOPE This Policy applies to all adults (18 years and older), with the exception of obstetric patients (please refer to the Trust Policy for Obstetric Thromoprophylaxis), who are admitted to hospital as inpatients or formally admitted to a hospital bed for day-case procedures. This Policy relates to the procedure for the risk assessment of adult patients on admission to identify those at increased risk of VTE using a local adaptation of the National VTE assessment tool. It details the management of patients considered to be at increased risk of thrombosis including special considerations and postdischarge care. It includes guidance regarding diagnosis and treatment of VTE, including appropriate use of approved documentation. Venous Thromboembolism Policy Version 2.1 Page 5 of 26

The application of this policy applies to both substantive and temporary clinical and non-clinical staff working in the Trust. Definitions: Thrombophilia: any inherited disorder or variant which increases the risk of VTE. Venous thromboprophylaxis: any mechanical device or drug which reduces the risk of venous thrombosis. LMWH: Low Molecular Weight Heparin INR: International normalised ratio VTE: Venous Thromboembolism PE: Pulmonary Embolism DVT: Deep Vein Thrombosis 4. DUTIES AND RESPONSIBILITIES 4.1. Trust Board Has overall responsibility for the strategic development and effective implementation of the Policy across the Trust. 4.2. Clinical Quality and Governance Committee This Committee monitors clinical standards and the effectiveness of this Policy through the annual review of the audit. The committee, through its membership, will ensure effective communication through all the clinical areas, including the embedding of any lessons learnt. 4.3. All Speciality Business Unit / Supporting Services Management Teams, including Deputy Directors of Operations (DDO s), Clinical Directors, Speciality Business Unit Managers and Matrons Must ensure adequate dissemination and implementation of the Policy, ensuring all staff are aware of their respective roles and responsibilities in VTE prevention. This includes ensuring staff are aware that a risk assessment form (Appendix C) must be completed for every relevant patient admitted to the Trust. 4.4. Ward/Departmental Managers Must ensure staff attend statutory updates relevant to their role to maintain optimum VTE screening levels. 4.5. Haemostasis & Thrombosis Committee Must ensure the development, monitoring and auditing of an effective VTE Policy within the Trust. 4.6. Trust Clinical Leads for VTE Must ensure development and provision of training courses for appropriate staff groups in order to meet the training needs analysis, maintain records of staff attendance at VTE training courses and monitor effective implementation of the Policy through data collection and audit activities. 4.7. Trust Employees Must take responsibility for ensuring that all relevant patients in their care have been appropriately assessed and to this end attend relevant training courses in order to achieve competence. Venous Thromboembolism Policy Version 2.1

5. SUBJECT MATTER OF POLICY This policy is designed to identify relevant adult patients with an increased risk of VTE and describe their subsequent management. The clinical management approach in adult (non obstetric) patients is found in Appendix B 5.1. Risk Assessment for Identifying Patients at Risk of VTE All adult patients admitted to hospital will have a risk assessment carried out as part of the admission process. The risk-assessment tool is found in Appendix C this document. There is a separate Trust Policy for Obstetric Thromboprophylaxis. It is the responsibility of medical staff to undertake a VTE risk assessment when a patient is admitted, to complete the risk assessment documentation and, if required, to prescribe the appropriate venous thromboprophylaxis. A patient's risk of bleeding and VTE must be reassessed within 24 hours of admission and whenever the clinical situation changes to ensure that the methods of VTE prophylaxis being used are suitable, to ensure that VTE prophylaxis is being used correctly and to identify any adverse events resulting from VTE prophylaxis. Nursing staff may complete risk assessments prior to a patient s admission in appropriate clinical areas e.g. in pre-assessment clinics but the admitting clinician MUST sign the assessment on the day of admission and enter the outcome of the assessment on the drug chart to confirm/ reassess there has been no change in the assessed risk. 5.2. Prophylactic Treatment of High Risk Patients Patients identified to be at risk of thrombosis using the risk assessment tool (Appendix C) will be prescribed thromboprophylaxis as well as being given general preventative advice and verbal and written information. All patients who require VTE thromboprophylaxis will be treated (according to NICE guidance) with either mechanical or pharmacological prophylaxis. The prophylactic treatment regime for high risk patients is detailed in Appendix B together with contra-indications to mechanical or pharmacological prophylaxis and considerations for specific patient groups. This policy is for guidance and in all instances clinical judgement in individual cases should take precedence. All treatments, whether mechanical or pharmacological, should be considered in line with their contra-indications. For a full list of contra-indications and drug interactions refer to the BNF or discuss with pharmacy where there is any doubt. 5.3. Clinical Assessment and Investigation of Patients with Suspected VTE Patients with suspected venous thromboembolism (VTE) whether deep vein thrombosis (DVT) or pulmonary embolus (PE) should be assessed as follows: Prompt assessment by a clinician and immediate commencement on therapeutic dose LMWH unless contra-indicated. Do not delay whilst awaiting investigation results Investigation with appropriate imaging (doppler ultrasound, CT pulmonary angiogram or ventilation-perfusion scan) Venous Thromboembolism Policy Version 2.1

