αβχ Instructions for Integrated Care Pathway use This pathway is to be used in place of all previous documentation for patients with a Deep Vein Thrombosis (DVT). It is to be used by Emergency Department doctors and Anticoagulant Nurse Practitioner(s) to assess and treat (see relevant PGDs) outpatients with a proven DVT. It is a legal document, therefore all entries on the pathway, must be signed for with the date and time of entry Where possible the pathway has been based on clinical evidence. Where no evidence is available, a decision has been made to use best clinical practise. The pathway is a prompt only, any deviations from the pathway, must be written into the pathway along with any action taken and the results of the action. The variance must also be signed. This process enables the practitioner to use their clinical judgement and also enables the pathway to be audited more easily. The pathway follows the patient throughout their treatment. To use the pathway, just follow the prompts, fill in the relevant spaces, add any variances and then sign at the bottom of the sheet, to indicate that you have completed the pathway of care. Abbreviations used: Appt = Appointment MAU = Medical admissions unit B.P. = Blood pressure Min = Minute D.V.T = Deep Vein Thrombosis 02 = Oxygen E.D = Emergency Department P.E = Pulmonary embolism e.g. = for example POP = Plaster of Paris G.P. = General Practitioner Pt = Patient G.I. = Gastro Intestinal Resps = Respiration Hb = Haemoglobin S/C = Subcutaneous ICP = Integrated Care Pathway S.O.B = Short of Breath IU = International Units Tel no = Telephone Number INR = International Normalised USS = Ultra sound scan Ratio -ve = negative Kg = Kilograms +ve = positive l = litres V.A.U = Vascular assessment unit LMWH = Low Molecular Weight Heparin If you have any problems with this pathway. Please contact Elaine Willman ext 4442, or Liz Murray - Anticoagulant Nurse Specialist ext 4006 C:\WebDev\pbc_support\source\bracknell\Clinical Pathways\Integrated Care Pathway.doc - 1 - Nov 04
αβχ Attach Patient Label Here D.V.T. Pathway Hospital Number Radiologist Written Report (please affix printed sheet or hand write report) If a positive DVT, is the Arterial Wave form at the ankle triphasic / biphasic / monophasic? C:\WebDev\pbc_support\source\bracknell\Clinical Pathways\Integrated Care Pathway.doc - 2 Nov04
Dr or Nurse Practitioner follow steps 1-6 Nurse Discharging Patient follow step 7 Treat ALL occlusive DVT s with anticoagulation. Non occlusive below knee DVT s need Aspirin and a repeat scan in 10 days (if already taking Aspirin please discuss with E.D. Senior) Step 1. Ensure patient has had LFT s. FBC, INR and U&E s taken and sent to the lab Step 2. Is the patient suitable for Out Patient treatment? All answers must be No to proceed to Out Patient Treatment REASONS FOR ADMISSION Yes No Suspected / confirmed Pulmonary emboli Significant swelling above knee, suggestive of iliac thrombus or vena cava thrombus Active bleeding e.g. intracranial bleed within the last 6 months, G.I. bleed within 1 month, oesophageal varices, macroscopic haematuria within 1 month Verified bleeding disorders e.g. haemophilia, platelets <100 Renal failure with serum creatinine >300mmols/ltre History of hypersensitivity to heparin, heparin induced thrombocytopenia, heparin induced thrombosis Baseline INR >1.4 or / and abnormal LFT s Other evidence of chronic Liver Disease Pregnant patients - refer to Haematologist Likelihood of non-compliance e.g. dementia, drug addiction, unable to self medicate safely C:\WebDev\pbc_support\source\bracknell\Clinical Pathways\Integrated Care Pathway.doc - 3 - Nov 04
αβχ Attach Patient Label Here D.V.T. Pathway Hospital Number Step 3 Presenting complaint: SOB? Chest Pain? Past Medical History: Medication: Allergies: Systemic Enquiry: Yes/ No Social History: Unexplained weight loss Anorexia Night Sweats Bowel Habit note changes Urinary problems Post menopausal bleeding If suspect occult carcinoma arrange urgent follow up OPA 2/52 OBSERVATIONS Thigh Measurement: Right Left Temp oc Calf Measurement: Right Left Pulse B.P. Affected Leg: Resps 02 Sats Pain Heat Weight Kgs Other examination findings: C:\WebDev\pbc_support\source\bracknell\Clinical Pathways\Integrated Care Pathway.doc - 4 Nov04
