In your query, you requested the following information: QUESTION ONE WRITTEN VTE PREVENTION POLICY 1a) Chelsea & Westminster Site. West Middlesex Site

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1 Chelsea and Westminster Hospital Information Governance Team Chelsea Harbour Harbour Yard Unit 111, 1 st Floor London SW10 0XD Our Ref: FOI Dear Requester Thank you for your information request received by us on 28/08/16 This request has been handled under the Freedom of Information Act In your query, you requested the following information: QUESTION ONE WRITTEN VTE PREVENTION POLICY 1a) Statement 1a) Does your Trust have a written policy in place for preventing and managing the risks of VTE for adult hospital admissions? If yes, please attach a copy of the policy. Chelsea & Westminster Site Policy for Venous Thromboembolism Pre West Middlesex Site 1b) If your Trust has a written VTE prevention policy in place, does it include the seven principles of best practice contained within the NICE quality standard on VTE prevention, which are set out below? Statement Statement 1: All patients, on admission, receive an assessment of VTE and bleeding risk using the clinical risk assessment criteria described in the national tool. Statement 2: Patients/carers are offered verbal and written information on VTE prevention as part of the admission process. Statement 3: Patients provided with anti-embolism stockings have them fitted and monitored in accordance with NICE guidance. Chelsea & Westminster Site West Middlesex Site

2 Statement 4: Patients are re-assessed within 24 hours of admission for risk of VTE and bleeding. Statement 5: Patients assessed to be at risk of VTE are offered VTE prophylaxis in accordance with NICE guidance. Statement 6: Patients/carers are offered verbal and written information on VTE prevention as part of the discharge process. Statement 7: Patients are offered extended (post hospital) VTE prophylaxis in accordance with NICE guidance. 1c) Statement Is your Trust part of a Patient Safety Collaborative where VTE is a priority? If yes, please name the collaborative. Chelsea & Westminster Site West Middlesex Site CLOT QUESTION TWO ADMISSION TO HOSPITAL FOR VTE a) How many patients were admitted to your Trust for VTE which occurred outside of a secondary care setting between 1 April 2014 and 31 March 2015? Unknown No system for this data collection this applies to both sites. b) Of these patients, how many were: - Residents of an elderly care home? - Patients of a mental health facility? Unknown No system for this data collection this applies to both sites. QUESTION THREE ROOT CAUSE ANALYSIS OF HOSPITAL-ASSOCIATED THROMBOSIS According to Service Condition 22 of the NHS Standard Contract 2015/16, the provider must: Perform Root Cause Analysis of all confirmed cases of pulmonary embolism and deep vein thrombosis acquired by Service Users while in hospital (both arising during a current hospital stay and where there is a history of hospital admission within the last 3 months, but not in respect of Service Users admitted to hospital with a confirmed venous thromboembolism but no history of an admission to hospital within the previous 3 months)... The provider must report the results of those Root Cause Analyses to the co-ordinating commissioner on a monthly basis. a) How many cases of hospital-associated thrombosis (HAT) were recorded in your Trust in each of the following quarters, and of these, how many occurred in patients admitted to a psychiatric ward?

3 Quarter Total recorded number of HATs Chelsea & Westminster Site West Middlesex Site Recorded number of HAT in patients admitted to an acute psychiatric ward Both Sites 2014 Q2 (Apr Jun) 9 2 Not applicable* 2014 Q3 (Jul Sep) Q4 (Oct Dec) 8 (***) See note below (***) See note below Not applicable* Not applicable* 2015 Q1 (Jan (***) See note 17 Not applicable* Mar) below *Acute psychiatric ward under a different NHS organisation. No psychiatric wards within C&W Trust. b) How many Root Cause Analyses of confirmed cases of HAT were performed in each of the following quarters? Number of Root Cause Analyses performed Quarter 2014 Q2 (Apr Jun) 2014 Q3 (Jul Sep) 2014 Q4 (Oct Dec) 2015 Q1 (Jan Mar) Chelsea & Westminster Site (***) NB We are not currently in a position to provide all of the data for questions 3a and 3b for the West Middlesex Hospital site. Due to staffing shortages we are currently tackling a backlog and unfortunately we will not be able to forward the data to you until the final quarter. c) Are patients with confirmed HAT specifically informed that they experienced an avoidable clot? Yes Duty of candour requirements complied with both sites West Middlesex Site (***) See note below 8 (***) See note below 17 (***) See note below d) How does your local commissioner quality assure that as a provider, you are complying with your obligation to perform Root Cause Analyses of all confirmed cases of HAT? (Tick as many boxes that apply)

4 Method Requests real-time submission of Root Cause Analyses on completion Requests a monthly report of Root Cause Analyses Requests a quarterly report of Root Cause Analyses Requests an annual report of Root Cause Analyses Requests a face-to-face meeting to discuss Root Cause Analyses Request made by other means not listed. (Please specify) Commissioners yet to request this information Tick box as applicable Chelsea & Westminster Site West Middlesex Site QUESTION FOUR INCENTIVES AND SANCTIONS In 2014/15, at least two per cent of a provider s total contract outturn was available for local Commissioning for Quality and Innovation (CQUIN) schemes to be agreed between commissioners and providers. Statement 4a) Has your Trust agreed a local CQUIN goal with your local commissioner to perform Root Cause Analyses on all confirmed cases of HAT? 4b) Has your Trust received any sanctions, verbal or written warnings from your local commissioning body between 1 April 2014 and 31 March 2015 for failure to comply with the national obligation to perform Root Cause Analyses of all confirmed cases of HAT? Chelsea & Westminster Site West Middlesex Site QUESTION FIVE VTE RISK ASSESSMENT NATIONAL QUALITY REQUIREMENT The NHS Standard Contract 2015/16 sets a National Quality Requirement for 95 per cent of inpatient service users to be risk assessed for VTE. Should providers fail to meet the 95 per cent minimum threshold, they will be subject to sanctions imposed by their local commissioning body. Statement Chelsea & Westminster Site West Middlesex Site

5 5a) Between 1 April 2014 and 31 March 2015, has your local commissioning body imposed a sanction on your Trust for failing to deliver the minimal VTE risk assessment threshold? 5b) If you answered Yes above, what is the total value of the sanctions imposed on your Trust for failure to deliver the minimum VTE risk assessment threshold between 1 April 2014 and 31 March 2015? N/A N/A QUESTION SIX PATIENT INFORMATION The NICE Quality Standard on VTE Prevention stipulates that patients/carers should be offered verbal and written information on VTE prevention as part of the admission as well as the discharge processes. a) What steps does your Trust take to ensure patients are adequately informed about VTE prevention? 6a) What steps does your Trust take to ensure patients are adequately informed about VTE prevention? Distribution of own patient information leaflet Distribution of the Preventing hospitalacquired blood clots leaflet produced by the NHS in conjunction with Lifeblood: The Thrombosis Charity Documented patient discussion with healthcare professional (If yes, please attach documented evidence that these discussions have taken place) Other (please specify) Chelsea & Westminster Site VTE patient information included on the hospital admission and discharge checklist on the electronic prescribing system, West Middlesex Site

6 completed by nursing staff Trust s VTE patient information leaflet included in the hospital admission pack Trust s VTE patient information leaflet available and visible on each adult ward (assessed by quarterly audits 6b) Please attach a copy of the written information on VTE prevention that your Trust provides to patients upon admission and discharge. Chelsea & Westminster - Please see attachments (VTE patient information leaflets for inpatients, outpatients/emergency Department/Urgent Care Centre and pregnant women) QUESTION SEVEN THROMBOPROPHYLAXIS a) Please list the generic name for the VTE prophylaxis treatments your Trust uses for the following categories. Chelsea & Westminster Site West Middlesex Site Category Generic name of prophylaxis First line therapy for DVT treatment Rivaroxaban Warfarin/rivaroxaban First line therapy for PE treatment Rivaroxaban R Warfarin/rivaroxaban First line high prophylaxis?vte prophylaxis Secondary prevention Enoxaparin Enoxaparin (prevention) Rivaroxaban (treatment) Tinzaparin Enoxaparin (prevention) Rivaroxaban (treatment) Warfarin(treatment) If you are not satisfied with this response

7 If you are not satisfied with how your request has been handled then please either 1. Respond to this and we will review our answers and get back to you or 2. Write directly to: The Chief Executive Chelsea and Westminster Hospital NHS Foundation Trust 4 Verney House 1B Hollywood Road London SW10 9HS If, after we have addressed your complaint, you remain dissatisfied with how we have responded, you are entitled to appeal to the Information Commissioner at: The Information Commissioner's Office, Wycliffe House, Water Lane, Wilmslow, Cheshire, SK9 5AF. Telephone: or Website: There is no charge for making an appeal. Re-use of information and copyright You are free to re-use the information contained in our response under the terms of the Open Government Licence You must take into account the exemptions and any other conditions such as the nonendorsement condition below This licence does not grant you any right to use the Information in a way that suggests any official status or that Chelsea and Westminster Hospital NHS Foundation Trust, the Information Provider and/or Licensor endorse you or your use of the Information Further information can be found at: Yours sincerely The Information Governance team Chelsea and Westminster Hospital NHS Foundation Trust foi@chelwest.nhs.uk

8 Policy for Venous Thromboembolism Prevention and Treatment Start date: May 2013 Next Review: May 2015 Committee approval: Endorsed by: Distribution: Location Thrombosis and Thromboprophylaxis Steering Committee Trust Executive Quality Committee Trustwide Trustwide Clinical - Anticoagulation Date: 22 nd May 2013 This document should be read in conjunction with: Author/Further information: Adult Pocket Guide: Prevention & Treatment of Venous Thromboembolism, 2nd Edition 2010 Guidelines for Peri-Operative Venous Thromboembolism (VTE) Prophylaxis in Adults Guidelines for venous thromboprophylaxis for acutely ill medical patients Thromboprophylaxis management of patients with a lower limb plaster cast in the urgent care centre/emergency department Prevention and treatment of venous thromboembolism in pregnancy Good practice guidelines for the management of patients wearing antiembolism stockings Protocol for the investigation of suspected pulmonary embolism (including pregnant patients) Protocol for the investigation of suspected deep vein thrombosis (DVT) (excluding pregnant women) Guideline for the management of deep vein thrombosis (DVT) and nonmassive pulmonary embolism (PE) (excluding pregnant women) Guidelines for the management of acute massive pulmonary embolism Guideline for adult patients requiring anticoagulation with warfarin Dr Helen Yarranton, Consultant Haematologist Sheena Patel, Specialist Anticoagulation Pharmacist Version: 4 Stakeholders involved: Applicable to: Directorate responsible for the document: Trustwide Medicine Haematology (Thrombosis and Thromboprophylaxis Committee) Policy for venous thromboembolism prophylaxis. Version of 16 July 2013

9 Document review history: Date Version Responsibility Comments May 2013 Apr 2012 Sep 2011 Nov 2009 Date Expired Helen Yarranton, Sheena Patel Helen Yarranton, Sheena Patel Helen Yarranton, Sheena Patel 1 Helen Yarranton Policy for venous thromboembolism prophylaxis. Version of 16 July 2013

10 POLICY FOR VENOUS THROMBOEMBOLISM PREVENTION AND TREATMENT CONTENTS 1 DEFINITION OF VENOUS THROMBOEMBOLISM PURPOSE OF POLICY Rationale for thromboprophylaxis Rational for the appropriate management of VTE once the diagnosis is made POLICY AIM PROCESS FOR PREVENTING VTE Which patients need to be risk assessed? When do patients need to be risk assessed? Who is responsible for undertaking and documenting risk assessments? Who is responsible for selecting and prescribing prophylaxis treatments? Who is responsible for administering pharmacological prophylaxis and who is responsible for administering mechanical prophylaxis? What VTE risk assessment tools are used and where can they be found? What thromboprophylaxis should patients at risk of VTE receive? What factors are used in the categorisation of risk in medical and surgical patients? What recommended treatment options apply to each risk category? What contraindications to pharmacological prophylaxis apply? What contraindications to mechanical prophylaxis apply? What is the timing, dosage and duration of pharmacological prophylaxis? What information should patients be offered on VTE prevention? PROCESS FOR THE INVESTIGATION OF SUSPECTED VTE AND MANAGEMENT OF A PATIENT ONCE A POSITIVE DIAGNOSIS OF VTE HAS BEEN MADE What investigations should be arranged for suspected VTE? Management of patients once a positive diagnosis of VTE is made Root cause analysis for hospital associated VTE EXPECTED OUTCOMES/MONITORING VTE prevention Suspected VTE VTE management Root cause analysis STAFF TRAINING REFERENCES APPENDIX Appendix 1: Cohorting Arrangements for Low Risk Patients Appendix 2: Electronic VTE Risk Assessment Policy for venous thromboembolism prophylaxis. Version of 16 July 2013