If imaging is negative for VTE, consider an alternative diagnosis. Reassess risk factors for thrombosis and bleeding and consider discontinuation of LMWH or change to prophylactic dose depending on VTE risk. If imaging is positive for VTE, continue therapeutic dose LMWH and see below. For Obstetric patients, please see the Policy for Obstetric Thromboprophylaxis (available on TrustNet). 5.4. Management of Patients Once a Positive Diagnosis has been Made Patients with confirmed VTE should be continued on therapeutic dose LMWH and commenced on warfarin provided there is no contra-indication. LMWH should be continued for 5 days and until the patient is fully warfarinised (INR 2). Local guidelines for the use of warfarin (initiation, monitoring and reversal) are available in the Red Book available as a PDF on all Trust desktops. For Obstetric patients, the Trust Policy for the Management of Women with Suspected or Confirmed Deep Vein Thrombosis or Pulmonary Embolism in pregnancy is available on the Trust intranet (TrustNet). On discharge the patient should be referred to the anticoagulant clinic using the designated referral proforma (available on TrustNet). All patients should be counselled prior to commencing warfarin and issued with a hand-held anticoagulation record. The warfarin dosage, recent INRs, diagnosis, treatment length and follow-up arrangement for the next INR check must be clearly documented in the discharge summary. If the thrombosis occurred in hospital or within 3 months of hospital discharge an incident form should be completed and a root cause analysis carried out (see below). 5.5. Root Cause Analysis (RCA) A RCA will be undertaken in all cases of hospital acquired pulmonary embolism or DVT. These are defined as events occurring during or within 90 days of hospital admission. The aim of the analysis will be to determine whether the patient concerned was correctly assessed for VTE risk and whether the appropriate prophylaxis was administered. The RCA form will be completed by the team responsible for the management of the patient during the index admission. This exercise will be lead by the Clinical Director of the SBU concerned with input from the haematology department and the VTE nurse as appropriate and the report form sent to the Medical Director and the Chair of the Hospital Thrombosis Committee. The requirement to undertake RCA does not apply to new admissions with DVT or PE unless they have had an inpatient stay within the last three months in which case a RCA should be performed. 5.6. Patient Information and Planning for Discharge The VTE patient information leaflet (Appendix E) outlines details of how and why a DVT develops, who is at risk and how the risk can be reduced. It also provides crucial information for discharge including the signs and symptoms to observe and duration of prophylaxis as required. This leaflet must be given to all patients on admission and documented that it has been given in the patient s medical record. All patients must also be Venous Thromboembolism Policy Version 2.1

