chairman’s action (dr guleri) (chairman’s€¦ · patients with diabetes mellitus, chronic...

Document Type: GUIDELINE

Unique Identifier: CORP/GUID/076

Title: Prevention Of Venous Thromboembolism (VTE) In Medical And Surgical Patients

Version Number: 4

Status: Ratified

Scope: Trust wide (Exclusion pregnancy and 6 week post-partum (Please see OBS/GYNAE/GUID/103 Venous Thromboembolism - Antenatal, Intrapartum and Postnatal Risk Assessments and Prophylaxis)

Classification: Organisational

Author/Originator and title: Dr S Mills Consultant Anaesthetist Jennifer Lomax Lead Pharmacist - Surgery

Responsibility: Clinical Governance

Replaces: Version 3 Prevention Treatment Of Venous Thromboembolism (VTE) In Medical And Surgical Inpatients CORP/GUID/076

Description of amendments: Amendments throughout 3.2 Insertion of NPSA alert directives Jan 2015 -concurrent anti-platelets or other interacting medicines

Name Of: Divisional/Directorate/Working Group: VTE Committee

Date of Meeting: 18/12/2014

Risk Assessment: Not Applicable

Financial Implications Not Applicable

Validated by: Medicines Management Committee Clinical Improvement Committee Chairman’s Action (Dr Guleri)

Validation Date: 19/02/2015 26/03/2015

Which Principles of the NHS Constitution Apply? 1 - 4

Ratified by: Trust Management Team (Chairman’s Action – Marie Thompson)

Ratified Date: 27/03/2015

Issue Date: 27/03/2015

Review dates may alter if any significant changes are made Review Date: 01/12/2017

Does this document meet the requirements of the Equality Act 2010 in relation to Race, Religion and Belief, Age, Disability, Gender, Sexual Orientation, Gender Identity, Pregnancy & Maternity, Marriage and Civil Partnership, Carers, Human Rights and Social Economic Deprivation discrimination? Initial Assessment

Blackpool Teaching Hospitals NHS Foundation Trust ID No. CORP/GUID/076


Revision No: 4 Next Review Date: 01/12/2017

Do you have the up to date version? See the intranet for the latest version

of 9

1 PURPOSE The aim of this guideline is to ensure the prevention of venous thromboembolism (VTE) in Medical and Surgical inpatients according to current best practice. 2 SCOPE The guideline applies to all doctors, nurses and pharmacists working with medical and surgical patients within the Trust. Exclusion pregnancy and 6 week post partum (Please see OBS/GYNAE/GUID/103 Venous Thromboembolism - Antenatal, Intrapartum and Postnatal Risk Assessments and Prophylaxis. 3 GUIDELINE 3.1 Introduction

The prevention of symptomatic Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) is important since they are associated with considerable acute morbidity, mortality and long term clinical and financial sequelae.

The guidelines contain evidence-based recommendations from the sources listed at the end of the document.

3.1.1 General Recommendations Mechanical prophylaxis: Thrombo-Embolic Deterrent (compression stockings) or Flowtron boots.

All inpatients having surgery should be offered below knee compression stockings.

Compression stockings or Flowtron boots should be considered for all patients at high risk of bleeding or in whom the use of dalteparin is contraindicated.

Compression stockings / Flowtron boots may be considered as an adjunct to dalteparin prophylaxis.

Flowtron boots should be considered for all patients with suspected # neck of femur and / or long periods of immobilisation pre or post-surgery.

3.2 Process / Risk Assessment for Identifying Patients at Risk of Venous

Thromboembolism

An initial Venous Thrombo-Embolism (VTE) Risk Assessment will be completed by the admitting Doctor / Nurse, for every adult patient either within 4 hours of admission to the Ward / Department, or in pre-op assessment clinic, utilising the Trust VTE Risk Assessment Form (see Appendix 1) which is part of the medical admission document.

The doctor completing the assessment must take in to account if the patient is taking any concurrent anti-platelets or other interacting medicines. The risk of VTE must outweigh the risk of bleeding if dalteparin is to be prescribed. Senior medical advice





of 9

should be sought if the doctor completing the assessment is unsure, consultation with whom and outcome and must be documented within the medical notes.

The appropriate prophylaxis must be prescribed on the patients inpatient medication chart within 4 hours of admission.

A secondary assessment must be completed within 24 hours of admission and be reviewed by a senior grade doctor at post take ward round.

The nursing staff looking after the patient must prompt the appropriate medical team to complete the secondary assessment within 24 hours.

The doctor must reassess the patient if the patient’s condition deteriorates and document this in the patient’s case notes.