11 1 DEFINITION OF VENOUS THROMBOEMBOLISM Venous thromboembolism (VTE) is the collective term for deep vein thrombosis (DVT) and pulmonary embolism (PE). 2 PURPOSE OF POLICY The purpose of this policy is to: prevent hospital associated venous thromboembolism (VTE) in accordance with the recommendations of NICE Clinical Guideline 92 (January 2010): Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital manage VTE appropriately once the diagnosis has been made 2.1 Rationale for thromboprophylaxis There is a high prevalence of VTE in hospitals Almost all hospitalised patients have at least one risk factor for VTE DVT is common in many hospitalised patient groups Hospital associated DVT and PE are usually clinically silent It is impossible to predict which at risk patients will develop symptomatic thromboembolic complications There are adverse consequences of unprevented VTE An estimated 25,000 people a year die from hospital-associated VTE in England and Wales 25 times more people die of VTE than hospital acquired infection There are significant costs of investigating symptomatic patients Many patients with VTE will suffer chronic problems such as post thrombotic syndrome and chronic thromboembolic pulmonary hypertension There is a 30% recurrence rate for VTE at 10 years Thromboprophylaxis is effective and efficacious Thromboprophylaxis is highly efficacious at preventing DVT and PE The majority of deaths from VTE are preventable Cost-effectiveness of thromboprophylaxis has repeatedly been demonstrated 2.2 Rational for the appropriate management of VTE once the diagnosis is made Under-anticoagulation in the treatment of DVT may lead to the extension of DVT or risk of PE. Under-anticoagulation in the treatment of PE may be fatal. Over-anticoagulation in the treatment of DVT or PE may lead to haemorrhage that may be major or fatal. Patients who do not wear anti-embolism stockings are at a higher risk of developing post-thrombotic syndrome. 3 POLICY AIM To enable healthcare professionals to identify patients at risk of developing VTE, select appropriate pharmacological and mechanical thromboprophylaxis and offer patients information to reduce the morbidity and mortality associated with VTE. To enable healthcare professionals manage patients with newly diagnosed VTE by treating with adequate anticoagulation unless contraindicated and arranging future monitoring of anticoagulation, providing low compression anti-embolism stockings unless contraindicated and informing patients and their GP to obtain high compression anti-embolism stockings. Policy for venous thromboembolism prophylaxis. Version of 16 July 2013

12 4 PROCESS FOR PREVENTING VTE 4.1 Which patients need to be risk assessed? All adult patients (aged 18 and above) admitted to hospital including day case patients All patients seen in the Emergency department or the Urgent Care Centre with limb immobilisation with plaster casts, back-slab or walking or air boot All antenatal patients at booking clinic appointments Note: Patients admitted and discharged from the Emergency Observation Unit will not require a VTE risk assessment these patients are at low risk of VTE and mobile 4.2 When do patients need to be risk assessed? Patients undergoing surgery seen in the surgical pre-assessment centre Should be risk assessed in the pre-assessment centre On the day of surgery the risk assessment does not need to be repeated unless there has been a clinical change or the risk assessment was completed more than 3 months previously The patient should be reassessed within 24 hours of admission and again whenever the clinical situation changes Patients undergoing surgery not seen in the surgical pre-assessment centre (including emergency admissions) A risk assessment should be completed on admission to hospital For low risk day cases receiving surgery under local anaesthetic (see Appendix 1), the risk assessment will be completed at the mobility screen of the electronic VTE risk assessment The patient should be reassessed within 24 hours of admission and again whenever the clinical situation changes Patients seen in the Emergency department or the Urgent Care Centre with limb immobilisation with plaster casts, back-slab or walking or air boot Should be assessed when they are seen in the department All other patients A risk assessment should be completed on admission to hospital 4.3 Who is responsible for undertaking and documenting risk assessments? Staff responsible for completing the VTE risk assessments are listed in the table below: Directorate/Department Staff Responsible for Completing VTE RA Medicine and Inpatient wards Doctors Emergency Medicine Medical day unit Nurses Emergency observation unit Doctors or nurses /urgent care centre patients admitted and transferred to inpatient ward Surgery Inpatient wards Doctors Treatment Centre Nurses Preoperative Assessment Nurses Centre Surgical Admissions Lounge Nurses HIV& Sexual Health Ron Johnson ward Doctors Kobler day care Nurses and Doctors Dermatology Dermatology inpatients Doctors Dermatology day cases Nurses Policy for venous thromboembolism prophylaxis. Version of 16 July 2013

13 Maternity All areas Midwives or doctors Endoscopy Nurses Diagnostics Bronchoscopy Nurses Patients seen in surgical pre-assessment centre The nurse assessing the patient is responsible for undertaking and documenting the risk assessment on Lastword and record the completion. If both a thrombotic and a bleeding risk are identified then the preassessment nurses will record this on the electronic surgical pre-assessment communication notes. 4.4 Who is responsible for selecting and prescribing prophylaxis treatments? The admitting doctor who has carried out the risk assessment is responsible for prescribing prophylaxis (pharmacological prophylaxis and mechanical prophylaxis) according to Trust guidelines. For patients with limb immobilisation in plaster casts, back-slab or walking or air boot seen in the Emergency department or the Urgent Care Centre, the nurse practitioner (if a qualified prescriber) or the doctor assessing the patient should prescribe thromboprophylaxis according to the Trust guidelines. 4.5 Who is responsible for administering pharmacological prophylaxis and who is responsible for administering mechanical prophylaxis? The nursing staff are responsible for administering pharmacological prophylaxis and mechanical prophylaxis as prescribed. 4.6 What VTE risk assessment tools are used and where can they be found? There are two VTE risk assessments (see Appendix 2) used in the Trust for patients admitted to hospital. The first is based on the Department of Health s risk assessment for venous thromboembolism and the second is for pregnant women. The risk assessments are in electronic format and the appropriate risk assessment will appear according to the department the patient is admitted to. There is a further paper VTE risk assessment tool specifically for patients seen in the Emergency department or the Urgent Care Centre with lower limb immobilisation Completing the risk assessment The first part of the risk assessment is to assess the mobility status of the patient. If the patient is not expected to have significantly reduced mobility relative to their normal state, this should be documented and the risk assessment is completed at this stage. If the patient is expected to have ongoing reduced mobility relative to their normal state (the majority of patients admitted overnight) then the assessment requires the documentation of thrombotic risk. If thrombotic risk factors are documented an assessment of bleeding risk is required Mandatory alerts When an admitted patient is activated on Lastword by staff in the doctor or nurse user groups, a VTE risk assessment alert will appear on admission and again within 24 hours of admission. These alerts will continue to appear until the risk assessments are completed. The alert will direct the user to the VTE risk assessment. Policy for venous thromboembolism prophylaxis. Version of 16 July 2013

14 4.6.3 Performing the VTE risk assessment when the mandatory alerts do not appear For example if the patient has already had a risk assessment completed on admission and were reassessed within 24 hours. A risk assessment can be completed at other times on Lastword by selecting VTE Risk Assessment Entry in the Lastword base screen under the PATIENT OPTIONS tab. Alternatively type vte in the command field Cancelling the mandatory alerts The mandatory alert can be inactivated by selecting one of the override reasons in the drop down list on the mandatory alert (see table below). Override reasons should NOT be used inappropriately and their use will be monitored. Override reasons A Patient requiring urgent attention B Reviewing results only C VTE risk assessment in preop OP & No change D Not admitting Dr/nurse E Not named team F Not trained to perform task G Patient activated in error For inpatients, nurses should be selecting option F Not trained to perform task if an alert appears when a patient is activated and should encourage the doctors to complete the VTE risk assessment. The mandatory alert will appear again when a different user activates the patient record Viewing a list of patients who have not had a risk assessment on admission or have not been reassessed within 24 hours of admission A list of patients who have yet to have a VTE risk assessment completed can be found by typing vta in the command field. Patients whose risk assessment is overdue are highlighted in black Viewing a risk assessment Previous VTE risk assessments can be found under VTE risk assessment viewer on Lastword on the base screen under the RESULTS tab. 4.7 What thromboprophylaxis should patients at risk of VTE receive? Patients should be prescribed thromboprophylaxis according to Trust guidelines available on Datix on the Trust intranet*: Guidelines for Peri-Operative Venous Thromboembolism (VTE) Prophylaxis in Adults Guidelines for venous thromboprophylaxis for acutely ill medical patients Prevention and treatment of venous thromboembolism in pregnancy Thromboprophylaxis Management of Patients with a Lower Limb Plaster Cast in the Urgent Care Centre/Emergency Department *a shortened form of the guidance is available within the Adult Pocket Guide: Prevention and Treatment of Venous Thromboembolism (also available on the intranet) Policy for venous thromboembolism prophylaxis. Version of 16 July 2013

15 4.8 What factors are used in the categorisation of risk in medical and surgical patients? Refer to Trust Thromboprophylaxis guidelines 4.9 What recommended treatment options apply to each risk category? Refer to Trust Thromboprophylaxis guidelines 4.10 What contraindications to pharmacological prophylaxis apply? Refer to Trust Thromboprophylaxis guidelines 4.11 What contraindications to mechanical prophylaxis apply? Refer to Trust Thromboprophylaxis guidelines 4.12 What is the timing, dosage and duration of pharmacological prophylaxis? Refer to Trust Thromboprophylaxis guidelines 4.13 What information should patients be offered on VTE prevention? Patients/carers should be offered verbal and written information on VTE as part of the admissions process. Information should be provided on: the risks and possible consequences of VTE the importance of VTE prophylaxis and its possible side effects the correct use of VTE prophylaxis (for example, anti-embolism stockings, intermittent pneumatic compression devices or foot impulse devices) how patients can reduce their risk of VTE (such as keeping well hydrated and, if possible, exercising and becoming more mobile) Patients/carers are offered verbal and written information on VTE prevention as part of the discharge process. Information should include: the signs and symptoms of deep vein thrombosis and pulmonary embolism the correct and recommended duration of use of VTE prophylaxis at home (if discharged with prophylaxis) the importance of using VTE prophylaxis correctly and continuing treatment for the recommended duration (if discharged with prophylaxis) the signs and symptoms of adverse events related to VTE prophylaxis (if discharged with prophylaxis) the importance of seeking help and who to contact if they have any problems using the VTE prophylaxis the importance of seeking medical help if deep vein thrombosis, pulmonary embolism or other adverse events are suspected What written information on VTE prevention is available for patients? There are three Trust patient information leaflets: Are you at risk of blood clots? Information for patients in hospital or going home from hospital Are you at risk of blood clots? Information for patients in A&E (Emergency Department), Urgent Care Centre and Outpatient Clinics Are you at risk of blood clots in pregnancy? Which patients should be offered the Are you at risk of blood clots? patient information leaflets? All patients admitted to hospital and all patients seen in the surgical preassessment centre who are to be admitted for a surgical procedure and on discharge from hospital. Policy for venous thromboembolism prophylaxis. Version of 16 July 2013

16 Who is responsible for providing patients with the VTE patient information? Patients seen in surgical pre-assessment centre The nursing staff in surgical pre-assessment centre should give the leaflets to all patients and record this in the communication notes via Command TRXALL on Lastword. Patients admitted to hospital The leaflet should be offered to all adult patients admitted to hospital by any healthcare professional. The leaflets should be visible and on display on all adult wards Where can new stocks of the patient information leaflet be obtained? VTE patient information leaflets can be obtained from Dr Helen Yarranton, Consultant Haematologist or Sheena Patel, Specialist Anticoagulation Pharmacist via Trust . 5 PROCESS FOR THE INVESTIGATION OF SUSPECTED VTE AND MANAGEMENT OF A PATIENT ONCE A POSITIVE DIAGNOSIS OF VTE HAS BEEN MADE 5.1 What investigations should be arranged for suspected VTE? Refer to Trust guidelines o Protocol for the investigation of suspected acute pulmonary embolism (including pregnant patients) o Protocol for the investigation of suspected deep vein thrombosis (DVT) (excluding pregnant women) o Prevention and treatment of venous thromboembolism in pregnancy 5.2 Management of patients once a positive diagnosis of VTE is made If a DVT or PE is confirmed the patient should be anticoagulated with therapeutic doses of low molecular weight heparin initially and warfarin or one of the novel oral anticoagulants (dabigatran, rivaroxaban or apixaban). Refer to Trust guidelines. o Guideline for the management of deep vein thrombosis (DVT) and nonmassive pulmonary embolism (PE) (excluding pregnant women) o Prevention and treatment of venous thromboembolism in pregnancy o Novel oral anticoagulants 5.3 Root cause analysis for hospital associated VTE A hospital associated VTE is defined as occurring during a hospital admission or within 3 months of a hospital admission. Cases will be identified by monitoring radiology reports. All patients with a new suspected hospital-associated VTE diagnosis are reviewed by the Haematology Consultant and the Specialist Anticoagulation Pharmacist who identify when a root cause analysis is required. A root cause analysis should be performed on cases where appropriate thromboprophylaxis was not used. Policy for venous thromboembolism prophylaxis. Version of 16 July 2013

