Best Practice Guidelines - BPG 7 VTE (Venous Thrombo Embolism)

Best Practice Guidelines - BPG 7 VTE (Venous Thrombo Embolism) (Venous Thrombo Embolism) 1

DOCUMENT STATUS: Approved DATE ISSUED: 10 th November 2015 DATE TO BE REVIEWED: 10 th November 2017 AMENDMENT HISTORY VERSION DATE AMENDMENT HISTORY V1 March 2014 Charlotte Hall V2 September 2014 Sarah Cotterill V3 May 2015 Sarah Cotterill V4 July 2015 Sarah Cotterill REVIEWERS This document has been reviewed by: NAME TITLE/RESPONSIBILITY DATE VERSION Sarah Cotterill (VTE CNS) RWT July 2015 4 Trisha Hayward Care Home Manager Forum 15th March 2015 4 Justine Hewitt QNA 30 th October 2015 5 APPROVALS This document has been approved by: GROUP/COMMITTEE DATE VERSION Practice Development Group 28 th October 2015 V5 Quality & Safety Committee 10 th November 2015 Final DISTRIBUTION This document has been distributed to: Distributed To: Care and Nursing Home Staff and Managers Care Home Managers Distributed by/when Care Home Managers development events December 2015 26 th November 2015 Paper or Electronic Paper Electronic/Paper Document Location Resource Folders WCCG Intranet DOCUMENT STATUS This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of the document are not controlled. (Venous Thrombo Embolism) 2

RELATED DOCUMENTS These documents will provide additional information: REF NUMBER DOCUMENT REFERENCE NUMBER TITLE 1. BPG 4 Infection Prevention Final 2. BPG 9 Medicines Management Final 3. BPG 10 Care Risk Assessment Final 4. BPG 11 Care of the deteriorating Resident Final 5. BPG 13 Good Record Keeping Final VERSION RELATED REFERENCES Links to these documents will provide additional information: REFERENCES NICE www.nice.org/guidance/cg92 NICE CG144 June 2012 NICE QS 29 March 2013 NICE TA261 July 2012 NICE TA341 June 2015 RWT Information for patients receiving treatment for the prevention of a blood clot. National Patient Safety Agency Thrombosis UK www.thrombosis-charity.org.uk 1.0 Introduction VTE is a condition of variable seriousness in which a blood clot (a thrombus) forms in a vein and results in it dislodging into the blood forming an embolus. It most commonly begins in the deep veins of the legs; this is called a deep vein thrombosis (DVT). The thrombus may dislodge from its site of origin to travel in the blood it can be potentially fatal if it results in a pulmonary embolism (PE). 1.1 Using the guideline This guideline is designed to be used and implemented by care homes (nursing and residential) across Wolverhampton 1.2 Specialist Advice and Support The Clinical Commissioning Group has a dedicated Quality Nurse Advisor Team who will support the implementation of this guideline. (Venous Thrombo Embolism) 3

However refer to the resident s GP or other health professional who can offer advice for any specific queries. New Cross Hospital VTE Nurse Telephone 01902 307999 ext 6458 pager 3938 Community Anticoagulation Team 01902 444092 or NHS Direct on 111 1.3 Accountability The care home manager is responsible for ensuring dissemination and implementation of these guidelines within the care home. 2.0 VTE Detection VTE encompasses a range of clinical presentations. VTE 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) Signs and symptoms of a deep vein thrombosis include unexplained pain and or swelling in the calf muscle. Skin feels hot, tender, appears discoloured (red, purple, and blue). Feet are numb or tingling. Veins near the surface of the leg appear larger than normal. Signs and symptoms of a pulmonary embolism include sudden onset of breathlessness, pain in chest, upper back or ribs which is worse when breathing deeply, expectoration of blood stained sputum (haemoptysis) low oxygen saturation levels and even cardiac arrest. In the event of these symptoms medical advice/999 must be sought. 2.1 Prevention of VTE A recent stay in hospital due to any illness or for surgery increases a person s risk of developing VTE. There are many factors that put hospital patients at increased risk of VTE: reduced mobility, anaesthetic, age > 60 years, active cancer, dehydration, obesity, thrombophilia s (conditions that increases the risk of blood clots in blood vessels) one or more significant medical illnesses or a past history of VTE. When members of the public are admitted to hospital for treatment they automatically receive a VTE assessment which assesses their risk of developing a VTE. Medical staff then ensure that preventative measures are put in place. A patients risk does not stop when they are discharged from hospital they may require preventative measures to be in place for up to a further 6 weeks. Many patients discharged from hospital will receive on going therapy to reduce their risk of VTE, this may be injections of low molecular weight heparin administered either by the RN in the home as prescribed or the district nurse in a residential home. Alternatively your resident may be discharged with graduated compression stockings. There will be information on discharge with the patient for you to follow. It is important that these preventative measures are continued for the recommended length of time. It is also important that you understand the side effects of heparin and how to care for someone using graduated compression stockings. (Venous Thrombo Embolism) 4

