1.0 PATIENT CARE Including Physical Healthcare

Transcription

1 SECTION: 1.0 PATIENT CARE Including Physical Healthcare POLICY /PROCEDURE: 1.33 NATURE AND SCOPE: SUBJECT: PROCEDURE - TRUST WIDE VENOUS THROMBOEMBOLISM (VTE) This procedure details Venous Thromboembolism (VTE) assessment, the preventative steps and management of the Service user with suspected or actual VTE DATE OF LATEST RATIFICATION: OCTOBER 2014 RATIFIED BY: EXECUTIVE LEADERSHIP TEAM IMPLEMENTATION DATE: OCTOBER 2014 REVIEW DATE: OCTOBER 2017 ASSOCIATED TRUST POLICIES AND PROCEDURES: Observation and Engagement of Patients Consent to Examination or Treatment Medical Emergency Physical Assessment and Examination of Patients (minimum standards) ISSUE 1 OCTOBER 2014

2 NOTTINGHAMSHIRE HEALTHCARE NHS TRUST VENOUS THROMBOEMBOLISM (VTE) PROCEDURE CONTENTS 1.0 Introduction 2.0 Procedure Principles 3.0 Definitions 4.0 Duties 5.0 Implementation 6.0 Training 7.0 Target Audience 8.0 Review Date 9.0 Consultation 10.0 Relevant Trust Policies/Procedures 11.0 Monitoring Compliance 12.0 Equality Impact Assessment 13.0 Legislation Compliance 14.0 Champion & Expert Writer 15.0 References /Source Documents Appendix 1 - VTE Risk Assessment Tool Appendix 2 - Risk level and risk of VTE Appendix 3 - Record of Change Appendix 4 - Employee Record of Having Read the Procedure ISSUE 1 OCTOBER

3 1.0 INTRODUCTION NOTTINGHAMSHIRE HEALTHCARE NHS TRUST VENOUS THROMBOEMBOLISM (VTE) PROCEDURE 1.1. Venous Thromboembolism (VTE) is the formation of a blood clot (thrombus) in a vein which may dislodge and cause an embolism. Most thrombi form in the deep veins of the legs and pelvis and are called deep vein thrombosis (DVT). However, dislodged thrombi may travel to the lungs, this is called a Pulmonary Emboli (PE) and can be fatal. Thrombi can cause long term morbidity such as post thrombotic syndrome The House of Commons Health Committee reported in 2005 that an estimated 25,000 people die from preventable hospital acquired venous thromboembolism (VTE) each year The NHS Safety thermometer indicates that the provider of care, dependent on the care setting must assess at risk patients. Patients classed at risk must receive appropriate prophylaxis following assessment. 2.0 PROCEDUE PRINCIPLES 2.1. The aim of this procedure is to ensure that all patients/service users are appropriately assessed for their risk of developing a VTE. They must receive appropriate prophylaxis and the level of risk must be reviewed throughout their admission whilst under the care of Nottinghamshire Healthcare NHS Trust, and documented thoroughly All service users/patients admitted to Nottinghamshire Healthcare NHS Trust must be screened for their risk of developing a VTE using the Trust Approved VTE Risk assessment (appendix 1) The signs and symptoms of a DVT and/or PE can include pain, swelling, redness, aching, itchy skin, warm/hot skin and/or prominent veins and a mild fever Adult patients (over 18years and not pregnant) deemed at risk, will be assessed using the Trust Approved Risk Assessment (appendix 1) 2.5. The identification of four or more risk factors and no other contraindications, as identified using the Trust Approved Risk Assessment indicates that the patient/service is at a high risk developing a VTE. The appropriate medication must then be prescribed, based on the presenting clinical features. The risk of bleeding must be assessed (appendix 3) 2.6. The identification of a score lower than four and no contraindications indicates that thrombo-embolism deterrent (TED) stockings to be prescribed All service users deemed to be at risk, will be assessed on an weekly basis, following admission to the ward/unit/community settings Prior to commencement of VTE prophylaxis, offer patient/families verbal and written information regarding the risk and consequences of VTE 2.9. As part of the discharge plan offer service users/ carers, verbal and written information regarding the signs and symptoms of DVT and PE. If discharged with prophylaxis ensure that the service user/carer is aware of the correct duration and use of the prophylaxis and details of who to contact if they have any concerns. ISSUE 1 OCTOBER