17 6 EXPECTED OUTCOMES/MONITORING 6.1 VTE prevention The VTE risk assessment target for the Trust is that more than 95% of adult patients admitted to Chelsea and Westminster Hospital will be risk assessed on admission. The risk assessment should be repeated within 24 hours of admission. This will be monitored and reviewed at each Thrombosis and Thromboprophylaxis Committee. The reports will be circulated to the Divisional Medical Directors for review and action. A quarterly report will be provided to the Quality committee via the quarterly update on quality objectives. Actions identified will be monitored by the Quality committee until completion All patients should receive appropriate pharmacological and mechanical thromboprophylaxis according to Trust guidelines. This will be monitored by monthly audits and will be reviewed by the Thrombosis and Thromboprophylaxis Committee. A quarterly report will be provided to the Quality committee via the quarterly update on quality objectives. Actions identified will be monitored by the Quality committee All patients should be offered verbal and written information on VTE prevention. For patients seen in the surgical pre-assessment centre, an annual audit of the nursing communication notes via command TRXALL will be performed and will be reviewed by the Thrombosis and Thromboprophylaxis Committee. The annual audit will be reported to Quality committee. Actions identified will be monitored by the Quality committee. 6.2 Suspected VTE The procedure to be followed for suspected VTE (either DVT or PE) will be audited as per the audit plan agreed annually by the Thrombosis and Thromboprophylaxis Committee (see monitoring sections of policies referenced in Section 5.1). 6.3 VTE management Appropriate VTE management will be monitored by annual audits and will be reviewed and actions identified will be monitored by the Thrombosis and Thromboprophylaxis Committee and be reported to the Quality committee. 6.4 Root cause analysis Completion of root cause analysis will be monitored by the Consultant Haematologist, Specialist Anticoagulation Pharmacist and the risk management team. Failure to complete root cause analysis investigations in a timely manner will be escalated to the relevant Divisional Medical Director. 7 STAFF TRAINING The organisations expectations in relation to staff training is identified in the training needs analysis. Policy for venous thromboembolism prophylaxis. Version of 16 July 2013

18 8 REFERENCES Report of the independent expert working group on the prevention of venous thromboembolism in hospitalised patients, April ce/dh_ Department of Health s Risk Assessment for Venous Thromboembolism, September ce/dh_ NICE Clinical Guideline 92 (January 2010): Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital NICE Quality Standards: VTE prevention, June APPENDIX Appendix 1 - Cohorting Arrangements for Low Risk Patients Appendix 2 Electronic VTE risk assessments Policy for venous thromboembolism prophylaxis. Version of 16 July 2013

19 Appendix 1: Cohorting Arrangements for Low Risk Patients Ms Heather Lawrence, Chief Executive Dr Andy Mitchell, SHA Medical Director Ms Cathy Mooney, Director of Governance and Corporate Affairs Mr Jeremy Thompson, Divisional Director for Medicine and Surgery Ms Zoe Penn, Divisional Medical Director Division of Women s & Neonatal Services; Children s & Young People s Services; HIV, GUM and Dermatology Ms Karen Robertson, Divisional Director Operations Clinical Support and Chief Pharmacist Dr Helen Yarranton, Chair of the Thrombosis and Thromboprophylaxis committee 25 th November 2010 Re: Chelsea and Westminster Hospital Foundation Trust Venous Thromboembolism (VTE) risk assessment; Cohorting arrangements, November 2010 At Chelsea and Westminster Hospital I agree to a cohort approach to risk assessment using the DH/NICE National Tool for VTE risk assessment for groups of patients undergoing procedures that are considered to be at low risk of VTE using the DH/NICE risk assessment categories and detailed NICE guidance (CG092). This will apply to the following cohorts of patients attending the treatment centre for day surgery. 1. Non-cancer endoscopy and cystoscopy procedures with local anaesthetic/regional/ sedation and not general anaesthetic 2. Ophthalmological procedures with local anaesthetic/regional/ sedation and not general anaesthetic 3. Non-cancer plastic surgery lasting less than 90 minutes with local anaesthetic/ regional/sedation and not general anaesthetic 4. Non-cancer dental and maxillo-facial surgery lasting less than 90 minutes with local anaesthetic/regional/ sedation and not general anaesthetic 6. Other similar minor procedures (see appendix 1) lasting less than 90 minutes with local anaesthetic/regional/ sedation and not general anaesthetic. These patients will be recorded on the Trust Lastword electronic VTE risk assessment as Day case surgery pt: NOT under GA, NOT to lower limb, non-cancer & NO reduced mobility cf normal. This will also apply to the following cohorts patients attending for day case medical procedures: 1. Chemotherapy 2. Dermatology patients receiving phototherapy or dressing or cleaning of skin wounds. These patients will be recorded on the Trust Lastword electronic VTE risk assessment as Medical patient not expected to have significant reduction in mobility relative to normal state. Please see Appendix 1 for more information. Dr Mike Anderson Medical Director Policy for venous thromboembolism prophylaxis. Version of 16 July 2013

20 Policy for venous thromboembolism prophylaxis. Version of 16 July 2013

21 Appendix 2: Electronic VTE Risk Assessment Policy for venous thromboembolism prophylaxis. Version of 16 July 2013

22 Electronic VTE Risk Assessment for Pregnant Women: Policy for venous thromboembolism prophylaxis. Version of 16 July 2013

23 Policy for venous thromboembolism prophylaxis. Version of 16 July 2013

24 Name of Policy, Procedure or Guidance Who should read the objectives of this policy/procedure Thrombosis Guidelines The guideline applies to all clinical staff working within West Middlesex University Hospitals NHS Trust Executive Summary All patients being admitted to the Hospital must have a risk-assessment for Venous thrombosis (VTE). This should be documented as having been completed on REALTIME. A medical decision should be made by the admitting doctor about the method of thromboprophylaxis. This should be prescribed in the treatment chart. In- patients should be reassessed at 24 hours and whenever the clinical situation changes during their inpatient stay as the risk may change LMWH prophylaxis should be considered in all hospitalised patients according to the following guidelines. All patients on low molecular weight heparin (LMWH) should have an admission weight recorded on the drug chart, core assessment document, and on a weight chart where applicable. All patients on LMWH should have the results of their renal function reviewed in the medical notes from bloods results from within two days prior or after the initiation of treatment. All patients should have verbal and written information about VTE on admission and discharge. Committee & date Drugs and Therapeutics Committee (January 2011) approved Ratified by Trust Board N/A on: Review Date April 2014 Director(s) responsible for ensuring this document is implemented For further information contact Medical Director Director of Operations/Deputy Chief Executive Director of Nursing & Midwifery Dr Anna Babb Haematology consultant ext Thewodros Leka Pharmacist ext or B/P 452 The formal/legal documents forming the basis of this document are NICE guidance CG92 Venous thromboembolism: reducing the risk NICE guidance CG144 Venous thromboembolic diseases Communication/ Doctors and other clinical staff during Trust induction. implementation/ training plan(s) Version 1.5 (amended April 2013) Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 1 of 36

25 QUICK REFERENCE GUIDE The quick reference guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware and follow the detail of this policy Pulmonary Embolism (PE) is the most common preventable cause of hospital death, being responsible for approximately 10% of hospital deaths. All patients must have a documented risk assessment for venous thromboembolism (VTE) undertaken by the admitting doctor on admission to hospital and a decision made about the method of thromboprophylaxis. All patients must be periodically reassessed during inpatient stay as risk may change. Reassessment should be undertaken at 24 hours. (See section 5.4) Low molecular weight heparin (LMWH) prophylaxis in an appropriate dose should be considered in all hospitalised patients weighing thrombotic risk against bleeding risk. All inpatients should be offered graduated compression stockings (GCS) as thromboembolic deterrents (TED) unless contraindicated. TEDs and Flowtron boots should be considered for all patients at high risk of bleeding or in whom the use of LMWH is contraindicated. TEDs and Flowtron boots may be considered as an adjunct to LMWH prophylaxis. Aspirin is NOT recommended as the sole VTE prophylaxis for any patient group All patients on LMWH should have an admission weight recorded on the drug chart, core assessment document, and on a weight chart where applicable. (See section 4.1) Monitoring of LMWH is recommended in patients receiving therapeutic doses belonging to the following categories: obese patients, pregnant women, children and patients with renal failure. (See section 4.1) All patients on LMWH should have the results of their renal function reviewed in the medical notes from bloods results within two days of starting treatment. Patient Discharge Summaries should have the name of the LMWH, indication of use, dose and duration of treatment clearly documented. All patients who had Total Hip Replacement (THR) and Total Knee Replacement should be given Dabigatran orally. (See section Orthopaedics and Trauma) unless contra-indicated. All patients should have verbal and written information about VTE on admission and discharge (and at pre-admission where applicable) Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 2 of 36

26 Table of Contents Ref Contents Page No. 1. Purpose 4 2. Scope 4 3. Guidelines for thromboprophylaxis Introduction & General recommendations 5 3.2a Risk factors for Venous Thromboembolism 6 3.2b Risk factors for Bleeding Surgical Patients: General Points General surgery Orthopaedics and trauma Spinal cord injury Podiatry Gynaecology Urology Head and Neck, ENT surgery Ophthalmic Combined oral contraceptive pill (cocp), Hormone 11 Replacement Therapy (HRT) and surgery 3.5 Cancer Medical Patients Critical Care Stroke Long distance travel Obstetrics Palliative Care Patient information Guidelines for treatment of Deep vein thrombosis (DVT)/ Pulmonary embolism (PE) General recommendations Treatment details Assessment of patients diagnosed with a spontaneous VTE 4.1 Guidelines for use of Tinzaparin Dose calculation Contraindications Dosing and Monitoring Renal impairment Reversal Regional anaesthesia 2010 Amendments 4.2 Guidelines for use of unfractionated heparin Protocol for dose adjustment Reversal Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 3 of 36

27 4.3 Guidelines for use of warfarin 25 Warfarin loading Reversal 4.4 Warfarin and anti-platelet agents Appendix Mechanical Thromboprophylaxis Inferior Vena Cava Filters Wells score for DVT and PE Risk assessment proforma for thromboprophylaxis Bridging protocols for peri-operative management of 33 anticoagulation 5.6 Monitoring the effectiveness Abbreviated NICE guidance CG References 36 1 PURPOSE The aims of this guideline are: To ensure the prevention of venous thromboembolism (VTE) in Medical and Surgical inpatients according to current best practice. To ensure treatment of Deep Vein Thrombosis (DVT) / Pulmonary Embolism (PE) according to current best practice. To provide information on the use of low molecular weight heparin (LMWH), unfractionated heparin (UFH), warfarin and other anticoagulants. 2 SCOPE The guideline applies to all Medical and Nursing staff working within West Middlesex University Hospitals NHS Trust. This guideline applies to the care of adult patients only. Paediatric patients are excluded from this guideline. 3 GUIDELINE FOR THROMBOPROPHYLAXIS 3.1a INTRODUCTION Approximately 10% of hospital deaths are attributed to pulmonary embolism. PE is the most common preventable cause of hospital death. The prevention of symptomatic VTE is important since it is associated with considerable acute morbidity and long term clinical and financial sequelae. Many VTEs associated with hospital admissions occur after discharge. Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 4 of 36

28 3.1b GENERAL RECOMMENDATIONS All patients must have a documented risk assessment for venous thromboembolism (VTE) undertaken by the admitting doctor on admission to hospital and a medical decision made about the method of thromboprophylaxis. This should be documented on Real Time and prescribed on the treatment chart. Low molecular weight heparin (LMWH) prophylaxis in an appropriate dose should be considered in all hospitalised patients weighing thrombotic risk (section 3.2a) against bleeding risk (section 3.2b), according to the guidelines that follow. All inpatients should be offered graduated compression stockings (GCS) as thromboembolic deterrents (TED) unless contraindicated. Prophylactic TEDs should comply with standards (British Grade II). TEDs and Flowtron boots may be considered as an adjunct to LMWH prophylaxis and should be considered for all patients at high risk of bleeding or in whom the use of LMWH is contraindicated. Patients should be encouraged to mobilise and dehydration prevented. Patients should be reassessed at 24 hours or if the clinical situation changes during their in-patient stay as the risk may change. Aspirin is NOT recommended as the sole VTE prophylaxis for any patient group All patients on LMWH should have an admission weight recorded on the drug chart, core assessment document, and on a weight chart where applicable. (See section 4.1) Dose adjustment of LMWH may be required in patients belonging to the following categories: obese patients, pregnant women, children and patients with renal failure. (See section 4.1) All patients on LMWH should have the results of their renal function reviewed in the medical notes from bloods results within two days of starting treatment. Patient Discharge Summaries should have the name of the LMWH, indication of use, dose and duration of treatment clearly documented. All patients who had Total Hip Replacement (THR) and Total Knee Replacement should be given Dabigatran orally. (See section Orthopaedics and Trauma) unless contra-indicated. All patients should have verbal and written information about VTE on admission and discharge (and at pre-admission where applicable). Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 5 of 36