3.3 Monitoring of Dalteparin therapy

Full Blood Count (FBC): Check at baseline, then as clinically indicated.

Platelets: Heparin induced thrombocytopenia (HIT) is a rare side effect of Low Molecular Weight Heparins (LMWHs) it usually, but not always, happens within the first 14 days of treatment. All patients should have platelets checked upon initiation then periodically throughout treatment (usual practice is to check weekly for 3 weeks then monthly). Signs of HIT include a reduction in platelet count of 30% or more, thrombosis and skin allergy. If HIT is confirmed / strongly suspected, stop treatment and discuss with haematologist / responsible secondary care clinician (within 24 hours).

Renal Function: LMWHs are renally excreted, and dose adjustment may be required as per the summary of medicines characteristics in renal impairment. Renal function should be checked on initiation then a minimum every 6 months, dependant on the patient’s risk of deterioration. If creatinine clearance is 30-50ml/min measure more frequently e.g. 2 monthly.

Potassium: LMWHs can inhibit aldosterone secretion, resulting in hyperkalaemia. Patients with diabetes mellitus, chronic renal failure, acidosis, raised plasma potassium or taking potassium sparing drugs are more susceptible. The risk appears to increase with duration of treatment. Potassium should be checked upon initiation of treatment and periodically thereafter dependant on the patient’s risk of developing hyperkalaemia.

Anti-factor Xa: This is a surrogate marker of anticoagulant effect. Routine monitoring is not recommended, however it may be of benefit in certain patient groups, e.g. very over / underweight patients, renal dysfunction and pregnancy.

3.4 Monitoring of Dalteparin therapy on discharge When dalteparin is prescribed on a discharge prescription, the doctor completing the eDischarge is responsible for requesting the urea and electrolytes (U&Es) and FBC are monitored weekly for the first 3 weeks of treatment and monthly thereafter.





of 9

4 ATTACHMENTS

Appendix Number Title

1 VTE Risk Assessment Form

2 Equality Impact Assessment Tool

5 ELECTRONIC AND MANUAL RECORDING OF INFORMATION

Electronic Database for Procedural Documents

Held by Policy Co-ordinators/Archive Office

6 LOCATIONS THIS DOCUMENT ISSUED TO

Copy No Location Date Issued

1 Intranet 27/03/2015

2 Wards, Departments and Service 27/03/2015

7 OTHER RELEVANT/ASSOCIATED DOCUMENTS

Unique Identifier Title and web links from the document library

CORP/POL/045 Corporate and Local Induction Policy http://fcsharepoint/trustdocuments/Documents/CORP-POL-045.docx

CORP/POL/199 Health records Life Cycle Management Policy http://fcsharepoint/trustdocuments/Documents/CORP-POL-199.doc

CORP/PROC/601 Dalteparin for Treatment of Venous Thromboembolism Procedure http://fcsharepoint/trustdocuments/Documents/CORP-PROC-601.docm

OBS/GYNAE/GUID/ 103

Venous thromboembolism – antenatal, intrapartum and post natal risk assessments and prophylaxis http://fcsharepoint/trustdocuments/Documents/OBS-GYNAE-GUID-103.doc

8 SUPPORTING REFERENCES/EVIDENCE BASED DOCUMENTS

References In Full

National Patient Safety Alert –

Harm from using Low Molecular Weight Heparins when contraindicated 19th January 2015

Prevention of Venous Thromboembolism: The Seventh American College of Chest Physicians Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004; 126: 338S-400S.

Venous Thromboembolism NICE Guidance CG92 – Reducing the Risk of Deep Vein Thrombosis and Pulmonary Embolism January 2010

9 CONSULTATION WITH STAFF AND PATIENTS

Name Designation

Mr Fewster Orthopaedic Consultant

Mr Tucker A+E Consultant

Miss Haslett Obstetrics and Gynaecology Consultant

C Haythornthwaite Clinical Improvement Facilitator

http://fcsharepoint/trustdocuments/Documents/CORP-POL-045.docx

http://fcsharepoint/trustdocuments/Documents/CORP-POL-045.docx

http://fcsharepoint/trustdocuments/Documents/CORP-POL-199.doc

http://fcsharepoint/trustdocuments/Documents/CORP-POL-199.doc

http://fcsharepoint/trustdocuments/Documents/CORP-PROC-601.docm

http://fcsharepoint/trustdocuments/Documents/CORP-PROC-601.docm

http://fcsharepoint/trustdocuments/Documents/OBS-GYNAE-GUID-103.doc

http://fcsharepoint/trustdocuments/Documents/OBS-GYNAE-GUID-103.doc

https://www.cas.dh.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=102284





of 9

10 DEFINITIONS/GLOSSARY OF TERMS

Doppler For measuring blood flow that transmits sound at a frequency of several megahertz along a blood vessel. Rapid pulsatile changes in flow as well as steady flow can be recorded; hence it is helpful in assessing intermittent claudication, thrombus obstruction of deep veins and other abnormalities of blood flow in the major arteries and veins.