4 2.10. Ensure that patients and their carers are aware of the correct and recommended duration of use of VTE prophylaxis at home (if discharged with prophylaxis). This must include the importance of seeking help and who to contact if they have any problems using the prophylaxis Patients and carers must be informed of the importance of seeking medical help and who to contact if DVT, PE or another adverse event is suspected if discharged into the community. 3.0 DEFINITIONS 3.1 Venous thromboembolism (VTE) Venous thrombosis is a condition in which a blood clot (thrombus) forms in a vein in any part of the venous system. The thrombus can reduce blood flow through the affected vein, causing pain and swelling. 3.2 Deep Vein Thrombosis (DVT) Venous thrombosis most commonly occurs in the deep veins in the legs, thighs or pelvis. 3.3 Embolism When a part or all of the thrombus in the deep vein breaks off from the site where it is forms and travels through the venous system. 3.4 Pulmonary Embolism (PE) A dislodged thrombus that travels to the lung is known as a pulmonary embolism. 4.0 DUTIES 4.1 The Trust has a responsibility to provide adequate and appropriate assessments to ensure that all patients and services users are appropriately assessed for the risk of developing VTE, dependant of the care setting. 4.2 It is the responsibility of all clinical staff to ensure that they adhere to best practice. Staff must comply with their professional organizations Code of Conduct and are responsible for practicing within their limit of competence 4.3 Doctors/Independent Prescribers Doctors/Independent prescribers have a responsibility to ensure that all patients/services users are assessed for their risk of developing a VTE on admission. 4.4 Nursing staff Registered nurses are responsible for prompting the doctors/independent prescribers to ensure that a VTE risk assessment is completed for all service users admitted to inpatient services. Nursing staff have a responsibility to ensure that patients are monitored for any signs of adverse effects of prophylactic treatments 4.5 Pharmacists Pharmacists have a responsibility to ensure that thrombprophylaxis medication is appropriately prescribed including dose, route and time. 4.6 Executive Directors, Clinical Directors, General Managers, Associate Directors of Nursing and Matrons, will be responsible for ensuring that this procedure and associated assessments are implemented within each Care Group they manage. 5.0 IMPLEMENTATION 5.1 The procedure will be implemented across the trust following ratification. ISSUE 1 OCTOBER

5 6.0 TRAINING 6.1 It is recognised that basic training in the assessment and management of VTE, forms part of the pre-registration training programme for nursing and other healthcare professionals. 6.2 Healthcare professionals are required to maintain their competencies as part of their continued professional registration. 7.0 TARGET AUDIENCE 7.1 The target audience for this procedure is all staff involved in the assessment, management and care of all service users. 8.0 REVIEW DATE 8.1 This procedure will be reviewed in 3 years or as changes are required to meet changes in care or treatment 9.0 CONSULTATION 9.1 Haematology, medical colleagues in acute care and Trust Wide Physical Health Care forums 10.0 RELEVANT TRUST POLICIES/PROCEDURES Observation and Engagement of Patients Consent to Examination or Treatment Medical Emergency Physical Assessment and Examination of Patients (Minimum Standards) MONITORING COMPLIANCE 11.1 Compliance with this procedure will be monitored as part of the: Monthly notes audit Serious Untoward Incident investigations 12.0 EQUALITY IMPACT ASSESSMENT 12.1 This procedure been assessed using the Equality Impact Assessment Screening Tool. The assessment concluded that the procedure would have no adverse impact on, or result in the positive discrimination of any of the diverse groups detailed. These include the strands of disability, ethnicity, gender, gender identity, age, sexual orientation, religion/belief, social inclusion and community cohesion LEGISLATION COMPLIANCE 13.1 This procedure has been considered in the context of the following legislation and evidence based guidance: Refer to Section 15 References / Source Documents ISSUE 1 OCTOBER

6 14.0 CHAMPION AND EXPERT WRITER 14.1 The champion of this procedure is Professor Chris Packham Associate Medical Director Local Services, and the expert writer is Annie Clarke Head of Physical Health Care and infection Prevention and Control Local services and Laura Hodgson Physical Heath Care Practitioner Local Services REFERENCES /SOURCE DOCUMENTS NICE Clinical Guideline 144 Management of VTE June 2012 NHS Safety Thermometer, Harm free Care Wells PS, Anderson DR, Rodger M, Stiell I, Dreyer JF, Barnes D, Forgie M, Kovacs G, Ward J, Kovacs MJ. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med Jul 17;135(2): PubMed PMID: Gage BF, Yan Y Milligan PE, et al. Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillatiion. Am Heart J 2006; 151: ISSUE 1 OCTOBER