given information verbally and have the opportunity to ask questions on VTE assessment and prophylaxis. If a patient is discharged on pharmaceutical thromboprophylaxis then additional instructions will be provided as part of the discharge letter. 5.7. Mandatory VTE Related Data Collection The data collection is to quantify the number of adult hospital admissions being risk assessed for VTE risk in order to allow appropriate prophylaxis based on national guidance from NICE. The data will be collected via Oasis and uploaded to the Information Services reporting system daily. This data collection serves as the mechanism to enable the Trust to demonstrate to commissioners the achievement against the National CQIUN goal on VTE. Data may also be collected at clinical coding. 6. TRAINING Trust staff are required to undertake VTE training as defined in the Trust's Statutory & Mandatory (SaM) training matrix. Processes for how the Trust records training completion and for following up those staff who do not complete relevant SaM training are described in the Trust s Statutory and Mandatory Training Policy (Section 5). 7. IMPLEMENTATION No action plan applicable as this policy has already been implemented. 8. MONITORING THE COMPLIANCE WITH AND EFFECTIVENESS OF THE POLICY Minimum requirement that is to be monitored Monitoring Process e.g. review of incidents/ audit/ etc Individual(s) responsible for monitoring and for developing action plan Minimum frequency of the monitoring Committee responsible for review of the results and of the action plan Individual(s)/ committee responsible for monitoring implementation of the action plan 1. How patients are assessed for their risk of developing venous thromboembolism (VTE), including timescales Audit VTE Prevention Nurse Annual Haemostasis and Thrombosis Committee VTE Prevention Nurse Haemostasis and Thrombosis Committee (Section 5.1) 2. Prophylactic treatment regime for high risk patients (Section 5.3) Audit VTE Prevention Nurse Annual Haemostasis and Thrombosis Committee VTE Prevention Nurse Haemostasis and Thrombosis Committee Venous Thromboembolism Policy Version 2.1

Minimum requirement that is to be monitored Monitoring Process e.g. review of incidents/ audit/ etc Individual(s) responsible for monitoring and for developing action plan Minimum frequency of the monitoring Committee responsible for review of the results and of the action plan Individual(s)/ committee responsible for monitoring implementation of the action plan 3. Procedure to be followed if VTE is suspected (Section 5.4) Audit VTE Prevention Nurse Annual Haemostasis and Thrombosis Committee VTE Prevention Nurse Haemostasis and Thrombosis Committee 4. Management of the patient once a positive diagnosis has been made (Section 5.5) Audit VTE Prevention Nurse Annual Haemostasis and Thrombosis Committee VTE Prevention Nurse Haemostasis and Thrombosis Committee 5. How the organisation trains staff, in line with the training needs analysis (Section 6) Audit VTE Prevention Nurse Annual Haemostasis and Thrombosis Committee VTE Prevention Nurse Haemostasis and Thrombosis Committee 9. REVIEW, RATIFICATION AND ARCHIVING The Policy will be reviewed every 3 years (or earlier if national policy or guidance changes) and re ratified. The author or Central Policy Officer is responsible for ensuring that archive copies of superseded working documents are retained in accordance with the Records Management: NHS Code of Practice, 2009 (refer to Policy Development and Management: Including Policies, Procedures, Protocols, Guidelines, Pathways and Other Procedural Documents). 10. DISSEMINATION AND PUBLICATION Dissemination of the final policy is the responsibility of the author. They must ensure the policy is uploaded to the Trust s Central Library (TrustNet) either via their Local Policy Officer or submitted directly to the Central Policy Officer. The Head of Marketing and Communication is responsible for the trust-wide notification of existence of the policy. Clinical Directors, DDO s, Specialty Business Unit (SBU), or supporting services management teams, Ward Managers and Heads of Department are responsible for distributing this policy and ensuring that all staff under their management (including bank, agency, contracted, locum and volunteers) are aware of the policy. Venous Thromboembolism Policy Version 2.1