Sign /Status/ Date & time: Step 4 Document blood results here. If abnormal discuss with Senior Dr before prescribing Warfarin Blood results: Hb g/dl Creatinine mol/l WBC x10/l INR Platelets x10/l LFT s Urea mmol/l D.Dimer Recommendations for Anticoagulant Treatment DVT Length of treatment Therapeutic Range Post op calf 6weeks 2-3 0 Spontaneous calf 3 months 2-3 0 Proximal 6 months 2-3 0 Recurrent (not taking warfarin)? long term(consider thrombophilia 2-3 0 screen) Recurrent (taking warfarin) Long term (refer to physicians) 3-4 5 Taken from Guidelines on Oral Anticoagulation prepared by the Haemostasis and Thrombosis Task force Reference BJH, 1998,101,374-387 Anticoagulant Nurse Practitioner to supply prescription against Patient Group Direction or E.D Dr to write prescription for 28 x 1mg Warfarin tablets 28 x 3mg Warfarin tablets Dalteparin (dose according to weight) S/C OD for 5 days. (Pre-labelled boxes of these drugs are stocked in SSEU drug cupboard) Give patient yellow anticoagulation book with written instructions for loading dose of warfarin (normally 10mg, 10mg & 5mg of warfarin over 3 days). Warfarin should only be started on Mondays, Tuesdays & Fridays to tie in with Anticoagulation Clinic for 1 st INR. Patient to attend Anticoagulation Clinic in Pathology Reception between 9am & 10am on 4 th day of warfarin treatment (do not need appointment but will need to bring yellow anticoagulation book with them) & to ask to see Anticoagulation Nurse. Dalteparin Doses USE ONLY FIXED DOSE PRE-FILLED SYRINGES Weight Dose < 46Kg 7,500iu 46-56kg 10,000iu 57-68kg 12,500iu 69-82kg 15,000iu >83kg 18,000iu C:\WebDev\pbc_support\source\bracknell\Clinical Pathways\Integrated Care Pathway.doc - 5 - Nov 04
Step 5 Dr to complete Anticoagulant Service Referral Form Patient Details: Hospital no. Surname Previous surname Date of birth Post Code Referral Details: Referring clinician GP Practice/ Ward / Clinic Date of referral Date of consultation Dear Doctor / Nurse Practitioner NHS no. Forenames Title Home tel. no. Work tel. no. Mobile no. Sex Preferred clinician (if applicable) New referral? Yes Rereferral? Date last seen Dates not available The above patient requires anticoagulation with warfarin for treatment of (please tick): Deep vein thrombosis Prophylaxis of DVT Pulmonary embolism Myocardial infarction Recurrent DVT/PE Transient ischaemic attack Prosthetic heart valve CABG Atrial fibrillation Arterial disease Other (please describe) Proposed duration of treatment is: 3 months 6 months 12 months Long term Other Desired therapeutic range: INR 2.0-3.0 INR 3.0-4.5 Other Treatment of DVT and PE Systemic embolism Prevention of venous thromboembolism after MI Mitral stenosis with embolism AF Transient ischaemic attacks Xenograft or homograft heart valve replacements (2.5-3.5 for Carbomedics valve replacements) Does patient have? Liver disease/alcoholism Malabsorption Renal failure Please list all concomitant medication Recurrent DVT and PE Mechanical prosthetic heart valves Arterial disease including MI Cardiac failure Peptic ulcer Mental impairment Should patient stop any medication before starting warfarin?. Has patient started warfarin?* Yes/ No Date prescription issued (the referring doctor must supply all patients with a prescription of warfarin) For non-urgent warfarinisation it is preferable to allow the clinic to commence warfarin, so that blood tests can be co-ordinated with clinic days. * If yes, please state doses already given (for patients being discharged from hospital, please ensure that inpatient anticoagulant record accompanies this form): Date INR Dose Date INR Dose Date INR Dose Date INR Dose No Signed Date C:\WebDev\pbc_support\source\bracknell\Clinical Pathways\Integrated Care Pathway.doc - 6 Nov04