7 VENOUS THROMBO-EMBOLISM 1 (VTE) RISK ASSESSMENT TOOL APPENDIX 1 FOR PERIPHERAL VTE (DEEP VENOUS THROMBOSIS) AND PULMONARY EMBOLUS CLINICAL STAFF GUIDANCE 2 Name.. Ward/Unit Hospital Number Date of Birth. Current level of mobility: Active/sedentary/immobile Step One: Is the patient at risk due to reduced mobility 3? (Nursing staff to complete) Yes: proceed with assessment No: no further VTE assessment required Yes /no Completed on.. Time Completed by (Sign and Print Name) Review Date: Triggered by change in mobility Completed by: (Print and Sign) 1 VTE is a term for deep vein thrombosis (DVT) and pulmonary embolism (PE). A DVT is a blood clot which develops deep in the vein, most commonly in the leg and a PE is a blood clot in the blood vessels that supply the lungs 2 This guidance is primarily for ward and community based staff assessing the risk of DVT and PE in patients not already known to be at risk. It does not cover more complex situations like drug injecting, cancer, other pathology such as pelvic disease, or post-surgical/oncology VTE situations 3 Reduced mobility: significant reduction in normal level of activity due to mental or physical ill health. Includes long spells (more than eight hours) lying on or in bed or under physical restraint or sedation (very rare) ISSUE 1 OCTOBER

8 Section 1: Who is at risk? For all reduced mobility in-patient adult and MHSOP psychiatric patients: Step Two: In patients with reduced mobility: (Medical staff to complete) RISK FACTORS Does the patient currently have active cancer or receiving cancer treatment? Above 60 years of age? Is the patient dehydrated? (eg poor fluid intake) Does the patient have an inherited (Family History) or acquired condition (Thrombophilia) that predisposes them to Thrombosis? Obesity (BMI above 30) One or more co-morbidities that are poorly controlled or in an very active phase (heart disease, respiratory disease, acute infectious diseases, or inflammatory condition?). Using oral hormone replacement therapy or Combined Contraceptive Pill First Degree relative with a history of VTE Varicose veins with active inflammation of the wall of the vein (Phlebitis) 4 Is the patient pregnant or has given birth within the last six weeks? Has the patient recently had a hip/knee replacement or hip fracture (within the last month)? Patients in the first three months of initiation with antipsychotics 5 (particularly quetiapine and haloperidol) If Yes- tick and add any comments including management plan It is important to discuss positive risk factors in the presence of reduced mobility with the Medical Team so preventative measures and/or further treatment including subcutaneous blood thinning prophylaxis treatment (Clexane/Enoxaparin 6 ) can be considered. Drug prophylaxis should be considered by weighing up thrombosis risk alongside Bleeding risk (section 2) In the presence of immobility, the risk of VTE climbs with multiple risk factors Section 2: Risk Assessment Tool for Bleeding Risk 7 It is important that bleeding risk is assessed as this will determine whether the patient is suitable for pharmacological VTE treatment if required. 4 Phlebitis: superficial vein becomes painful and tender and sometimes hard - surrounding skin feels hot and appears red. 5 Antipsychotic drugs and risk of venous thromboembolism: nested case-control study. BMJ 2010;341:c mg Enoxaparin subcutaneously OD (20mg if egfr <30) 7 NICE guidelines 92 Reducing the risk of VTE January 2010 ISSUE 1 OCTOBER

9 Discuss with the patient/assess Active bleeding (i.e., ulcer) Acquired bleeding disorder (i.e. acute liver failure) Concurrent use of anticoagulants (drug used to prevent clotting of the blood) that are known to increase the risk of bleeding. Has the patient recently had an acute stroke? Thrombocytopenia (lower than 75) number of platelets in the blood. Uncontrolled systolic blood pressure (above 230/120mmHg or higher). Untreated inherited bleeding disorders Has the patient recently (within last 3 weeks) had any surgery or other procedure (eg lumbar puncture) that had a high risk of bleeding? Inform the medical team if any of these answer YES State yes or no - add any comments Section 3: Preventative action to avoid VTE for someone at risk due to immobility (discuss with ward doctor or senior nurse) 8 Try and rectify risk factors for VTE (eg dehydration, immobility) Regular mobilization out of chair or bed (at least once every 2-3 hours) Encourage at-risk patients to regularly (every 15 minutes) stretch legs or move feet and toes around even if sitting or lying Use Compression stockings once patient assessed as suitable o Must not have severe poor blood flow to legs or very fragile skin Consider use of preventative blood thinning (prophylaxis) depending on number of risk factors o Requires medical assessment and prescription including assessment of bleeding risk (Section 6) o Aspirin is not adequate protection for venous thrombosis risk. Section 4: How do I recognise a DVT? Signs and symptoms of a DVT include: Pain, swelling and tenderness in a leg, usually in the calf area (not always) Redness, swelling and difficulty weight bearing or pain walking on that leg Change in colour of leg. Associated superficial phlebitis Signs and symptoms of a PE include: Coughing up blood (not common) Sharp or dull Chest pain which is made worse if a big breath is taken. Shortness of breath at rest (may be sudden onset and no obvious cause) Collapse If any of the above symptoms are present the patient must be seen immediately by a medic or emergency services must be contacted 8 NICE guidelines 92 Reducing the risk of VTE January 2010 ISSUE 1 OCTOBER