29 3.2a RISK FACTORS FOR VENOUS THROMBOEMBOLISM Immobilisation, bed rest, limb paralysis Surgery especially o hip and knee replacement o hip facture o to pelvis or lower limb with total anaesthetic time >60 min o total anaesthetic time >90 min o acute surgical admission with inflammatory or intra-abdominal condition o Critical care admission Trauma (major or lower extremity) Active cancer or cancer treatment* (hormones, chemotherapy, radiotherapy) Age > 60 years Dehydration History of Venous Thromboembolism* Idiopathic or acquired thrombophilia Family history of VTE in a first degree relative i.e. parent or sibling Significant medical comorbidities o Heart disease o Metabolic, endocrine or respiratory pathologies o Acute infectious diseases o Inflammatory conditions including inflammatory bowel diseases Obesity* (Body Mass Index > 30 kg/m 2 ) Pregnancy and the post-partum period* (up to six weeks after delivery) Oestrogen-containing oral contraception or Hormone Replacement Therapy Selective oestrogen response modifiers (SERMs) e.g. raloxifene Varicose veins with phlebitis *Conditions in bold are major patient risk factors Miscellaneous conditions Nephrotic syndrome Myeloproliferative disorders Prolonged travel (> 4hours) Paroxysmal nocturnal haemoglobinuria Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 6 of 36

30 3.2b RISK FACTORS FOR BLEEDING Active bleeding Acquired bleeding disorders (such as acute liver failure) Concurrent use of anticoagulants known to increase the risk of bleeding (such as warfarin with international normalised ratio [INR] higher than 2) Lumbar puncture/epidural/spinal anaesthesia expected within the next 12 hours Lumbar puncture/epidural/spinal anaesthesia within the previous 4 hours Acute stroke Thrombocytopenia (platelets less than 75 x 109/l) Uncontrolled systolic hypertension (230/120 mmhg or higher) Untreated inherited bleeding disorders (such as haemophilia and von Willebrand s disease) 3.3 SURGICAL PATIENTS General points: Surgical and trauma patients are at increased risk of VTE if they meet one of the following criteria: surgical procedure with a total anaesthetic and surgical time of more than 90 minutes, or 60 minutes if the surgery involves the pelvis or lower limb acute surgical admission with inflammatory or intra-abdominal condition expected significant reduction in mobility one or more of the risk factors: Active cancer or cancer treatment Age over 60 years Critical care admission Dehydration Known thrombophilias Obesity (body mass index [BMI] over 30 kg/m2) One or more significant medical comorbidities (for example: heart disease; metabolic, endocrine or respiratory pathologies; acute infectious diseases; inflammatory conditions) Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 7 of 36

31 Personal history or first-degree relative with a history of VTE Use of hormone replacement therapy Use of oestrogen-containing contraceptive therapy Varicose veins with phlebitis (see obstetric guidelines for women who are pregnant or have given birth within the previous 6 weeks). All patients should be encouraged to mobilise as soon as possible. Dehydration should be avoided unless clinically indicated. Regional anaesthesia should be used where practicable. Clinicians should time the administration of pharmacological prophylaxis appropriately. Prophylaxis is not required if patients are undergoing a procedure under local anaesthetic and will have no consequent reduction in mobility. Mechanical prophylaxis should be commenced on admission. Pharmacological prophylaxis should be offered to all patients at increased risk of VTE as long as this is not outweighed by a significant risk of bleeding (see section 3.2b). Pharmacological prophylaxis should be commenced hours pre or 12 hours postoperatively unless patients require bridging anticoagulation (refer to Bridging protocol- appendix 5.5). For patients with high risk of bleeding, use TEDs + Flowtrons and commence pharmacological prophylaxis when bleeding risk is reduced. The SPC for enoxaparin recommends a dose of 20mg in low-moderate risk surgical patients and 40mg for patients at higher risk. Clinical judgement should be used to assess higher risk in terms of procedure (e.g. orthopaedic operations) and patient factors (e.g. previous VTE, obesity, cancer, multiple risk factors) to determine whether the higher 40mg dose should be used. Second line drugs in Elective HR and TKR Dabigatran is recommended for first line use. This is agreed by Orthopaedics and Haematology. Where patients are intolerant of Dabigatran, or for other patient specific clinical reasons, Rivaroxaban is also NICE approved and may be considered. Further advice is available from Haematology/Orthopaedic/ Pharmacy Drug Information a GENERAL SURGERY Surgical procedure with a total anaesthetic and surgical time of less Patient risk factors Recommendation: Duration Low risk (no patient risk factors) Low Risk (<10% risk of calf vein thrombosis) Early and frequent ambulation Moderate risk TEDs + Until ambulatory Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 8 of 36

32 than 90 minutes Not acute surgical admission No reduction in mobility Surgical procedure with a total anaesthetic and surgical time of more than 90 minutes Acute surgical admission with inflammatory or intraabdominal condition Expected significant reduction in mobility (one minor risk factor) High risk (one major or several minor risk factors) Low risk (no patient risk factors) Moderate- high risk (any patients risk factors) Enoxaparin 20mg once daily TEDs + Enoxaparin 40mg once daily +/- Flowtrons until ambulatory. TEDs + Enoxaparin 20-40mg once daily TEDs + Enoxaparin 40mg once daily +/- Flowtrons until ambulatory. Until ambulatory Until ambulatory Until ambulatory except in high risk patients (previous recent VTE, cancer surgery) when Enoxaparin should be continued for 30 days b VASCULAR SURGERY no additional patient risk factors additional patient risk factors 3.3.1c LAPAROSCOPIC SURGERY no additional patient risk factors ORTHOPAEDICS AND TRAUMA Elective Total Hip Replacement Elective Total Knee Replacement Knee Arthroscopy additional patient risk factors If high risk of bleeding If high risk of bleeding Routine arthroscopy with no patient risk factors TEDs (caution if peripheral vascular disease) + early mobilisation TEDs (caution if peripheral vascular disease) + Enoxaparin 20-40mg once daily TEDs + early mobilisation TEDs + Enoxaparin 20-40mg once daily TEDs + Dabigatran (See Protocol for use of Dabigatran). Use Intermittent pneumatic compression (IPC) until bleeding risk diminishes.. LMWH should be added when bleeding risk decreases. TEDs + Dabigatran (See Protocol for use of Dabigatran) or IPC Use Intermittent pneumatic compression (IPC) until bleeding risk diminishes.. LMWH should be added when bleeding risk decreases. Early mobilisation Until ambulatory Until ambulatory 28 days from date of surgery 10 days from date of surgery Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 9 of 36

33 Prolonged/complicated Enoxaparin 40mg once daily procedure or risk factors Hip Fracture Surgery TEDs + Enoxaparin 40mg once daily. If high risk of bleeding Intermittent pneumatic compression (IPC) until bleeding risk diminishes.. Prophylactic dose LMWH should be added when bleeding risk decreases. Elective spine surgery No patient risk factors Early mobilisation. With patient risk factors TEDs + Enoxaparin 40mg once daily +/- Flowtron boots. Trauma patients Isolated injuries distal to the knee SPINAL CORD INJURY Without prophylaxis, SCI patients have the highest incidence of DVT among all hospitalised groups (asymptomatic DVT occurs in %) PODIATRY Incidence of procedure related symptomatic VTE is 0.3%, increasing to 4.6% with prior VTE. Risk assessment tools not validated At least one risk factor for VTE Consider if lower limb plaster cast required TEDs + Enoxaparin 40mg once daily. IPC +/- TEDs if LMWH contraindicated Contraindications to early initiation of Enoxaparin in trauma include: Spinal cord injury Lower extremity / pelvic fracture Major head injury Indwelling femoral line Consider Doppler Ultrasound screening if high risk. Early mobilisation. Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 10 of 36 Until mobile 4 weeks from date of surgery. If hip fracture surgery delayed, LMWH should be given between hospital admission and surgery. Until mobile LMWH should be commenced after primary haemostasis has been achieved Thromboprophylaxis should be continued until optimal mobility is achieved Consider continuing thromboprophylaxis until lower limb plaster cast removed. No patient risk factors With patient risk factors Routine thromboprophylaxis Until mobile Lower limb plaster cast required All patients with spinal cord injury (SCI) should have thromboprophylaxis Consider thromboprophylaxis TEDs + Enoxaparin 40mg once daily when primary haemostasis is achieved Flowtron boots should be used when Enoxaparin is contra indicated Inferior Vena Caval Filter is not recommended as primary prophylaxis No patient risk factors early mobilisation With prior h/o VTE TEDs + Enoxaparin 20-40mg peri-procedure With more than 1 risk TEDs + factors including prior Enoxaparin 20-40mg peri-procedure VTE Lower limb plaster cast Consider thromboprophylaxis required Until lower limb plaster cast removed. Enoxaparin or a Vitamin K antagonist should be continued into the rehabilitation phase consider using until ambulatory Until lower limb plaster cast removed.

34 GYNAECOLOGY Brief procedure <30 minutes duration (including laparoscopic surgery) No patient risk factors Early mobilisation. With patient risk factors TEDs + Enoxaparin 40mg once daily until ambulatory Major surgery TEDs + Enoxaparin 40mg once daily until ambulatory UROLOGY Transurethral and other simple procedures No patient risk factors Early mobilisation. With patient risk factors TEDs + Enoxaparin 40mg once daily until ambulatory TEDs + Enoxaparin 40mg once daily until ambulatory Major, open urologic procedures HEAD AND NECK, ENT SURGERY (There is little evidence on which to base recommendations) Non-major surgery No patient risk factors specific prophylaxis not recommended With patient risk factors TEDs + Enoxaparin 40mg once daily Major cancer surgery in head and neck OPHTHALMIC There is no evidence on which to base recommendations TEDs + Enoxaparin 40mg once daily until ambulatory until ambulatory 3.4 COMBINED ORAL CONTRACEPTIVE PILL (cocp), HRT OR RALOXIFENE IN THE PERIOPERATIVE PERIOD Patients can reduce the overall risk of perioperative VTE to that of non-users by stopping these medications 4 weeks prior to surgery. If stopped, provide advice on alternative contraceptive methods. 3.5 CANCER Cancer surgery with no additional patient risk factors Recommendation: use routine thromboprophylaxis that is appropriate to the type of surgery. Cancer surgery with other risk factors Recommendation: TEDs + Enoxaparin 40mg once daily until ambulatory or preferably for 28 days. Major cancer surgery to abdomen/pelvis Recommendation: TEDs + Enoxaparin 40mg once daily until ambulatory or preferably for 28 days. Cancer patients with indwelling venous catheters Recommendation: LMWH or mini dose warfarin should not be used to prevent catheter related thrombosis. Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 11 of 36

35 Cancer patients receiving chemotherapy or hormonal therapy Recommendation: routine use of thromboprophylaxis should not be used for primary prevention of VTE or to improve survival. 3.6 MEDICAL PATIENTS Thromboprophylaxis is recommended for medical in-patients who have had or are expected to have significantly reduced mobility for 3 days or more or are expected to have ongoing reduced mobility relative to their normal state and have one or more additional risk factors: Active cancer or cancer treatment Age over 60 years Critical care admission Dehydration Known thrombophilias Obesity (body mass index [BMI] over 30 kg/m2) One or more significant medical comorbidities (for example: heart disease; metabolic, endocrine or respiratory pathologies; acute infectious diseases; inflammatory conditions) Personal history or first-degree relative with a history of VTE Use of hormone replacement therapy Use of oestrogen-containing contraceptive therapy Varicose veins with phlebitis (see obstetric guidelines for women who are pregnant or have given birth within the previous 6 weeks) Pharmacological prophylaxis should be offered to all patients at increased risk of VTE as long as this is not outweighed by a significant risk of bleeding (see section 3.2b) For stroke patient see section 3.8 below. Recommendation: Enoxaparin 40mg once daily Patients considered to be at high risk for bleeding use TEDs (contraindicated in acute stroke however intermittent pneumatic compression device could be considered as an alternative) Thromboprophylaxis should be continued until the patient is no longer at increased risk of VTE. 3.7 CRITICAL CARE All patients should be risk assessed on admission and frequently during their stay as the balance of VTE risk and bleeding risk may change with fluctuations in the patient s condition. Recommendation: In patients with moderate or high risk of VTE, use LMWH. If egfr is <30ml/min Unfractionated Heparin should be prescribed. Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 12 of 36