For further assistance please contact the anticoagulant nurse 01722 429006 or Dr Jonathan Cullis 01722 336262 ext 4828 C:\WebDev\pbc_support\source\bracknell\Clinical Pathways\Integrated Care Pathway.doc - 7 - Nov 04
Step 6 assessing Dr must complete this and send to GP αβχ DOB (or affix patient label) Emergency Department/ Short Stay Emergency Unit Date: / / GP details:.. PATIENT DISCHARGE SUMMARY Deep Vein thrombosis Dear Dr Your patient attended the Emergency Department and was diagnosed with the following:- Above knee DVT Occlusive DVT Diagnosis Below knee DVT Non occlusive DVT Treatment Your patient has/ has not commenced anticoagulation treatment Predisposing factors:- As no cause for the patient s DVT has been identified please would you ensure that your patient has a general health screen within the next month. Waveform from Duplex scan is Monophasic please do not prescribe compression hosiery Biphasic / Triphasic please prescribe compression hosiery Your patient has / has not been referred to the physicians for follow up If your patient requires a Thrombophilia screen, this will be arranged by the anticoagulant clinic at the end of anticoagulation treatment Additional Comments Thank you Signed Designation Please give a copy of the letter to the patient C:\WebDev\pbc_support\source\bracknell\Clinical Pathways\Integrated Care Pathway.doc - 8 Nov04
αβχ Attach Patient Label Here D.V.T. Pathway Hospital Number Step 7 Nurse to complete the following discharge procedure Subject Discuss diagnosis with patient / relatives and give patient information leaflet. Comments Does patient need additional social care? Medications given to patient Yes / No Patient aware of need to obtain Compression Stockings from G.P. /Community Nurse Comments: Patient taught to self administer Dalteparin Relative / carer taught to administer Dalteparin Referral to District Nurse /Practise nurse for daily Dalteparin Community Nurse letter completed and given to the patient Patient given sharps bin and instruction for use Yes / No Yes / No Yes / No Yes / No Yes / No Dalteparin Record of Administration Dalteparin S/C Dose Given by Batch Number Date Time Site of injection VARIANCE RECORDING SHEET DATE TIME VARIANCE/ REASON ACTION TAKEN AND RESULT FROM ACTION SIGN C:\WebDev\pbc_support\source\bracknell\Clinical Pathways\Integrated Care Pathway.doc - 9 - Nov 04
αβχ Date / / Community Nurse DISCHARGE SUMMARY Deep Vein thrombosis Anticoagualtion Service DOB Salisbury District Hospital Salisbury Wiltshire SP2 8BJ (or affix patient label) Tel 01722 429006 GP Dear Community Nurse/Practice Nurse The above patient has been diagnosed with a DVT and has commenced Anticoagulation treatment with Dalteparin and Warfarin. As the patient is unable to self-inject could you please ensure that the Dalteparin is given as per the following instructions: Day, Date & Time Dose of Dalteparin Injection site Batch No Exp date Given by The patient is due to start Warfarin as follows: Day & Date Dose of Warfarin to be taken @ 6pm The patient needs to have their first INR taken on.. and have been given an appointment to attend the Anticoagulant Clinic at Salisbury District Hospital. The patient needs to have their first INR taken on.. but is unable to attend the Anticoagulant Clinic at Salisbury District Hospital. Please would you could take the INR in the community and send it to us. Many thanks for your assistance. Drs Signature Date and time Note for the Patient: If you have not heard from the community nurse by 5pm on the day that you are expecting your injection, please phone either of the following numbers and speak to someone who can help you to contact the community nurse. The numbers are: Twilight Nurses 01722 429152 (mobile 07879 444898) or Hants patients 01962 868155 ext 6308, Dorset 01202 896689 ext 6305 C:\WebDev\pbc_support\source\bracknell\Clinical Pathways\Integrated Care Pathway.doc - 10 Nov04