Community DVT Service. Phase 1: Patient visits their Registered GP/Out of Hours Provider

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1 Community DVT Service Quick Reference Guide Phase 1 and 2 Before referring a patient to the GP Care DVT Pathway please familiarise yourself with the Exclusion Criteria to help reduce the number of inappropriate referrals made to the Community DVT Service. Phase 1: Patient visits their Registered GP/Out of Hours Provider Where Patient presents with potential DVT: Registered GP/Out of Hours GP ( GP ) prepares Patient Record Card (electronic version available for auto completion of Patient details); GP performs Wells Score; Wells Criteria: Present Score Lower limb trauma or surgery or immobilisation in a plaster cast +1 Bedridden for more than three days or surgery within the last four weeks +1 Tenderness along line of femoral or popliteal veins +1 Entire limb swollen +1 Calf more than 3cm bigger circumference compared to other limb +1 Pitting oedema +1 Dilated collateral superficial veins (non-varicose) +1 Malignancy (including treatment up to six months previously) +1 Previous DVT +1 Alternative diagnosis more likely than DVT -2 Clinical probability of DVT with score >2 High 1-2 Moderate <1 Low GP performs D-dimer test using Near Patient Testing Kit where: Wells Score < 1 but high clinical suspicion; or Wells Score >/= 1. Select appropriate instruction dependent upon preferred D-Dimer Testing Kit used; CLEARTEST D-dimer test: Tear open foil pouch and place the test device on a clean and level surface. Note: o Best results will be obtained if the test is performed immediately after opening the foil pouch Take finger prick blood sample: o Wash the patient s hand with soap and warm water or clean with an alcohol swab. Allow to dry. o Massage the hand without touching the puncture site by rubbing down the hand towards the fingertip of the middle or ring finger. o Puncture the skin with a sterile lancet. Wipe away the first sign of blood. o Gently rub the hand from wrist to palm to finger to form a rounded drop of blood over the puncture site. o Note venous sample can be taken as alternative if necessary Using the pipette supplied, hold the pipette horizontally and draw up sufficient blood for the test. Allow 2 hanging drops of fingerstick whole blood specimen (approximately 40 µl) to fall into the centre of the specimen well of the test device. Immediately add 1 drop of buffer solution to the specimen well and start the timer. Leave the test device lying horizontal and wait for the coloured line(s) to appear. Read results at 10 minutes (although positive results can often be seen much earlier than this) Do not interpret results after more than 15 minutes. Author : NC/PN Page 1 of 5 June 2012

2 CLEARVIEW D-dimer test: Tear open foil pouch and place the test device on a flat horizontal surface. Note: o Once pouch is opened, commence use of the device within 10 minutes o Test and PC (Patient Control) zones are dyed yellow for manufacturing quality control purposes; the dye does not interfere with the test results Take finger prick blood sample: o Lance patient s finger using sterile lancing device (min depth 1.8mm) o Using the capillary pipette provided collect finger prick blood sample (Do not use the venous pipettes.) Hold a capillary pipette horizontally and touch the tip to the blood drop on the patient s finger Do not squeeze the bulb of the pipette during sampling or obstruct the vent; capillary action will automatically draw the blood into the pipette Allow the pipette to fill to the black line o Note venous sample can be taken as alternative if necessary Immediately dispense all of the blood (35ul) from the capillary pipette into the round sample well of the test device o Hold the capillary pipette in a vertical position above the round sample well o Place a finger over the vent hole in the capillary pipette and dispense all of the blood into the well Allow the blood sample to completely penetrate the sample pad before adding 2 drops of the buffer solution Leave the test device lying horizontal and read the result at 10 minutes (although positive results can often be seen much earlier than this) Further instruction including diagrams is available at If D-dimer is negative, and ultrasound is not required, then GP completes sections 1a and 2a of Patient Record Card and faxes to GP Care on The clinical diagnosis should not be based on the result of the D-dimer test alone. The full clinical context of the patient must be included when making a diagnostic decision taking into account the clinical signs and other relevant information such as the Wells pre-test probability score or equivalent. Therefore the D-dimer must not be used as a stand alone test. If D-dimer is positive, or the GP has a high clinical suspicion of the presence of DVT, then GP: o Explains implications of DVT to Patient and that it is only a potential DVT at this stage; o Calculates appropriate Clexane dosage (1.5mg per 1kg of body weight) and administers to Patient (see table on following page). Author : NC/PN Page 2 of 5 June 2012

3 (Treatment of DVT by subcutaneous injection of Clexane, 1.5mg/kg (150units/kg) every 24 hours for at least 5 days (or until excluded or adequate oral anticoagulation established)) CLEXANE DOSES Weight (kg) Dose (mg) Size of vial Vol (ml) unit/ml 100 units or under dose required volume/ After 100 units ie 67kgs weight = volume/ CLEXANE DOSES Weight (kg) Dose (mg) Size of vial Vol (ml) unit/ml After 150 units ie 103kgs weight = volume/ x x x x x x x x x x The GP then: o Books a same or next working day Ultrasound Appointment by calling GP Care on (office hours) and informs the Patient of Ultrasound Appointment time and location; NB: If the Patient Appointment is after hours and there is no answer at GP Care then the GP advises the patient that GP Care will telephone the patient as soon as possible on the next working day and ensures the telephone number that the patient will be contactable on is written on the Patient Record Card; o Completes sections 1a, 1b, 2a, 2b and 3 of Patient Record Card, immediately faxes to GP Care on and gives original to Patient to take to the Ultrasound Appointment. NB: If Patient has to wait over a weekend for an Ultrasound Appointment then the GP refers the Patient to attend Frendoc on each day over the weekend to receive further Clexane injections pending the Ultrasound Scan. The referral should be made by faxing the Patient Record Card to Frendoc on ; a copy is also faxed to GP Care. The patient should be advised to telephone Frendoc after 08.00am on Saturday to arrange a same day appointment on (the telephone number is printed on the Frendoc map). Author : NC/PN Page 3 of 5 June 2012