11. EQUALITY IMPACT ASSESSMENT The author of this policy has undertaken an Equality Analysis Initial Screening. No adverse impacts were identified. The Equality Analysis Initial Screening has been archived and is available via the Central Policy Officer. 12. ASSOCIATED DOCUMENTS Statutory & Mandatory Training Policy Policy for Obstetric Thromboprophylaxis Local Clinical Protocols and Referral Procedures 22nd Edition 2012 (icon on all Trust PC desktops labelled 'RSCH red book') Medicines Management Policy Healthcare Records Policy (incorporating record keeping standards) The RSCH Hospital formulary and the Local Clinical Guidelines (RED BOOK), (located on Desktop) Incidents and Serious Incidents Policy 13. REFERENCES House of Commons Health Committee (2005) The prevention of venous thromboembolism in hospitalised patients. London. The Stationary Office Department of Health/Chief Medical Officer (2007) Report of the Independent Expert Working Group on the prevention of venous thromboembolism in hospitalised patients London: The Stationery Office. NICE Guidance Venous Thromboembolism: reducing the risk NICE Clinical Guideline 92 January 2010 Department of Health Guidance Notes to accompany VTE risk assessment data collection May 2010 The Royal College of Ophthalmologists, Information from the Professional Standards Committee. Preventing venous thromboembolism in patients undergoing ophthalmic procedures. May 2010 British Thoracic Society. Guidelines for the management of suspected acute pulmonary embolism. Thorax 2003:58; 470-484 James Kelly and Beverly J Hunt. Exclusionary testing plasma D-dimers Thrombus 2002: Vol. 6. No. 4 9-11. Updated November DH Commissioning for Quality and Innovation (CQUIN) payment framework 2010/11: National goal to reduce avoidable death, disability and chronic ill health from venous thromboembolism (VTE) British National Formulary, Royal Pharmaceutical Society. Venous Thromboembolism Policy Version 2.1

APPENDIX A: LOW RISK COHORTS The following low risk cohort of patients has been identified in line with Department of Health additional guidance issued in May 2010. Patients in these groups are assumed to have been assessed as not needing VTE prophylaxis but this assessment must be recorded in the VTE assessment documentation for each patient. Day Case Patients who remain ambulant and attend a day case area for assessment, treatment or short procedures under local anaesthetic can be assessed as low risk and do not require prophylaxis. If they subsequently require admission overnight a full VTE risk assessment must be completed. This includes the following patient groups: Haematology Day Unit Patients These patients include Haematology and Rheumatology patients who are admitted for treatment as a day case. These patients are all ambulant and require no VTE prophylaxis and therefore are classified as low risk. This is documented in the admission documentation. Endoscopy Outpatients Patients attending as an outpatient for an Endoscopy procedure have been identified as low risk for VTE as they are ambulant within 2-4 hours and therefore require no VTE prophylaxis. This will be recorded on the admission documentation. Elective Patients for Coronary Angiography, Angioplasty and Pacing Procedures These patients are all low risk of VTE as they are ambulant within 4 hours of procedure, discharged within 24 hours and therefore do not require any prophylaxis treatment. Ophthalmology Elective patients admitted for eye procedures under local anaesthetic are at low risk of VTE due to the patient s mobility being normally limited to the duration of the surgery itself typically less than 30 minutes. Therefore they do not require prophylaxis against VTE. This is supported by the Royal College of Ophthalmologists from the Professional Standards Committee (May 2010). This will be documented in the patient s notes. ENT Patients ENT patients undergoing a procedure under local anaesthetic including skin lesions, lymph node biopsies, grommets, TNO, LAUP, electrocautery nose operation remain ambulant and are therefore at low risk of VTE and do not require prophylaxis treatment. Dermatology Day Case Patients Dermatology day case patients undergoing minor procedures under local anaesthetics remain ambulant and are therefore at low risk of VTE and do not require prophylaxis treatment. Respiratory Day Case Patients These patients undergoing minor procedures remain ambulant and therefore at low risk of VTE and do not require prophylaxis treatment. Venous Thromboembolism Policy Version 2.1

Pain Procedures Patients being admitted to the day unit remain ambulant and therefore at low risk of VTE and do not require prophylaxis treatment. Neurology Patients Patients being treated as a day case by the Neurologist remain ambulant and therefore at low risk of VTE and do not require prophylaxis treatment. Urodynamics Patients admitted as a day case for Urodynamics remain ambulant and therefore at low risk of VTE and do not require prophylaxis treatment. Surgery Ambulant patients undergoing short procedures under local anaesthesia Venous Thromboembolism Policy Version 2.1