36 When LMWH/UFH is contraindicated use TEDs and /or IPC until the bleeding risk decreases. 3.8 STROKE Do not use TEDs. Consider LMWH if Haemorrhagic stroke excluded Low risk of haemorrhagic transformation of ischaemic stroke Low risk of bleeding into another site Additional risk factors including dehydration, decreased mobility prior history of VTE and other comorbities Consider intermittent compression devices if pharmacological prophylaxis is contra-indicated and patient is at significant risk of VTE 3.9 LONG DISTANCE TRAVEL For long distance air travel (>4 hrs) with additional risk of VTE risk factors the following are reasonable precautions: frequent ambulation, calf muscle exercises. There is a lack of evidence to support these recommendations. It is likely that recent major surgery (within 1 month), active malignancy, previous unprovoked VTE, previous travel-related VTE with no associated temporary risk factor or presence of more than one risk factor identifies those travellers at highest thrombosis risk. Travellers at the highest risk of travel-related thrombosis undertaking journeys of >3 h should wear well fitted below knee compression hosiery. Prophylactic doses of LMWH prior to flying may be considered in those with significant risk factors; however there is no evidence to support this recommendation OBSTETRICS Consider offering pharmacological VTE prophylaxis with LMWH (or UFH for patients with renal failure) to women who are pregnant or have given birth within the previous 6 weeks who are admitted to hospital but are not undergoing surgery, and who have one or more of the following risk factors: expected to have significantly reduced mobility for 3 or more days active cancer or cancer treatment age over 35 years critical care admission dehydration excess blood loss or blood transfusion Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 13 of 36

37 known thrombophilias obesity (pre-pregnancy or early pregnancy BMI over 30 kg/m2) one or more significant medical comorbidities (for example: heart disease; metabolic, endocrine or respiratory pathologies; acute infectious diseases; inflammatory conditions) personal history or a first-degree relative with a history of VTE pregnancy-related risk factor (such as ovarian hyperstimulation, hyperemesis gravidarum, multiple pregnancy or pre-eclampsia) varicose veins with phlebitis. Consider offering combined VTE prophylaxis with mechanical methods and LMWH (or UFH for patients with renal failure) to women who are pregnant or have given birth within the previous 6 weeks who are undergoing surgery, including caesarean section. Offer mechanical and/or pharmacological VTE prophylaxis to women who are pregnant or have given birth within the previous 6 weeks only after assessing the risks and benefits and discussing these with the woman and with healthcare professionals who have knowledge of the proposed method of VTE prophylaxis during pregnancy and post-partum. Plan when to start and stop pharmacological VTE prophylaxis to minimise the risk of bleeding. Please refer to obstetric guidelines for further information PALLIATIVE CARE Consider VTE prophylaxis in palliative care patients if there is a potentially reversible acute pathology Take into account the risks and benefits of prophylaxis and the views of the patient, family and carers. Review the appropriateness of prophylaxis regularly PATIENT INFORMATION Be aware that heparins are of animal origin and this may be of concern to some patients. For patients who have concerns about using animal products, consider offering synthetic alternatives based on clinical judgement and after discussing their suitability, advantages and disadvantages with the patient. Before starting VTE prophylaxis, offer patients and/or their families or carers verbal and written information on: the risks and possible consequences of VTE the importance of VTE prophylaxis and its possible side effects the correct use of VTE prophylaxis (for example, anti-embolism stockings or intermittent pneumatic compression devices). how patients can reduce their risk of VTE (such as keeping well hydrated and, if possible, exercising and becoming more mobile). Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 14 of 36

38 As part of the discharge plan, offer patients and/or their families or carers verbal and written information on: the signs and symptoms of deep vein thrombosis and pulmonary embolism the correct and recommended duration of use of VTE prophylaxis at home (if discharged with prophylaxis) the importance of using VTE prophylaxis correctly and continuing treatment for the recommended duration (if discharged with prophylaxis) the signs and symptoms of adverse events related to VTE prophylaxis (if discharged with prophylaxis) the importance of seeking help and who to contact if they have any problems using the prophylaxis (if discharged with prophylaxis) the importance of seeking medical help and who to contact if deep vein thrombosis, pulmonary embolism or other adverse events are suspected. Ensure that patients who are discharged with anti-embolism stockings: understand the benefits of wearing them understand the need for daily hygiene removal are able to remove and replace them, or have someone available who will be able to do this for them know what to look for, such as skin marking, blistering or discolouration, particularly over the heels and bony prominences know who to contact if there is a problem. Ensure that patients who are discharged with pharmacological and/or mechanical VTE prophylaxis are able to use it correctly, or have arrangements made for someone to be available who will be able to help them. Notify the patient s GP if the patient has been discharged with pharmacological and/or mechanical VTE prophylaxis to be used at home. Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 15 of 36

39 4.0 TREATMENT OF DEEP VEIN THROMBOSIS (DVT)/ PULMONARY EMBOLISM (PE) 4.01 GENERAL RECOMMENDATIONS Use the Wells scoring system (see Wells score: appendix 5.3) to make a clinical diagnosis of VTE. Upon diagnosing DVT or PE, commence treatment with Tinzaparin (see section 4.1) at 175 units/kg subcutaneously and loading dose of warfarin. Tinzaparin should be continued for at least 5 days or until the INR is in target range for 2 days whichever is longer. Rivaroxaban may also be used in some patients. If diagnostic tests are delayed and clinical suspicion of VTE is high, start LMWH while waiting for confirmation of diagnosis. Start warfarin (see section 4.3) when diagnosis of VTE is confirmed. A Doppler ultrasound should be carried out within 24 hours of assessment. NICE guidance recommends that patients undergo proximal leg ultrasound rather than whole leg ultrasound. In patients with high clinical risk (high Wells score and positive D-dimer) and initial negative proximal Doppler ultrasound, a Doppler ultrasound should be repeated a 7 days). If a whole leg ultrasound is carried out, this does not need to be repeated if negative, unless there is significant clinical concern or progression of symptoms. Treat patients with DVT as out-patients where possible. In acute VTE and severe renal failure, use unfractionated heparin (see section 4.2). In patients with acute proximal DVT or PE, if anti-coagulation is not possible because of risk of bleeding, consider placement of IVC filter. Commence treatment with anti-coagulation and remove filter once risk of bleeding resolves. Patients with symptomatic proximal DVT should be offered Grade 2 graduated compression stockings (GCS/TEDs) which provide an ankle pressure gradient of mm Hg. This pressure gradient is higher than that recommended for prophylactic TEDs. Their use should be continued for 2 years or longer. They should be encouraged to be mobile and prescribed analgesics as necessary. In patients with PE, thrombolytic treatment should be used when there is haemodynamic compromise and this should be administered via a peripheral cannula over a short (e.g. 2 hour) infusion. In massive PE where sub- cutaneous absorption is doubtful or where thrombolytic treatment is being considered, use intravenous adjusted dose unfractionated heparin (see section 4.2). Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 16 of 36

40 4.02 TREATMENT DETAILS Duration: VTE related to reversible factors: 3 months Unprovoked VTE: 3-6 months, consider long term anticoagulation. See section nd episode of unprovoked VTE: Consider long term anti-coagulation. See section VTE + cancer: use LMWH for 6 months. Then consider substitution with warfarin indefinitely or until cancer resolves. Target INR: 2.5 (2-3) including patients with antiphospholipid syndrome Other clinical situations: 3.5 (3-4) recurrent VTE while on anticoagulation with INR within therapeutic range Treatment of asymptomatic DVT should be as for symptomatic DVT Treatment of infusional thrombophlebitis: Oral or topical NSAID s for 2 weeks or until symptom resolution. Treatment of superficial vein thrombosis: Prophylactic or intermediate therapeutic doses (80units/kg) of Tinzaparin for 4 weeks or warfarin (target INR 2) for 4 weeks. VTE at unusual sites e.g. mesenteric vein thrombosis- refer for specialist Haematology opinion. Upper extremity DVT- Treat with LMWH as for leg DVT, do not remove indwelling catheter if catheter is functional and there is ongoing need for its use unless symptoms persist despite anti-coagulation. Clot directed thrombolysis may be considered only in patients with severe symptoms of recent onset. Anticoagulation should be given for minimum 3 months regardless of whether the catheter is left in or removed. Routine use of compression bandages is not required ASSESSMENT OF PATIENTS DIAGNOSED WITH A SPONTANEOUS VTE All patients diagnosed with an unprovoked VTE should be screened for cancer with: a physical examination (guided by the patient's full history) and a chest X-ray and blood tests (full blood count, serum calcium and liver function tests) and urinalysis. Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 17 of 36

41 Consider further investigations for cancer with an abdomino-pelvic CT scan (and a mammogram for women) in all patients aged over 40 years with a first unprovoked DVT or PE who do not have signs or symptoms of cancer based on initial investigation (see recommendation above). All patients with an unprovoked VTE should be considered for long-term anticoagulation. This should take into account Thrombosis risk factors Bleeding risk from continued anticoagulation (see HASBLED score*) Patient preference All patients with an unprovoked VTE should be screened for anti-phospholipid syndrome (lupus anticoagulant and antibodies to cardiolipin and beta glycoprotein I). If this is positive then long-term anti-coagulation should be strongly recommended. D-dimer can be used for risk stratification in patients with an unprovoked VTE who have stopped anticoagulation. Residual vein occlusion has no predictive value independent of d-dimer measurement. In a systematic review of patients who had completed at least 3 months of anticoagulation for a first episode of unprovoked VTE and after approximately 2 years of follow-up, a negative D-dimer result was associated with a 3.5% annual risk for recurrent disease, whereas a positive D-dimer result was associated with an 8.9% annual risk for recurrence. Testing for inherited thrombophilia (antithrombin, protein C, protein S, factor V Leiden and prothrombin gene mutation) should not be carried out routinely. This should only be done if there is a first degree relative with VTE. Other cases should be discussed with the haematology team. Thrombophilia testing only be carried out once the patient has completed anti-coagulation. Patients with intra-abdominal thrombosis should be screened for the JAK-2 mutation and have a PNH screen. * The HASBLED score was developed to assess bleeding risk in patients on warfarin for AF: Letter Clinical Characteristic Points Awarded H Hypertension (uncontrolled, >160 mmhg systolic) 1 A Abnormal renal and liver function (1 point each) 1 or 2 S Stroke 1 B Bleeding history or predisposition [anemia] 1 L Labile INRs [i.e. therapeutic time in range <60%] 1 E Elderly (>65) 1 D Drugs or alcohol (1 point each) [antiplatelet agents, non-steroidal anti-inflammatory drugs] Maximum possible score is 9 1 or 2 Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 18 of 36

42 The risk of major bleeding within one year in atrial fibrillation patients enrolled in the Euro Heart Survey. HAS-BLED score n Bleeds, n Bleeds/100 patients* Any score Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 19 of 36

43 4.1 GUIDELINES FOR USE OF TINZAPARIN DOSE CALCULATION INDICATION DRUG AND DOSE COMMENTS (A) Treatment of DVT and Tinzaparin DO NOT MONITOR APPT PE 175 units/kg sc od Pre-filled syringes 20,000 units/ml For at least 5 days or until oral anticoagulation established. Overlap warfarin and LMWH by two days. Do not use multidose vials in patients who are pregnant. (B) Treatment unstable angina and Non ST Elevation MI (See the ACS guideline under Cardiology on the intranet) (C) Treatment of ST Elevation MI For the treatment of unstable angina and Non ST Elevation MI (except those patients receiving emergency (<120minutes) PCI: Fondaparinux 2.5mg SC od For the treatment of ST Elevation MI in patients not receiving emergency PCI Fondaparinux 2.5mg SC od The first dose should be administered intravenously* and subsequent doses by subcutaneous injection The first dose should be administered intravenously* and subsequent doses by subcutaneous injection CONTRAINDICATIONS to the use of unfractionated heparin or low molecular weight heparin: Known hypersensitivity to specific heparin product Generalised haemorrhagic tendency Uncontrolled severe hypertension Active peptic ulcer Septic endocarditis Heparin-Induced Thrombocytopenia (HIT) CAUTION (heparin induced thrombocytopenia) On starting heparin Check a baseline FBC. Platelet monitoring if patients are on unfractionated heparin or on LMWH post cardiac bypass. If the platelet count falls by more than 50% of the baseline, discontinue heparin and seek advice from a Haematologist. Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 20 of 36