4 Phase 2: Ultrasound Scan The Patient attends the GP Care Ultrasound Clinic at Christchurch (Downend), West Walk (Yate), Almondsbury Surgery or Greenway Community Practice (Southmead), staffed by GP Care s team of ultrasonographers. If Ultrasound Scan is negative Patient is discharged back to the Registered GP by the relevant GP Care Ultrasound Clinic; and the GP is notified of the scan result by fax; If Ultrasound Scan is positive: o Patient is immediately transferred to the Duty Doctor at the Treatment Centre where they have been scanned; o Registered GP is notified of positive Scan result by fax. NB: Following day 1 of anticoagulation, patients can attend an alternative DVT Treatment Centre if they wish but have to attend that centre for the remainder of the anticoagulation course. As well as the four Treatment Centres listed above, patients can also choose to be treated at Seymour Medical Centre in Easton, from Day 2 onwards. Phase 3: Anticoagulation at DVT Treatment Centres Refer to separate Guide to Anticoagulation Pulmonary Embolism If at any point during the pathway a Pulmonary Embolism is suspected, the Duty Doctor should contact the patient s registered GP and ascertain consent to refer the patient directly to secondary care. The clinicians at secondary care will assess whether the patient is suitable for community anticoagulation; if this is deemed the case GP Care will accept the patient back onto the pathway at the centre of patient s choice. DNAs Procedures to minimise risk of DNAs are as follows: If at any point a Patient does not attend an anticoagulation appointment then the DVT Treatment Centre should endeavour to make contact with the Patient by phone; If no contact has been possible within 24 hours of the appointment time the DVT Treatment Centre should send a Chasing Patient Letter using the pro forma letter in the Blue DVT File and notify GP Care and inform the Patient s Registered GP that the Patient is being discharged back to the Registered GP; Responsibility for the Patient then reverts to the Patient s Registered GP. House-bound Patients requiring transport The Service is available only to Patients who can attend a DVT treatment centre for an Ultrasound Scan and follow-up anticoagulation. Patients not able to use Warfarin The Service is available only to Patients who can use Warfarin. Payments by GP Care to Performers GP Care will pay Performers according to the work performed as documented on the Patient Record Card. Consumables (D-dimer tests, Clexane and Coaguchek testing strips will also be reimbursed by GP Care on a usage basis); Payments will be made on a calendar month basis in respect of work performed for Patients whose Pathways were completed in that calendar month; An electronic pro-forma invoice detailing services provided and amounts due to the Performer will be supplied by GP Care at the end of each month. Once agreed, the Performer should print the invoice on their headed notepaper and forward it to GP Care for payment. NB: It is critical that Patient Record Cards (including those for Negative D-dimer tests) are completed on an accurate and timely basis and forwarded to GP Care in order that Performers are remunerated correctly. Author : NC/PN Page 4 of 5 June 2012

5 Inclusion Criteria Aged 18 years and over Prior to Doppler Ultrasound: Patients assessed to be at significant risk of DVT based on a clinical assessment and examination by a qualified medical practitioner together with Wells scoring and a D-dimer test if appropriate. Following a positive Doppler Ultrasound scan: Patients who have a deep vein thrombosis proven on scan and who require treatment to prevent complication of the thrombosis. Exclusion Criteria Age less than 18 years Housebound patients Visiting patients (i.e. Non South Gloucestershire PCT patients) Absolute Contra indications: (Please seek guidance from a consultant physician prior to referring patients with any of the following conditions to the Community DVT Service) Pulmonary Embolism or suggestion thereof (including dyspnoea or chest pain+ unilateral leg swelling) Potential bleeding lesions Active Peptic Ulcer, oesophageal varices, aneurysm and proliferative retinopathy Recent Organ biopsy Recent Trauma or Surgery to the head, orbit or spine Recent stroke or transient ischaemic attack Confirmed intracranial or intraspinal bleed or following surgery to the eye or central nervous system (within 1 month) Infective Endocarditis History of heparin induced thrombocytopenia or thrombosis Homozygous protein C deficiency (risk of skin necrosis) Other disease process that requires admission Axillary Vein DVT Positive DVT but contraindication to anticoagulation Patients with complications that prevent use of Warfarin Pregnant women and breast feeding mothers Hypersensitivity to enoxaparin sodium, Heparin or its derivatives including other low molecular weight heparins. Relative Contraindications Past history of gastrointestinal bleeding Liver disease/liver damage Renal failure Alcoholism Mental Impairment Thrombocytopenia Coagulation disorders Interacting Drugs, in particular non steroidal anti-inflammatory drugs, Clopidogrel and glucocorticoids Poor attendance for regular blood tests or commitment to treatment. Uncontrolled hypertension Recent surgery (within 1 month) other than for minor conditions Social circumstances which may prevent community based treatment Pain inadequately controlled Mentally unstable or uncooperative patient. Proliferative diabetic retinopathy. Should a patient exhibit any of the above exclusions, at any stage during the Service Pathway, the Treatment Centre Duty Doctor should liaise with the patient s registered GP to agree the most suitable means of treatment. Author : NC/PN Page 5 of 5 June 2012