APPENDIX B: THROMBOPROPHYLAXIS IN ADULT (NON-OBSTETRIC) PATIENTS 1. Documentation All adults (over 18 years), except day case patients, must be assessed on admission to identify those who are at increased risk of VTE. The information used in the assessment must be recorded on the VTE assessment forms in Appendix C. Patients who meet a pre determined cohort low risk criteria must have that documented by ticking the low risk statement on the risk assessment form and signed by the admitting clinician. 2. Assessment of Patient Risk Factors and Need for Thromboprophylaxis The risk assessment should be made using the information below which is incorporated into the risk assessment form in Appendix C. Where a patient is identified as at risk of VTE, thromboprophylaxis should be prescribed according to the guidelines below. These are summarised in Appendix D. Where a patient has been risk assessed in the pre-operative assessment clinic, the admitting clinician must sign the risk assessment form on admission to confirm there has been no change in risk. The risk assessment must be repeated after 24 hours of admission, and at intervals thereafter according to changes in the patient s clinical condition, to ensure that the methods of VTE prophylaxis being used are suitable, to ensure that VTE prophylaxis is being used correctly and to identify adverse events resulting from VTE prophylaxis. There must be a completed risk assessment form in the patient s healthcare records. Prophylaxis should continue at least until the patient is discharged home. Longer periods may be required in specific categories e.g. following orthopaedic surgery. 3. Assessing Risk of Bleeding All adult patients must have their risk of bleeding assessed in addition to their risk of VTE. If a bleeding risk is present use appropriate mechanical methods only. If the bleeding risk is considered too great the reason for not using low molecular weight heparin (LMWH) or alternative must be recorded in the patient s medical record. 3.1 General Risk Factors for VTE Active cancer or cancer treatment Age >60 years Critical care admission Dehydration Known thrombophilia Obesity (BMI>30 kg/m2) One or more significant medical co-morbidities (for example: heart disease, metabolic, endocrine or respiratory pathologies; acute infectious diseases; inflammatory conditions) Personal history or first degree relative with a history of VTE Venous Thromboembolism Policy Version 2.1

Use of HRT Use of oestrogen-containing oral contraceptive therapy Varicose veins with phlebitis 3.2 Additional Risk Factors in Medical Patients Mobility significantly reduced for 3 days or more Expected to have ongoing reduced mobility relative to normal state plus any VTE risk factor (see 3.1) 3.3 Additional Risk Factors in Surgical and Trauma Patients Total anaesthetic + surgical time >90 minutes Surgery involves pelvis or lower limb and total anaesthetic + surgical time >60 minutes Acute surgical admission with inflammatory or intra-abdominal condition Patients expected to have significant reduction in mobility 3.4 Patients at Increased Risk of Bleeding Active bleeding Acquired bleeding disorders (such as acute liver failure) Current use of anticoagulants known to increase the risk of bleeding (such as warfarin with INR>2) Antiplatelet agents including aspirin, clopidogrel, dipyridamole, especially when taken in combination Lumbar puncture / epidural / spinal anaesthesia within the previous 4 hours or expected within the next 12 hours Acute stroke Thrombocytopenia (platelets < 75 x 10 9 /l) Uncontrolled hypertension (>230/110 mmhg) Untreated inherited bleeding disorders (such as haemophilia and von Willebrand disease) 4. Methods of VTE Prophylaxis All treatments, whether mechanical or pharmacological, should be considered in line with their contra-indications. For a full list of contra-indications and drug interactions refer to the BNF or discuss with pharmacy where there is any doubt. 4.1 General Measures Patients should be encouraged to mobilise as soon as possible Do not allow patients to become dehydrated unless clinically indicated Do not regard aspirin or other antiplatelet agents as adequate prophylaxis for VTE Consider offering temporary inferior vena cava filters to patients who are at very high risk of VTE (such as patients with a previous VTE event or an active malignancy) and for whom mechanical and pharmacological VTE prophylaxis are contraindicated 4.2 Mechanical Prophylaxis Graduated compression (anti-embolism) stockings Intermittent pneumatic compression devices Foot impulse devices The first two can be used together or separately. Venous Thromboembolism Policy Version 2.1