Low molecular weight heparin (LMWH) is an anticoagulant given by injection. It can be used for both prevention and treatment of VTE. Some people may experience side effects such as being more susceptible to bruising and bleeding. Other possible effects are mild irritation or skin reaction at the injection site e.g redness, small hard lumps or bleeding into the skin. Many people describe a stinging sensation just after the injection they should be discouraged from rubbing the site as this will cause bruising. 2.2 For Nursing Homes only or if Residential, the District Nurses will be responsible for the following bullet points. A sharps box must be available. Consideration must be given to using safety needles if not already incorporated in the presentation. Monitoring and recording of the injection site must take place for redness, small hard lumps or bleeding into the skin along with escalation to the appropriate professional. A doctor should be contacted straight away day or night if a resident complains of chest pain or shortness of breath, if an injury occurs particularly to the head, eyes or joints, heavy bleeding from a cut, nose bleeds or gums bleeding heavily, unusual heavy menstrual period, unexpected bruises such as brown or black spots on the skin, vomiting of blood or something that looks like coffee grounds, passing red urine or black stools. 2.3 Graduated compression stockings help to reduce the risk of a blood clot by reducing leg swelling and preventing blood from collecting in the veins. It is very important that these medical devices are worn correctly. The stockings should be worn day and night. The stockings should be removed at least once per day to allow legs to be washed and to check skin integrity. Residents at high risk of pressure damage should have skin checked at least 3 times per day. Do not allow the stockings to roll down as this may cause constriction and restrict blood flow. Stockings should be washed regularly (min every 3 days) they can be hand washed in warm water or in a machine at 40 degrees. It is unusual to experience problems with stockings but advice from a nurse or doctor should be sought if unusual markings of the skin are noted, blistering of the skin or any discolouration of the skin especially over the heels. 2.4 General preventative measures should include; Mobilising as much as possible, Drinking plenty of water, Simple leg exercises these include lying the resident on his/her back or sit in (Venous Thrombo Embolism) 5

the chair and bend and straighten your leg and flex your calf muscles through your ankles quickly repeat 20 times four times a day. Raising a resident s leg whenever resting can help relieve the pressure in the veins of the calf returning the blood flow. 2.5 Treatment of VTE If a resident is suspected of having a DVT or PE then medical advice should be sought (see section 2.0 detection) a resident would then usually be immediately referred to the hospital for investigations which will include examination, medical history and blood tests. If a DVT is suspected a ultra sound scan will be carried out. If a PE is suspected a chest x ray will be carried out followed by a CTPA or VQ scan. Once a VTE is confirmed the resident will require anticoagulation therapy. This therapy can be commenced as an inpatient or in the community depending on the residents symptoms, risk factors and drug therapy being used. 2.6 Anticoagulation therapy Anticoagulation drugs work by interrupting part of the process involved in the formation of clots. This prevents further clots from forming and allows the body to naturally breakdown the clot that has formed. Residents can be anticoagulated either with oral medication or injections of heparin (if in residential care, injections will be given by District Nurses). Oral anticoagulants include drugs such as Warfain, Acenocumarol, Dabigatran, Rivoroxaban, Edoxaban or Apixaban. Persons commenced on these drugs should receive information booklets on the drug being used and an alert card. All care homes must ensure the information is transferred into an appropriate care plan. Injected Fondaparinux or heparins. Heparins that may be prescribed include Enoxaparin, Dalteparin, Fondaparin and Tinzaparin (injections will be administered by District nurses in Residential care homes). Treatment doses are based on a person s actual body weight. A dose will need to be given once per day or if of an extreme body weight twice per day. Heparins are usually an alternative to oral anticoagulants prescribed if there are contraindications to an oral drug such as sensitivities or chemotherapy. 2.7 Aspirin is not an anticoagulant. Duration of treatment can range from 3 months to lifelong therapy (for people with recurrent VTE). It is important that other health care professionals (e.g Doctors, nurses dentist, pharmacist) are made aware that a resident is taking anticoagulation therapy as many medicines and supplements can interact with anticoagulants (particularly antibiotics). Oral anticoagulation therapies often require specific dosing, monitoring and care, all treatments and prevention information should be included in the care plan. 2.8 Warfarin Warfarin is the most commonly used anticoagulant. It is taken once per day at about the same time with a full glass of water. The dose of warfarin taken will vary depending on blood results (INR test) The INR test measures how fast a person s blood clots and the dose of warfarin is then adjusted accordingly. The hospital/pharmacy will supply warfarin tablets in different strengths so that the required dose can be made up. (Venous Thrombo Embolism) 6