DVT Deep Vein Thrombosis

FBC Full Blood Count

HIT Heparin induced thrombocytopenia

LMWHs Low Molecular Weight Heparins

PE Pulmonary Embolism

Thrombo-Embolic Deterrent

compression stockings or Flowtron boots

U&Es urea and electrolytes

VTE Venous Thromboembolism

11 AUTHOR/DIVISIONAL/DIRECTORATE MANAGER APPROVAL

Issued By Jenny Lomax Checked By Dr S Mills

Job Title Lead Pharmacist – Surgery

Job Title Consultant Anaesthetist

Date 10/10/14 Date February 2015





of 9

Appendix 1: VTE Risk Assessment





of 9

Appendix 2: Equality Impact Assessment Form Department Organisational Service or Policy Guideline Date Completed: October 2014

GROUPS TO BE CONSIDERED Deprived communities, homeless, substance misusers, people who have a disability, learning disability, older people, children and families, young people, Lesbian Gay Bi-sexual or Transgender, minority ethnic communities, Gypsy/Roma/Travellers, women/men, parents, carers, staff, wider community, offenders.

EQUALITY PROTECTED CHARACTERISTICS TO BE CONSIDERED Age, gender, disability, race, sexual orientation, gender identity (or reassignment), religion and belief, carers, Human Rights and social economic / deprivation.

QUESTION RESPONSE IMPACT

Issue Action Positive Negative What is the service, leaflet or policy development? What are its aims, who are the target audience?

The Procedural Document is to ensure that all members of staff have clear guidance on processes to be followed. The target audience is all staff across the Organisation who undertakes this process.

Raise awareness of the Organisations format and processes involved in relation to the procedural document.

Yes – Clear processes identified

Does the service, leaflet or policy/ development impact on community safety

Crime

Community cohesion

Not applicable to community safety or crime

N/A N/A

Is there any evidence that groups who should benefit do not? i.e. equal opportunity monitoring of service users and/or staff. If none/insufficient local or national data available consider what information you need.

No N/A N/A

Does the service, leaflet or development/ policy have a negative impact on any geographical or sub group of the population?

No N/A N/A

How does the service, leaflet or policy/ development promote equality and diversity?

Ensures a cohesive approach across the Organisation in relation to the procedural document.

All policies and procedural documents include an EA to identify any positive or negative impacts.

Does the service, leaflet or policy/ development explicitly include a commitment to equality and diversity and meeting needs? How does it demonstrate its impact?

The Procedure includes a completed EA which provides the opportunity to highlight any potential for a negative / adverse impact.

Does the Organisation or service workforce reflect the local population? Do we employ people from disadvantaged groups

Our workforce is reflective of the local population.

Will the service, leaflet or policy/ development i. Improve economic social conditions

in deprived areas

ii. Use brown field sites iii. Improve public spaces including

creation of green spaces?

N/A

Does the service, leaflet or policy/ development promote equity of lifelong learning?

N/A

Does the service, leaflet or policy/ development encourage healthy lifestyles and reduce risks to health?

N/A

Does the service, leaflet or policy/ development impact on transport? What are the implications of this?

N/A

Does the service, leaflet or policy/development impact on housing, housing needs, homelessness, or a person’s ability to remain at home?

N/A

Are there any groups for whom this policy/ service/leaflet would have an impact? Is it an adverse/negative impact? Does it or could it (or is the perception that it could exclude disadvantaged or marginalised groups?

None identified





of 9

Appendix 2: Equality Impact Assessment Form Does the policy/development promote access to services and facilities for any group in particular?

No

Does the service, leaflet or policy/development impact on the environment

During development

At implementation?

No

ACTION:

Please identify if you are now required to carry out a Full Equality Analysis

Yes No (Please delete as appropriate)

Name of Author: Signature of Author:

Jenny Lomax Date Signed: 10/10/14

Name of Lead Person: Signature of Lead Person:

Jenny Lomax Date Signed: 10/10/14

Name of Manager: Signature of Manager

Dr S Mills Date Signed: 10/10/14