4.2.1 Anti-embolism Stockings Do not offer to patients with:- Suspected or proven peripheral arterial disease or peripheral arterial bypass grafting Peripheral neuropathy or other sensory impairment Other condition in which stockings may cause damage such as fragile skin, dermatitis, gangrene or recent skin graft Acute stroke Allergy to material of manufacture Cardiac failure Severe leg oedema or pulmonary oedema from congestive cardiac failure Unusual leg size, shape or major limb deformity preventing correct fit Use with caution in patients with venous ulcers or wounds 4.3 Pharmacological Thromboprophylaxis The current low molecular weight heparin (LMWH) used in the Trust is Dalteparin (Fragmin ) If LMWH is inappropriate (e.g. previous heparin induced thrombocytopenia) seek advice from pharmacy and discuss with a Haematology Consultant. Fondaparinux can be used as an alternative Rivaroxaban (Xarelto ) is used in elective hip and knee surgery, including extended thromboprophylaxis post discharge 4.4 Dosing Guidelines for Thromboprophylaxis For patients whose weight is within the normal population, estimated GFR may be considered to be an approximate of creatinine clearance. For patients with extremes of body weight creatinine clearance must be calculated using the Cockroft and Gault method (calculation available in antibiotic guidelines section of Red Book available on all Trust desktops). Although egfr can be used to estimate renal function as above dosing for ALL patients should be based on calculated CrCl. Dalteparin (Fragmin ) The usual prophylactic dose is 5000 units subcutaneously once daily. o If weight > 130kg use Dalteparin 5000 units TWICE DAILY Contraindicated if there is a history of heparin induced thrombocytopenia If thrombocytopenia develops 5-14 days after starting LMWH contact a haematologist immediately Rivaroxaban (Xarelto ) 10 mg daily orally No dose adjustments required for age Caution if egfr < 30mL/min Do not use if egfr <15 ml/min Contra-indicated in hepatic disease associated with prolonged PT or APTT Venous Thromboembolism Policy Version 2.1

Contra-indicated if patients are taking HIV protease inhibitors (e.g. ritonavir) or azole anti-fungals (e.g. itraconazole, voriconazole, ketoconazole, posaconazole) 4.5 Specific Patient Groups 4.5.1 All Surgery Consider stopping oestrogen-containing oral contraceptives or hormone replacement therapy 4 weeks before elective surgery Assess the risks and benefits of stopping pre-existing established antiplatelet therapy 1 week before surgery. Consider involving the multidisciplinary team in the assessment Consider regional anaesthesia for individual patients as it carries a lower risk of VTE If regional anaesthesia is used, plan the timing of pharmacological VTE prophylaxis to minimise the risk of epidural haematoma For patients already on treatment dose anticoagulation (warfarin or heparin) refer to the red book guidelines on Interruption of Anticoagulation for Surgery, available as a PDF on all Trust desktops 4.5.2 Orthopaedic Surgery Total hip replacement Total knee replacement Hip fracture Other orthopaedic Mechanical prophylaxis on admission plus LMWH or rivaroxaban started 12 hours post-op On discharge rivaroxaban until patient is 28-35 days post-op Mechanical prophylaxis on admission plus LMWH or rivaroxaban started 12 hours post op On discharge rivaroxaban until patient is 10-14 days post-op Mechanical prophylaxis on admission plus LMWH started on admission Stop LMWH 12 hours before surgery 6-12 hours post-op restart LMWH and continue until 28-35 days post-op Lower limb surgery or plaster cast Mechanical prophylaxis started on admission plus LMWH started 6-12 hours post-op in high risk patients Continue until mobility no longer significantly reduced or plaster cast removed Upper limb surgery Do not routinely offer VTE prophylaxis 4.5.3 Other Surgical Specialties Cardiac General No patient-related or VTE risk factors Mechanical prophylaxis Mechanical prophylaxis One or more patient related or VTE risk factors (see 7.4) Mechanical prophylaxis plus LMWH (if patient is not otherwise anticoagulated Mechanical prophylaxis plus LMWH Venous Thromboembolism Policy Version 2.1