44 DOSING AND MONITORING Obese patients (BMI >40 kg/m2): Use weight (preferably lean body mass) based dosing for prophylactic doses. Children: Use weight based dosing but children aged between 0 to 5 years will require longer to achieve therapeutic levels and may require increasing the therapeutic dose from the standard 175 units/kg to units/kg/day. Tinzaparin has an anti Xa : anti IIa ratio of 1.6:1 (3.9:1 for Enoxaparin). Monitoring of Tinzaparin is recommended for the following patients receiving therapeutic doses: o Patients at extremes of body weight o pregnant women o children o patients with renal failure. Frequency of monitoring should be approximately once a month or less. Monitoring is done by measurement of anti Xa levels at 4 hours after the injection. For anti-xa levels blood should be taken in a citrated (light blue top) tube. Peak anti-xa levels of 0.6 to 1.0 anti-xa unit/ml (mean 0.85 units/ ml) are considered therapeutic for once-a-day Tinzaparin. These are seen 3 to 4 hours after a subcutaneous dose is given. Trough levels of <0.2 anti-xa units/ml are considered acceptable. There is a lack of complete co-relation between the efficacy and safety of LMWH and the anti-xa levels. A level of anti- Xa units/ml is considered appropriate for prophylactic purposes when measured 4 hours after the injection. Prophylactic Tinzaparin does not usually require monitoring. RENAL IMPAIRMENT Additional caution in: Severe renal impairment as associated with acquired platelet function defect Concurrent use of anti-platelet agents Elderly patients and those with low body mass index as egfr likely to overestimate actual GFR Prophylaxis: egfr >30 ml/min: standard dose prophylactic LMWH egfr ml/min: Consider 50% dose prophylactic LMWH egfr <20 ml/min: 5000 units unfractionated heparin sc twice daily (consider reducing to 2500 units if clinical concern) Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 21 of 36

45 Treatment In severe renal impairment (Serum Creatinine >400 micromol /L), consider use of unfractionated heparin. If LMWH is used, start treatment at 50% of recommended prophylactic or therapeutic dose, it will be necessary to monitor anti factor Xa activity. Measure peak (6 hours) and trough levels (at 24 hours) to adjust the dose. REVERSING ANTICOAGULATION WITH TINZAPARIN If LMWH is given within 8 hours, administer Protamine sulphate in a dose of 1mg per 100units (=anti Xa units) Tinzaparin administered. Usually, a standard dose of 50 mg is used in the first instance. It should be administered as a slow IV injection given over 10 minutes. This neutralises approximately 65% to 85% of the anti-xa activity almost immediately. A second dose of 0.5 mg Protamine sulphate per 100 anti-xa units should be administered if bleeding continues. Smaller doses of Protamine sulphate can be given if the time since LMWH administration is longer than 8 hours. APTT (reflecting neutralisation of anti IIa activity) will normalise sooner than anti Xa levels. If Protamine sulphate is first administered later than three hours after Tinzaparin administration, an adjustment in dosage may be considered to reflect decreasing tissue levels of Tinzaparin. Volunteer data shows peak plasma levels occurring 4-6 hours post sc administration. USE OF LMWH AND ANAESTHESIA The use of LMWH in patients undergoing regional anaesthesia (i.e. spinal and epidural anaesthesia) may be associated with epidural or spinal haematoma. The following guidance must be adhered to: Do not use regional anaesthesia until: At least 12 hours after a prophylactic dose of LWMH or At least 24 hours after a therapeutic dose of LWMH Do not remove an epidural catheter until: At least 12 hours after a prophylactic dose of LWMH or At least 24 hours after a therapeutic dose of LWMH Do not give a dose of LWMH until 4 hours after the removal of an epidural catheter Do not give a dose of LWMH until 4 hours after the insertion of a spinal block Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 22 of 36

46 AMENDMENTS 2010 REGARDING USE OF TINZAPARIN All patients on low molecular weight heparin (LMWH) should have an admission weight recorded on the drug chart, core assessment document, and on a weight chart where applicable. All patients on LMWH should have the results of their renal function reviewed in the medical notes from bloods results from within two days prior or after the initiation of treatment. Clinically stable patients (eg. those who attend pre-assessment clinic) requiring prophylactic dose of LMWH need not have their renal functions re-checked on admission if LMWH is used in prophylactic doses. In critically ill patients who require prophylactic dose of LMWH renal function must be checked and reviewed within two days of starting LMWH. All wards should have current LMWH dosing guides available in the treatment rooms and at nursing stations, or anywhere else that is appropriate. All wards should have current LMWH dosing guides available in the treatment rooms and at nursing stations, or anywhere else that is appropriate. Patient Discharge Summaries should have the name of the LMWH, indication of use, dose and duration of treatment clearly documented. Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 23 of 36

47 4.2 GUIDELINES FOR THE USE OF UNFRACTIONATED HEPARIN Protocol for dose adjustment of unfractionated Heparin 1. Before starting or restarting IV Heparin treatment, APTT, LFT and platelets should be screened. 2. Use heparin 20,000 units in 20 ml. Do not dilute. 3. Loading dose: heparin 80 units per kg body weight as an IV infusion over 5 minutes. 4. Start initial infusion of heparin at 18 units per kg per hour (0.018 ml/kg/hr) 5. Check APTT ratio 4-6 hours after starting heparin and 4-6 hours after each dose change. Adjust dose as shown below to maintain target APTT ratio. The dose is changed by altering the flow rate. 6. Target APTT ratio is When stable, ensure that the APTT is measured every 24 hours. 7. Dose adjustment: Weight Based Nomogram APTT ratio /APTT Dose Initial dose 80 units/kg bolus, then 18 units/kg/hr (0.018 ml/kg/hr) <1.2 /<35 s 80 units/kg bolus, then increase by 4 units/kg/hr /35-45 s 40 units/kg bolus, then increase by 2 units/kg/hr /46-70s No change /71-90s Decrease infusion rate by 2 units/kg/hr > 3.0 />90s Stop infusion for 1hour, then decrease infusion rate by 3units/kg/hr Therapeutic APTT range of s corresponds to anti-xa activity of U/ml. Reversal 1mg of Protamine sulphate will reverse 100 units of Heparin. For a patient who has recd IV bolus of 5000 units and experiences a bleed, use 50 mg of Protamine sulphate. Half life of Protamine sulphate is 7 minutes and half life of UFH is minutes. Therefore only use the recent dose of UFH in calculating the dose of Protamine sulphate. Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 24 of 36

48 4.3 GUIDELINES FOR THE COMMENCEMENT OF WARFARIN WARFARIN LOADING SCHEDULE: Warfarin dosing DAY INR DOSE (mg) 1 < or patients >60 years >2.0 2 No test required 10 10* 5 None 5 (if INR> 1.4 on day 1 or patients >60 years 3 < > Omit dose 4 (Predicted maintenance dose) < >4.5 > Miss next day s dose then give 2mg Miss 2 days doses then give 1mg * First dose should be reduced if base-line prothrombin time prolonged/ INR raised, if liver function tests abnormal, or if patient in cardiac failure, on parenteral feeding, less than average body weight, elderly or receiving other drugs known to potentiate oral anticoagulants. REVERSAL Patients with rapid onset neurological symptoms need urgent INR and CT within an hour. Please discuss other life/ function threatening haemorrhage such as intraocular/ pericardial / retroperitoneal (confirmed by radiology)/ compartment/ active bleeding with hypotension, or drop of 2g Hb with the duty Haematology Registrar Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 25 of 36

49 Major bleeding (intra-cranial haemorrhage or other major haemorrhage) Stop warfarin Vitamin K 5-10 mg iv** PCC* (Prothromplex Total) 50 Units/kg iv (discuss with haematologist) Repeat coagulation screen at 20 minutes and 4 hours to ensure adequate correction Seek haematologist advice if inadequate correction Significant bleeding (without haemodynamic compromise) Stop warfarin Vitamin K 5-10 mg iv** PCC* (Prothromplex Total) 30 Units/kg iv (discuss with haematologist) Repeat coagulation screen at 4 hours or if clinical deterioration to ensure adequate correction Seek haematologist advice if inadequate correction Minor bleeding Stop warfarin Vitamin K** 5mg po Consider 0.5 mg vitamin K iv in certain circumstances such as unsteady patients Repeat clotting in 24 hours or sooner if clinical deterioration INR >8, No bleeding Stop warfarin Vitamin K** 5mg po Consider 0.5 mg vitamin K iv in certain circumstances such as unsteady patients Repeat clotting in 24 hours or sooner if clinical deterioration *PCC Prothrombin Complex Concentrate Must be authorised by duty haematologist Obtained from blood transfusion (x5515 / bleep 238 out of hours Administer by slow intravenous infusion at rate of 3 ml/minute PCC should not be used to enable elective or non-urgent surgery **Vitamin K Use the Trust preparation Konakion MM paediatric (Roche) 10mg/ml comes in 0.2ml=2mg ampoules. Administer orally 0.5ml ( 5mg) Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 26 of 36

50 4.4 WARFARIN AND ANTIPLATELET AGENTS In general it is advisable to avoid dual therapy with warfarin and antiplatelet agents due to the increased bleeding risk associated with this combination. If a patient on an antiplatelet agent is to commence warfarin, the antiplatelet agent should be stopped if it is for: Primary prophylaxis of cardiovascular disease Treatment of peripheral vascular disease Previous ischaemic CVA Secondary prophylaxis of cardiovascular disease with aspirin/clopidogrel if ischaemic heart disease is stable and at least 12 months following acute MI. Secondary prophylaxis in patients less than 12 months following acute MI if they are at high risk of bleeding If a patient on warfarin is to commence an antiplatelet agent Consider whether it is possible to stop warfarin Consider a bare metal stent for angioplasty rather than drug eluting, in order to limit duration of combined therapy Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 27 of 36

51 5 APPENDIX 5.1. MECHANICAL PROPHYLAXIS i. Graduated Elastic Compression Stockings (GCS), Thrombo Embolic Deterrent Stockings (TEDs) Should be properly fitted and preferably reach up to mid thigh level. If this is not possible then knee length stockings may be used as an alternative. The stockings should provide 18 mm Hg at the ankle, 14 mm Hg at mid calf and 8 mm Hg at mid thigh level. The stockings should be worn day and night until the patient returns to usual level of mobility. Patients should be shown how to wear them correctly by trained nursing staff. Stockings should be removed daily for hygiene purposes and the underlying skin inspected (more frequently in patients at risk of skin problems). Contraindications: Massive leg oedema Heart failure Severe peripheral arterial disease including peripheral arterial bypass grafting Severe peripheral neuropathy or other causes of sensory impairment Major leg deformity Dermatitis or other conditions in which stockings may cause damage known allergy to material of manufacture Acute stroke ii. Intermittent Pneumatic Compression - Flowtron Boots Should be used for as much of the time as practicable until the patient is ambulatory for a period of at least 72 hours. Contraindications: Severe arteriosclerosis or other ischaemic vascular diseases Known or suspected DVT/PE or phlebitis Severe congestive cardiac failure Local wound or inflammatory/infective condition 5.2 IVC FILTERS iii. Inferior Vena Caval Filters (IVCF) IVC filters are not recommended as primary prophylaxis IVCF insertion is indicated in the presence of proven proximal DVT when either full anticoagulation is contraindicated or major surgery is planned in the near future A plan for IVC filter removal must be made at the time of insertion Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 28 of 36

52 5.3 MODIFIED WELL S SCORE FOR DVT AND PE PRE-TEST PROBABILITY SCORE OF DVT Patient sticker: CLINICAL SCORING SYSTEM* (WELLS ET AL: 1995, 1997) History: Date of assessment: Present? Score Paralysis, paresis or recent plaster immobilisation 1 Bedridden for>3 days and/or major surgery in last 4/52 airline and/or flight>4 hours Active cancer undergoing treatment in last 6 months or on palliative treatment Strong family history of DVT(2 or more affected first degree relatives) On examination: Entire leg swollen 1 Swollen calf>3cm larger than other leg measured (10cm below tibial tuberosity) Tenderness along deep venous system 1 Pitting oedema in symptomatic leg only 1 Dilated superficial veins (non-varicose) 1 Alternative diagnosis likely -2 TOTAL SCORE (RISK CATEGORY: 2 Probability of DVT likely; <2 DVT unlikely) Observations: temperature; pulse; blood pressure; respiratory rate; SpO2 Investigations / Management: Wells scoring (which includes Calf measurements) D-dimer only if Wells score <2. If Wells score 2, arrange USS as D-dimer not useful Analgesia e.g. paracetamol 1g qds po If Wells score <2 and D-dimer +ve, arrange USS. If Wells score <2 and D-dimer ve, DVT is ruled out. Patients are only suitable for Outpatient investigation if mobile, clinically stable and no signs of PE. Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 29 of 36

53 PRE-TEST PROBABILITY SCORE OF PE Patient sticker: Date of assessment: CLINICAL SCORING SYSTEM* (WELLS ET AL: 2000) Present? Clinical signs and symptoms of DVT 3 An alternative diagnosis is less likely than PE 3 Score Heart rate above 100bpm 1.5 Immobilisation or surgery in the previous 4 weeks 1.5 Previous DVT or PE 1.5 Active cancer undergoing treatment in last 6 months or on palliative treatment Haemoptysis 1.0 TOTAL SCORE ( RISK CATEGORY: 4 Probability of PE likely; <4 PE unlikely ) 1.0 Observations: temperature; pulse; blood pressure; respiratory rate; SpO2 Investigations / Management: ABCD resuscitation and oxygen FBC, U&Es ABGs CXR ECG Wells scoring D-dimer only if Wells score <4 and PE a possibility. If Wells score 4, arrange imaging as D-dimer not useful Adequate analgesia LMWH if high pre-test probability or Low / intermediate probability with D-dimer +ve and clinically suspicious If Wells score <4 and D-dimer +ve, reassess considering other diagnoses. Refer for further imaging if PE seems clinically reasonable. If Wells score <46 and D-dimer ve, PE is very unlikely; seek an alternative diagnosis. Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 30 of 36