A person on warfarin will require regular INR monitoring either by the community anticoagulation service or GP practice. Once the blood result is known medical staff will advise on the required dose to be taken. The dose will either be confirmed in writing in the residents yellow oral anticoagulation therapy record book or via a fax message. Sometimes if a person s INR test is lower than it should be then heparin injections may also be given at the same time. This is usually the case when someone first starts taking warfarin for VTE, they often need both warfarin and heparin for around 5 days. In this case the resident will either be kept in hospital until warfarin treatment is therapeutic or it can be done in the care home with the support of the community nursing team using a specific care pathway. A persons INR result can also be affected by diet and alcohol. It is important to eat a well-balanced diet and not exceed the recommended national alcohol guidelines. The amount of vitamin K in a person s diet can affect the INR result. Examples of foods rich in vitamin K include green leafy vegetables, chick peas, liver, egg yolks, cereals, mature and blue cheeses, avocado and olive oil. These foods do not need to be avoided but major changes in diet may effect how the body responds to anticoagulation therapy. Drinking cranberry juice can affect the INR and should be avoided altogether if possible. If an INR result is higher than it should be a resident may need to omit a dose of warfarin, if the INR is extremely high the resident will be referred to the hospital to have this corrected with vitamin K or blood products. The anti coagulation team or GP will advise you if this problem occurs. 2.9 Non vitamin K oral anticoagulants (NOACs) These are a new generation of anticoagulant drugs that have become licensed in recent years to treat VTE. They include drugs such as Rivoroxaban, Apixaban and Edoxaban. These drugs do not require regular blood monitoring however the GP may wish to monitor the client periodically for other related conditions such as kidney function. They should be taken at the same time each day. They should be taken with a glass of water and swallowed whole. A higher dose is usually taken initially then followed with a reduced dose. It is important that these drugs are taken exactly as directed by the doctor to ensure they work effectively. These drugs are of a fixed dose and have less interactions with other medicines and foods compared to Warfarin. Patients commenced on these drugs will be given a yellow information booklet and alert card. 2.9.1 Side effects. The most serious side effect of all anticoagulants is bleeding. If any of the following symptoms are observed a Doctor should be contacted straight away:- Prolonged nose bleeds (more than 10 minutes), bleeding of the gums, bleeding from cuts that take a long time to stop Blood in vomit Blood in sputum Passing blood in urine or faeces Passing black faeces Severe or spontaneous bleeding Unusual headaches (Venous Thrombo Embolism) 7

For women heavy or increased bleeding during a period or any other vaginal bleeding Immediate medical attention/999 may be required if a resident suffers a major trauma/accident, suffers a significant blow to the head or you are unable to stop any bleeding. 2.9.2 Anticoagulants should not be stopped/omitted without discussing with a Doctor first. If a resident needs to have any surgical or dental procedures the dose of anticoagulants may need to be reduced or temporarily stopped beforehand the doctor or dentist will advise on how to do this. 2.10 Conclusion VTE prevention, detection and treatment can be complex. In recent years there have been lots of changes to how patients in hospital are managed to help prevent VTE occurring. On discharge back to the care home some of these preventative therapies will need to be continued. It is not possible to prevent everyone developing VTE and care staff need to be familiar with the signs and symptoms of VTE and what action to take if VTE is suspected. Treatment of VTE has also changed with newly licensed drugs available and in use. If a resident suffers a VTE there can be long term side effects even after treatment has finished. Post thrombotic syndrome (PTS) is a common complication of DVT. Damage to the veins caused by the clot can lead to pain, swelling, discolouration, varicose veins, and in severe cases leg ulcers which are slow to heal. In order to reduce the risk of this occurring people who have had an above knee DVT should be offered a below knee graduated compression stocking for the effected leg. This is best supplied at 7-10 days after diagnosis or when swelling has reduced. The stocking should be worn for at least 2 years and replaced 2-3 times per year. VTE occurring in someone over the age of 40 with no known risk factors usually will require further investigations to be carried out to exclude the possibility of an underlying cancer. 3.0 Dissemination The care home manager is responsible for ensuring this guideline is disseminated to all staff and can evidence that staff have read it. This can be done via team or individual meetings. 4.0 Monitoring Arrangements Implementation will be monitored utilising Wolverhampton CCG quality monitoring framework e.g. Internal audits Quality Indicators returns Quality monitoring visits 5.0 Appendices VTE Algorithms (Venous Thrombo Embolism) 8

Appendix 1 (Venous Thrombo Embolism) 9