No patient-related or VTE risk factors Gynaecological (excl caesarean) Neurosurgery (including spinal surgery) Thoracic Urological Vascular Mechanical prophylaxis Mechanical prophylaxis Mechanical prophylaxis Mechanical prophylaxis Mechanical prophylaxis One or more patient related or VTE risk factors (see 7.4) Mechanical prophylaxis plus LMWH Mechanical prophylaxis plus LMWH (unless the patient has ruptured cranial or spinal vascular malformations and the lesion has not been secured) Mechanical prophylaxis plus LMWH Mechanical prophylaxis plus LMWH Mechanical prophylaxis plus LMWH 4.5.4 Prophylaxis for Medical and Cancer Patients All medical admissions including cancer patients assessed to be at increased risk of VTE will be offered thromboprophylaxis with LMWH in the absence of contra-indications. This will be commenced as soon as possible after the risk assessment has been completed and continued until the patient is no longer at risk of VTE If anticoagulants are contraindicated (see 3.4) use mechanical prophylaxis. 4.5.5 Stroke Patients Patients admitted with stroke should not be prescribed pharmacological thromboprophylaxis for the first 2 weeks following a stroke as it increases the risk of haemorrhagic transformation. The patient should be risk assessed after two weeks and LMWH prescribed as required. Anti-embolism stockings are contra-indicated in acute stroke. 4.5.6 Palliative Care Consider offering pharmacological VTE prophylaxis to palliative care patients who have potentially reversible acute pathology. Take into account potential risks and benefits and the views of patients and their families and/or carers. Neither mechanical nor pharmacological VTE prophylaxis should be routinely offered to patients admitted for terminal care or those commenced on an end-of-life care pathway. Venous Thromboembolism Policy Version 2.1

APPENDIX C: VTE ASSESSMENT TOOL (NON-OBSTETRIC) Venous Thromboembolism Policy Version 2.1 Page 19 of 26

Venous Thromboembolism Policy Version 2.1 Page 20 of 26

Risk Assessment for Venous Thromboembolism (VTE) Step One Assess all adult patients admitted to hospital for level of changed mobility due to planned treatment (tick one box).patients identified as belonging to a cohort are listed below *.tick box and go straight to box 5. Medical patients not expected to have significantly reduced mobility, tick box and go straight to box 5. Surgical and medical patients with significantly reduced mobility require full 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 should prompt thromboprophylaxis according to Trust s thromboprophylaxis guidelines If no box is ticked for thrombosis, the patient is at low risk for VTE 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 the 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 Assign risk category and tick appropriate box. Date and sign the risk assessment / drug chart box 5 and file in the medical notes. Prescribe thromboprophylaxis (pharmacological and or mechanical) in accordance with the Trust thromboprophylaxis guidelines. Ensure the patient has received information leaflet regarding VTE risk and thromboprophylaxis. Ensure the patient is reassessed within 24 hours of admission, Box 6 and whenever their clinical condition changes, Box 7/8 * VTE Low risk cohorts The following low risk cohort of patients has been identified in line with Department of Health additional guidance issued in May 2010. Patients in these groups are assumed to have been assessed as not needing VTE prophylaxis but this assessment must be recorded in the VTE assessment documentation for each patient. Day Case Patients who remain ambulant and attend a day case area for assessment, treatment or short procedures under local anaesthetic can be assessed as low risk and do not require prophylaxis. If they subsequently require admission overnight a full VTE risk assessment must be completed. This includes the following patient groups: Haematology Day Unit Patients These patients include Haematology and Rheumatology patients who are admitted for treatment as a day case. These patients are all ambulant and require no VTE prophylaxis and therefore are classified as low risk. This is documented in the admission documentation. Endoscopy Outpatients Patients attending as an outpatient for an Endoscopy procedure have been identified as low risk for VTE as they are ambulant within 2-4 hours and therefore require no VTE prophylaxis. This will be recorded on the admission documentation. Elective patients for Coronary Angiography, angioplasty and pacing procedures These patients are all low risk of VTE as they are ambulant within 4 hours of procedure, discharged within 24 hours and therefore do not require any prophylaxis treatment. Venous Thromboembolism Policy Version 2.1 Page 21 of 26