54 5.4 RISK ASSESSMENT PROFORMA FOR THROMBOPROPHYLAXIS Risk Assessment for Venous Thromboembolism (VTE): Instructions to the admitting doctor Risk assessment must be undertaken on all patients expected to have reduced mobility relative to their normal state on admission to hospital. All patients must be periodically reassessed during inpatient stay as risk may change. Reassessment should be undertaken after at least 48 to 72 hours. Step One Review the patient-related factors shown on the assessment sheet against thrombosis risk, ticking each box that applies (more than one box can be ticked). Use the highest category of risk if more than one box is ticked (e.g. if both moderate and high risk are ticked, use guidance for high-risk patients). Any tick for thrombosis risk should prompt thromboprophylaxis according to guideline. The risk factors identified are not exhaustive. Clinicians may consider additional risks in individual patients and offer thromboprophylaxis as appropriate. Step Two Review the patient-related factors shown against bleeding risk and tick each box that applies (more than one box can be ticked). Any tick for bleeding risk should prompt clinical staff to consider if bleeding risk is sufficient to preclude pharmacological intervention. Step Three If the form has been filled out correctly and no boxes are ticked, then the patient is at low risk of venous thromboembolism and no intervention is indicated. Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 31 of 36

55 Risk Assessment for Venous Thromboembolism (VTE) Thrombosis Risk Patient Related Procedure Related At Admission (tick) High Age >60 years Previous PE or DVT Tinzaparin 4500 u Active cancer s/c daily. Commence Acute or chronic lung disease hours post-op once Acute or chronic inflammatory disease haemostasis Chronic heart failure secure, then 6PM Lower limb paralysis (excluding acute daily. stroke) + TED stockings Acute infectious disease, e.g. pneumonia +/- BMI > 30kg/m² Sequential F/H/o VTE/thrombophilia compression device Immobilisation of lower limbs Hip or knee replacement Hip fracture Other major orthopaedic surgery At 72 hrs (tick) Moderate Tinzaparin 4500 u s/c daily as above + TED stockings Low TEDs/early mobilisation Hormone therapy Pregnant/ post partum Age > 40y Severe varicose veins None of the above Surgical procedure lasting > 30 minutes Plaster cast immobilisation of lower limb Bleeding Risk Patient Related Procedure Related Tick Tick Haemophilia or other known bleeding disorder Known platelet count < 100 Acute stroke in previous month (haemorrhagic or ischaemic) Blood pressure > 200 systolic or 120 diastolic Severe liver disease (prothrombin time above normal or known varices) Severe renal disease Active bleeding Major bleeding risk, existing anticoagulant therapy or antiplatelet therapy Neurosurgery, spinal surgery or eye surgery Other procedure with high bleeding risk Lumbar puncture/spinal/epidural in previous 4 hours LMWH TEDs Other: For details of treatment please refer to Thrombosis Policy on the intranet:haematology/thrombosis/thromboprophylaxis. To seek specialist advice please bleep Haematology SpR on 121/272. JG/MS/jun 2009 Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 32 of 36

56 5.5 BRIDGING PROTOCOLS FOR PERI-OPERATIVE MANAGEMENT OF ANTICOAGULATION- FOR SPECIALIST HAEMATOLOGY USE The following do not require interruption of oral anticoagulation Joint injections Cataract surgery Endoscopy Ensure pre-procedure INR <2.5 Moderate risk Low risk AF (no TIA/CVA) Bi-leaflet mechanical AVR VTE >3/12 since diagnosis High risk VTE within 3/12 of diagnosis AF with previous CVA Other Mechanical MVR High risk patient with significant renal impairment Consider in high risk patient undergoing surgery with high bleeding risk 1. Stop warfarin 5-6 days before surgery 2. Commence standard LMWH prophylaxis 3. Stop prophylactic dose LMWH 12 hours pre-surgery 4. Restart prophylactic dose LMWH 6 hours post-surgery or once haemostasis satisfactory 5. Restart usual dose of warfarin in the evening post-op if haemostasis satisfactory 6. Continue prophylactic LMWH until INR in target range 1. Stop warfarin 5-6 days before surgery 2. Commence treatment dose LMWH once INR<2 (or 2/7 after stopping warfarin) 3. Stop treatment dose LMWH 24 hours pre-surgery (a prophylactic dose of LMWH may be given 12 hours presurgery) 4. Give prophylactic LMWH 6 hours post-surgery or once haemostasis satisfactory 5. Give treatment dose LMWH 24 hours post-surgery or once haemostasis satisfactory 6. Restart usual dose of warfarin in the evening post-op if haemostasis satisfactory 7. Continue treatment dose LMWH until INR in target range. 1. Stop warfarin 5-6 days before surgery 2. Commence unfractionated heparin infusion (UFH) once INR<2 3. Stop UFH infusion 4-6 hours pre-surgery 4. Recommence UFH infusion 6 hours post-surgery or once haemostasis satisfactory 5. Restart usual dose of warfarin in the evening post-op if haemostasis satisfactory 6. Continue UFH infusion until INR in target range. Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 33 of 36

57 5.6 MONITORING COMPLIANCE AND EFFECTIVENESS Monitoring Requirement : how patients are assessed for their risk of developing venous thromboembolism (VTE), including timescales procedure to be followed if VTE is suspected. Monitoring Method: Report Prepared by: Monitoring Report presented to: Frequency of Report Audit, incident analysis, Risk Assessment, review of training records held in the Trust Learning Management System Clinical Lead CLOT Committee Drugs and Therapeutics Committee Six Monthly Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 34 of 36

58 6. ABBREVIATED NICE GUIDANCE CG92 (CLICK ON DOCUMENT TO OPEN) Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 35 of 36

59 REFERENCES Prevention of Venous Thromboembolism: The Eighth American College of Chest Physicians Conference on Antithrombotic and Thrombolytic Therapy. Chest Venous Thromboembolism: the prevention of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients undergoing orthopaedic surgery and other high-risk surgical procedures. NICE guideline, October 2007 Prophylaxis of Venous Thromboembolism: Scottish Intercollegiate Guidelines Network, Published October 2002 and reviewed in 2005 Venous Thromboembolism prevention in surgery and obstetrics: clinical practice guidelines. European Journal of Anaesthesiology 2006; 23: The Prevention of Venous Thromboembolism in Hospitalised Patients. House of Commons Health Committee, second report of session Summary of Product (tinzaparin) Characteristics: Leo Laboratories Horlocker TT, Wedel DJ, Benzon H et al. Regional Anaesthesia in the Anticoagulated Patient: Defining the Risks. Reg Anaesth Pain Med 2004; 20 (no2 suppl 1): 1-11 Briggs, G; Freeman, R.K and Yaffe, S.J (2005), Drugs in Pregnancy and Lactation; 7 th Edition; Special thanks to Wirral Hospital NHS Trust. P Green/C Friaz-Jimenez, Lippincott Williams & Wilkins Guidelines on the management of venous thrombosis at unusual sites. BCSH Guideline. British Journal of Haematology Volume 159, Issue 1, pages 28 38, October 2012 NICE guidance CG92 Venous thromboembolism: reducing the risk. Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital, January Systematic review: D-dimer to predict recurrent disease after stopping anticoagulant therapy for unprovoked venous thromboembolism. Verhovsek M, Douketis JD, Yi Q, Shrivastava S, Tait RC, Baglin T, Poli D, Lim W. Ann Intern Med Oct 7;149(7):481-90, W94 Guidelines on oral anticoagulation with warfarin fourth edition British Journal of Haematology Volume 154, Issue 3, pages , August 2011 Guideline on the management of bleeding in patients on antithrombotic agents. British Journal of Haematology, 2012, 160, Guidelines on the diagnosis and management of heparin-induced thrombocytopenia: second edition. British Journal of Haematology Volume 159, Issue 5, pages , December 2012 Guidelines on travel-related venous thrombosis. British Journal of Haematology Volume 152, Issue 1, pages 31 34, January 2011 Thrombosis Guidelines (Amended May 2013) Mr Thewodros Leka, Pharmacy and Dr Anna Babb, Haematology CAUTION: This document is only correct at the time of printing, refer to the Intranet for current version 36 of 36

60 Are you at risk of blood clots? (DVT & PE) This leaflet has been written for you by staff from the Thrombosis & Thromboprophylaxis Committee. We hope it answers some of the questions you may have. Who can I contact for more information? If you would like any more information, please ask a doctor, nurse or pharmacist. Alternatively, the following websites provide patient information on blood clots: NHS Choices Lifeblood Notes Membership and Patient Advice & Liaison Service (M-PALS) If you require information, support or advice about our services, you can contact the M-PALS office on the Ground Floor of the hospital just behind the main reception. Alternatively, you can feedback your comments/ suggestions on one of our comment cards, available at the M-PALS office, or on a feedback form on our website We value your opinion and invite you to provide us with feedback of the service. In some of our wards and departments we have devices that enable patients/carers to give us their feedback before going home. Please ask a member of staff for more information. T: E: m-pals@chelwest.nhs.uk Are you at risk of blood clots? DVT (deep vein thrombosis) & PE (pulmonary embolism) Chelsea and Westminster Hospital 369 Fulham Road London SW10 9NH T: W: October 2012 Information for patients in A&E (Emergency Department), Urgent Care Centre and Outpatient Clinics Español Lietuviškai Polska Português Русский Soomaali

61 DVT (deep vein thrombosis) Deep vein thrombosis (DVT) is a common medical condition which occurs when a thrombus (blood clot) forms in a deep vein, usually in the leg or the pelvis. DVT can block off or reduce the flow of blood in the vein. DVT in the leg or pelvis can cause pain and swelling in the leg and may result in lifelong disability with painful leg swelling, varicose veins and leg ulcers. PE (pulmonary embolism) Sometimes the DVT (blood clot) in the leg breaks off and travels to the arteries of the lung where it will cause a pulmonary embolism (PE). PE may cause breathing difficulties and chest pain and may be fatal. VTE (venous thromboembolism) DVT and PE are known under the collective term of venous thromboembolism (VTE). Diagram reproduced with permission of the Thrombosis Research Institute, London UK, April 2008 How common are blood clots? More people die from VTE than the total deaths from AIDS, breast cancer and in road traffic accidents VTE is one of the most common preventable causes of hospital deaths Am I at risk of blood clots? There are several factors that may increase the chances of developing VTE. If you have more than one of these factors, you may be considered to be high risk: if you are older than 60 years of age the risk of VTE is higher the older you are young people can get blood clots too if you have previously had DVT or PE or a close member of your family (parents or brothers and sisters) has had DVT or PE if you have certain illnesses such as cancer, heart failure, lung disease or infections (eg pneumonia) if you are immobile (eg unwell and confined to your bed) or if you have a leg injury and have a plaster cast or limited movement if you are obese if you are pregnant if you are taking the contraceptive pill or hormone replacement therapy (HRT) What can I do to reduce my risk of developing blood clots? Keep mobile (move around) if confined to bed with an illness, do some foot exercises Take care on journeys if you do need to travel on long journeys, try to move your legs regularly (if travelling by car, have a break and walk around every 1 2 hours) If you are taking the contraceptive pill or hormone replacement therapy (HRT) and you think you have a number of risk factors for VTE, talk to your doctor these medications may increase your risk of VTE If you are considered to be at high risk of developing DVT or PE, preventative measures may be taken for example, you may be offered medication to thin your blood or compression stockings to help the blood flow in your veins How can I help reduce my risk of blood clots? Here is a simple exercise you can do, even when you are lying in bed, to help your blood to move around your body. 1. Lie on your back or sit 2. Bend and straighten your ankles quickly If you keep your knees straight during the exercise you will stretch your calf muscles. Will my risk of blood clots be assessed? If you are admitted to hospital, a doctor or a nurse will assess your risk of DVT and PE. If you have a leg injury and require a plaster cast, your risk of VTE and bleeding will be assessed in A&E. How will I know if I have DVT or PE? The symptoms of DVT in the leg include: swelling pain warm skin tenderness redness (particularly at the back of your leg below the knee) DVT usually (although not always) affects one leg. The pain may be made worse by bending your foot upward towards your knee. In some cases, there may be no signs or symptoms of DVT at all in the leg. The symptoms of PE include: shortness of breath pain in your chest that is worse when you breath in collapse (in severe cases) Both DVT and PE are serious conditions that require urgent investigation and treatment. If you suspect you may have DVT or PE, you should seek medical advice immediately either from your GP or nearest A&E (Emergency Department)