10 Section 5: Managing a suspected VTE 9 Think about who is at risk so you remain particularly vigilant in high risk persons Make a diagnosis if you suspect a PE the patient must been seen by a doctor immediately and certainly within one hour and diagnosis and management commenced. For a DVT the patient should be seen as soon as possible but certainly within 4 hours. History and Clinical examination For a DVT, use a Wells two-level score and D dimer test if indicated (Section 5) Assess patients suitability for treatment (ensure it is safe to prescribe blood thinning medicine (Section 6) Check routine blood tests and weight. Prescribe blood thinning as appropriate (follow NICE guidance number 144 June 2012) Use correctly fitted anti-embolism stockings Section 6: Diagnostic method for DVT DVT PE Wells scores (scoring system to assess risk of DVT) If you suspect a PE always call the duty doctor immediately Wells two-level Score (2003) for suspected DVT Clinical Feature Points Active cancer (treatment ongoing, within 6 1 months, or palliative) Paralysis, paresis or recent plaster 1 immobilisation of the lower extremities Recently bedridden for 3 days or more or 1 major surgery within 12 weeks requiring general or regional anaesthesia Localised tenderness along the distribution of 1 the deep venous system Entire leg swollen 1 Calf swelling at least 3 cm larger than 1 asymptomatic side Pitting oedema confined to the symptomatic 1 leg Collateral superficial veins (non varicose) 1 Previously documented DVT 1 Alternative diagnosis at least as likely as DVT 2 Clinical probability simplified score DVT likely 2 points or more DVT unlikely 1 point or less Subsequent management 10 If DVT unlikely on Wells score, do blood D-Dimer. If negative DVT v unlikely. If positive patient needs proximal leg vein scan and anticoagulation until that is done and result available and follow NICE Guidance. If DVT likely on Wells score, Urgent proximal leg scan within 4 hours Or Interim anticoagulation ahead of a scan within 24 hours Followed in both cases by a D dimer to aid subsequent management 9 NICE Clinical Guideline 144 Management of VTE June NICE Clinical Guideline 144 Management of VTE June 2012 ISSUE 1 OCTOBER

11 APPENDIX 2 RISK LEVEL AND RISK OF VTE Section 6: Risk Assessment Tool for Bleeding Risk 11 It is important that bleeding risk is assessed as this will determine whether the patient is suitable for pharmacological VTE treatment if required. Discuss with the patient/assess Active bleeding (i.e., ulcer) Acquired bleeding disorder (i.e. acute liver failure) Concurrent use of anticoagulants (drug used to prevent clotting of the blood) that are known to increase the risk of bleeding. Has the patient recently had an acute stroke? Thrombocytopenia (lower than 75) number of platelets in the blood. Uncontrolled systolic blood pressure (above 230/120mmHg or higher). Untreated inherited bleeding disorders Has the patient recently (within last 3 weeks) had any surgery or other procedure (eg lumbar puncture) that had a high risk of bleeding? Inform the medical team if any of these answer YES State yes or no - add any comments 11 NICE guidelines 92 Reducing the risk of VTE January 2010 ISSUE 1 OCTOBER

12 Procedure for: Venous Thromboembolism (VTE) APPENDIX 3 Issue: 1 Status: Author Name and Title: APPROVED Annie Clarke, Head of Physical Healthcare and Infection Prevention Control. Chris Packham, Associate Medical Director for Local Services Issue Date: OCTOBER 2014 Review Date: OCTOBER 2017 Approved by: Distribution/Access: EXECUTIVE LEADERSHIP TEAM Normal RECORD OF CHANGES DATE AUTHOR PROCEDURE DETAILS OF CHANGE ISSUE 1 OCTOBER

13 EMPLOYEE RECORD OF HAVING READ THE POLICY/PROCEDURE APPENDIX 4 Title of Procedure: Venous Thromboembolism (VTE) I have read and understand the principles contained in the named procedure. PRINT FULL NAME SIGNATURE DATE ISSUE 1 OCTOBER