Ophthalmology Elective patients admitted for eye procedures under local anaesthetic are at low risk of VTE due to the patient s mobility normally limited to the duration of the surgery itself typically less than 30 minutes. Therefore do not require prophylaxis against VTE. This is supported by the Royal College of Ophthalmologists from the Professional Standards Committee (May 2010). This will be documented in the patient s notes. ENT Patients ENT patients undergoing a procedure under local anaesthetic including skin lesions, lymph node biopsies, Grommets, TNO, LAUP, electrocautery nose operation remain ambulant and are therefore low risk of VTE and do not require prophylaxis treatment. Dermatology Day Case Patients Dermatology day case patients undergoing minor procedures under local anaesthetics remain ambulant and are therefore low risk of VTE and do not require prophylaxis treatment. Respiratory Day Case Patients These patients undergoing minor procedures remain ambulant and therefore low risk of VTE and do not require prophylaxis treatment. Pain Procedures Patients being admitted to the day unit remain ambulant and therefore low risk of VTE and do not require prophylaxis treatment. Neurology Patients Patients being treated as a day case by the Neurologist remain ambulant and therefore low risk of VTE and do not require prophylaxis treatment. Urodynamics Patients admitted as a day case for Urodynamics remain ambulant and therefore low risk of VTE and do not require prophylaxis treatment. Surgery Ambulant patients undergoing short procedures under local anaesthesia Venous Thromboembolism Policy Version 2.1 Page 22 of 26

APPENDIX D: THROMBOPROPHYLAXIS GUIDELINE SUMMARY THROMBOPROPHYLAXIS GUIDELINE SUMMARY Risk of VTE SURGICAL PATIENTS MEDICAL PATIENTS HIGH VTE RISK (with low risk of bleeding) Dalteparin 5000 units sc od + TEDS + Early mobilisation Dalteparin 5000 units sc od + Early mobilisation HIGH VTE RISK (with significant risk of bleeding) TEDS +/- sequential compression device + Early mobilisation TEDS +/- sequential compression device + Early mobilisation LOW VTE RISK Early mobilisation Early mobilisation CONTRA-INDICATIONS Dalteparin Rivaroxaban TEDS egfr < 30ml/min no dose adjustment necessary for VTE prevention doses. Reduce by 50% if treatment dose. egfr < 30ml/min caution egfr < 15ml/min do not give Previous heparin induced thrombocytopenia / allergy to dalteparin Active bleeding Thrombocytopenia (platelets <75x x 10 9 /l) Known bleeding disorder On therapeutic anticoagulation Liver disease causing prolonged APTT Drug interactions with azoles (e.g. itraconazole, voriconazole), HIV protease inhibitors (e.g. ritonavir) Peripheral vascular disease Leg ulcers or fragile skin Peripheral neuropathy Leg oedema Stroke patients Allergy to fabric Leg deformity Timing Elective surgery: Commence Dalteparin 6-12 hours post-operatively, once haemostasis is secure. Thereafter give Dalteparin at 1800. Dalteparin can be given the evening before surgery on consultant advice. Hip fracture: Depending on timing of surgery, consider commencing Dalteparin on admission. Stop Dalteparin 12 hours prior to surgery and restart 12 hours post-operatively, once haemostasis is secure. Thereafter give at 1800. Venous Thromboembolism Policy Version 2.1 Page 23 of 26

Extended prophylaxis Elective hip and knee replacements: Rivaroxaban 10mg od po (28-35 days post-operatively(hip), 10-14 days (knee)) Hip fracture surgery: Dalteparin 5000 units sc od (28-35 days post-operatively) Consider extended prophylaxis with Dalteparin for other high risk procedures Epidural / spinal anaesthesia / lumbar puncture Dalteparin: Placement or removal of catheter should be delayed for 12 hrs after administration of Dalteparin. Dalteparin should not be given sooner than 4 hours after catheter removal. Rivaroxaban: Placement or removal of catheter should be delayed for 18 hours after administration on rivaroxaban. Rivaroxaban should not be given sooner than 6 hours after catheter removal Extremes of body weight Dalteparin: Weight >130kg give 5000 units sc BD Please see Trust Guidelines on VTE Prevention. For patients on treatment doses of anticoagulation see Guidelines on Interruption of Anticoagulation for Surgery. Obstetric patients: see Risk Assessment for VTE in Pregnancy. Venous Thromboembolism Policy Version 2.1 Page 24 of 26

APPENDIX E: PATIENT INFORMATION Venous Thromboembolism Policy Version 2.1 Page 25 of 26

Venous Thromboembolism Policy Version 2.1 Page 26 of 26