62 Are you at risk of blood clots in pregnancy? DVT (deep vein thrombosis) & PE (pulmonary embolism) Information for pregnant women DVT Obs A5 Sep 2014.indd 1 22/09/ :35

63 Are you at risk of blood clots in pregnancy? (DVT & PE) This leaflet has been written for you by staff from the Thrombosis & Thromboprophylaxis Committee. We hope it answers some of the questions you may have. Who can I contact for more information? If you would like any more information, please ask a doctor, midwife, nurse or pharmacist. Alternatively, the NHS Choices website ( or Lifeblood ( provide patient information on blood clots. Notes DVT Obs A5 Sep 2014.indd 2 22/09/ :35

64 DVT (deep vein thrombosis) Deep vein thrombosis (DVT) is a common medical condition which occurs when a thrombus (blood clot) forms in a deep vein, usually in the leg or the pelvis. DVT can block off or reduce the flow of blood in the vein. DVT in the leg or the pelvis can cause pain and swelling in the leg and may result in lifelong disability with painful leg swelling, varicose veins and leg ulcers. PE (pulmonary embolism) Sometimes the DVT (blood clot) in the leg breaks off and travels to the arteries of the lung where it will cause a pulmonary embolism (PE). PE may cause breathing difficulties and chest pain and may be fatal. Diagram reproduced with permission of the Thrombosis Research Institute, London UK, April 2008 VTE (venous thromboembolism) DVT and PE are known under the collective term of venous thromboembolism (VTE). How common are blood clots? The risk of DVT is 10 times more common in pregnant women compared to non-pregnant women of the same age On average 1 2 women in every 1000 will get DVT or PE in pregnancy VTE is one of the most common preventable causes of hospital deaths Am I at risk of developing a blood clot? There are many changes in your body during pregnancy that increases your chances of developing blood clots. Your blood becomes more sticky and the blood flow slows down in the veins in your legs and pelvis. There are several additional factors that may increase your risk of a blood clot: If you are pregnant If you are older than 40 years of age If you are obese If you have three or more children If you have excessive vomiting during your pregnancy (hyperemesis) If you have previously had a DVT or PE, or a close member of your family (parents or brothers/sisters) has had a DVT or PE If you have certain illnesses such as cancer, heart failure, lung disease, infections (eg pneumonia) If you are a smoker 3 DVT Obs A5 Sep 2014.indd 3 22/09/ :35

65 4 If you are immobile (for example, unwell and confined to your bed, or you have a leg injury and have a plaster cast or limited movement) If you travel long-distance (more than four hours) If you have a caesarean section delivery and an additional risk factor What can I do to reduce my risk of developing blood clots? If you or a close member of your family (parents or brothers/sisters) has had DVT or PE in the past then let your GP/midwife know about it Keep mobile move around as much as possible (if confined to bed with an illness carry out some foot exercises) Take care on journeys if you do need to travel on long journeys, try to move your legs regularly. If travelling by car, have a break and walk around every one to two hours Exercises to help reduce your risk of developing blood clots Here is a simple exercise you can do, even when you are lying in bed, to help your blood to move around your body: 1. Lying on your back or sitting 2. Bend and straighten your ankles quickly If you keep your knees straight during the exercise you will stretch your calf muscles. Will my risk of developing blood clots be assessed? Your risk of developing blood clots will be assessed when you visit the hospital at your booking appointment. If you are admitted to hospital, a doctor or midwife will assess your risk of developing blood clots. Your risk will be re-assessed during your admission to ensure that any changes are identified. Your risk will be assessed again after delivery. What will be done to reduce my risk of developing blood clots? If you are considered to be at high risk of developing a blood clot, preventative measures may be taken: You may be offered medication to thin your blood (anticoagulant medication) the anticoagulant medication prescribed at Chelsea and Westminster Hospital is enoxaparin, which is given by injection Compression stockings may be offered to help the blood flow in your veins Do treatments to reduce the risk of developing blood clots have any possible side effects? The anticoagulant medication, enoxaparin, increases the time it takes your blood to clot. This will make you bruise and bleed more easily. Tell your doctor or midwife if you experience any of the following side effects: Long or excessive bleeding Unexplained bruising DVT Obs A5 Sep 2014.indd 4 22/09/ :35

66 You will be measured and fitted with compression stockings. You should be shown how to wear compression stockings. This will help reduce your risk of developing blood clots. You should remove your stockings daily so you can wash your legs and check your skin for any changes. Compression stockings if appropriate should be worn while you are in hospital and until you return to your usual level of mobility. Please refer to the manufacturer s instructions for washing and handling advice. Tell your doctor or midwife if you experience any of the following in your feet or legs: Marking Blistering Pain Discomfort Discolouration of skin What happens when I am discharged from hospital or I need to take anticoagulation medication at home during my pregnancy? Some women may need to have anticoagulation medication (enoxaparin injections) during their pregnancy or once they have gone home after having their baby your doctor, midwife or pharmacist will discuss this with you. If you have any questions or concerns about how long you need to take your medication at home, please speak to your doctor, midwife or pharmacist. If you need to take enoxaparin injections at home, your midwife will show you or your partner how to do this if you need additional help with administration of enoxaparin injections, please ask your midwife If you need to take enoxaparin injections at home, please ask a midwife for a sharps bin to dispose of the injections safely You can return your used sharps bin to the ward that gave it to you, or to your GP surgery or local council How will I know if I have DVT or PE? The symptoms of DVT in the leg include: swelling pain warm skin tenderness redness (particularly at the back of your leg below the knee) DVT usually (although not always) affects one leg. The pain may be made worse by bending your foot upward towards your knee. In some cases, there may be no signs or symptoms of DVT at all in the leg. The symptoms of PE include: shortness of breath pain in your chest that is worse when you breath in collapse (in severe cases) Both DVT and PE are serious conditions that require urgent investigation and treatment. If you suspect you may have DVT or PE, you should seek medical advice immediately either from your GP or nearest A&E (Emergency Department) 5 DVT Obs A5 Sep 2014.indd 5 22/09/ :35

67 Patient Advice & Liaison Service (PALS) If you require information, support or advice about our services, you can contact the PALS office on the ground floor of the hospital just behind the main reception. Alternatively, you can feedback your comments/suggestions on one of our comment cards, available at the PALS office, or on a feedback form on our website We value your opinion and invite you to provide us with feedback of the service. Please ask a member of staff for more information. T: E: pals@chelwest.nhs.uk Notes 6 DVT Obs A5 Sep 2014.indd 6 22/09/ :35

68 DVT Obs A5 Sep 2014.indd 7 22/09/ :35

69 369 Fulham Road London SW10 9NH Main Switchboard Website September 2014 Español Lietuviškai Polski Português Русский Soomaali Speak to your clinician DVT Obs A5 Sep 2014.indd 8 22/09/ :35

70 Are you at risk of blood clots? DVT (deep vein thrombosis) & PE (pulmonary embolism) Information for patients in hospital or going home from hospital

71 Are you at risk of blood clots? (DVT & PE) This leaflet has been written for you by staff from the Thrombosis & Thromboprophylaxis Committee. We hope it answers some of the questions you may have. Who can I contact for more information? If you would like any more information, please ask a doctor, nurse or pharmacist. Alternatively, the NHS Choices website ( or Lifeblood ( provide patient information on blood clots. Notes

72 DVT (deep vein thrombosis) Deep vein thrombosis (DVT) is a common medical condition which occurs when a thrombus (blood clot) forms in a deep vein, usually in the leg or the pelvis. DVT can block off or reduce the flow of blood in the vein. DVT in the leg or the pelvis can cause pain and swelling in the leg and may result in lifelong disability with painful leg swelling, varicose veins and leg ulcers. PE (pulmonary embolism) Sometimes the DVT (blood clot) in the leg breaks off and travels to the arteries of the lung where it will cause a pulmonary embolism (PE). PE may cause breathing difficulties and chest pain and may be fatal. VTE (venous thromboembolism) DVT and PE are known under the collective term of venous thromboembolism (VTE). How common are blood clots in hospital? We often hear about the risks of DVT on long distance flights but DVT is more likely to occur in patients who have stayed in hospital: In England each year, 25 times more people die from preventable VTE contracted in hospital than from MRSA infection 1 in 3 patients having an operation in hospital can develop VTE if no preventative measures are taken 7 out of 10 deaths from VTE in hospital occur in medical patients (those who have not had an operation) Diagram reproduced with permission of the Thrombosis Research Institute, London UK, April 2008 Am I at risk of blood clots in hospital? There are several factors that may increase the chances of developing VTE in hospital. If you have more than one of these factors, you may be considered to be high risk: if you are older than 60 years of age the risk of VTE is higher the older you are young people can get blood clots too if you have previously had DVT or PE or a close member of your family (parents or brothers and sisters) has had DVT or PE 3

73 4 if you have certain illnesses such as cancer, heart failure, lung disease or infections (eg pneumonia) if you are immobile (especially if you are confined to your bed in hospital) if you are obese if you are pregnant if you are having major surgery, especially hip and knee replacements if you are taking the contraceptive pill or hormone replacement therapy (HRT) your doctor may advise you to stop taking them in the weeks leading up to your surgery What can I do to reduce my risk of developing blood clots before I come into hospital for a planned operation? Keep mobile move around as much as possible in the weeks leading up to your surgery Take care on journeys if you can, avoid long uninterrupted journeys of more than three hours in the month before your surgery and if you do need to travel on long journeys, try to move your legs regularly and walk around every 1 2 hours Talk to your doctor if you are taking the contraceptive pill or hormone replacement therapy (HRT) these medications may increase your risk of VTE and so your doctor may advise you to stop taking them in the weeks leading up to your surgery Talk to your doctor if you are taking antiplatelet therapy (eg aspirin) you may be advised to stop taking this a week before your surgery Will my risk of blood clots be assessed? A doctor or a nurse will assess your risk of DVT and PE when you are admitted to hospital. Your risk will be reassessed during your stay in hospital to ensure that any new risk factors are identified. What will be done to reduce my risk of developing blood clots in hospital? If you are considered to be at high risk of developing DVT or PE in hospital, preventative measures may be taken: You may be given medication to thin your blood. This is called anticoagulant medication: The anticoagulant medication normally prescribed at Chelsea and Westminster Hospital is enoxaparin which is given by injection If you are having hip or knee replacement surgery, you will be prescribed rivaroxaban tablets instead of enoxaparin injections Compression stockings to help the blood flow in your veins Calf pumps will sometimes be put on your legs in the operating theatre during your operation to help the blood flow in your veins Ask your doctor or nurse: What is being done to reduce my risk of blood clots?

74 What happens when I am discharged from hospital? Some patients may need to continue their anticoagulation medication at home your doctor, nurse or pharmacist will discuss this with you. The table below tells you what medication you may need to take at home and the duration following certain operations: Type of operation Hip replacement Knee replacement Hip fracture Bariatric surgery Medication Rivaroxaban tablets Rivaroxaban tablets Enoxaparin injections Enoxaparin injections Medication duration Up to 35 days Up to 14 days 28 days Up to 28 days If you have any questions or concerns about how long you are to take your medications at home for, then please speak to your doctor, nurse or pharmacist. If you need to take enoxaparin injections at home, a nurse will show you the correct way to do so please ask the nurse for a sharps bin to dispose of the injections safely If you are unable to give the enoxaparin injections to yourself, a nurse can show a relative or friend how to give them to you alternatively, a nurse can arrange for someone else to give you the injections when you are at home Compression stockings if appropriate should be worn while you are in hospital and until you return to your usual level of mobility How will I know if I have DVT or PE? The symptoms of DVT in the leg include: swelling pain warm skin tenderness redness (particularly at the back of your leg below the knee) DVT usually (although not always) affects one leg. The pain may be made worse by bending your foot upward towards your knee. In some cases, there may be no signs or symptoms of DVT at all in the leg. The symptoms of PE include: shortness of breath pain in your chest that is worse when you breath in collapse (in severe cases) Both DVT and PE are serious conditions that require urgent investigation and treatment. If you suspect you may have DVT or PE, you should seek medical advice immediately either from your GP or nearest A&E (Emergency Department) 5

75 6 Do the treatments to reduce my risk of developing blood clots have any possible side effects? Compression stockings If you are having an operation or you are unable to take anticoagulant medication, you may be offered compression stockings You will be measured and fitted with compression stockings depending on your leg measurements You should be shown how to wear them this will help reduce your risk of developing VTE Tell your doctor or nurse if you have any marking, blistering, pain, discomfort or discolouration of skin in your feet or legs You should remove your compression stockings every day so you can wash your legs and check your skin for any changes Alternatives to compression stockings Your doctors or nurses may ask you to wear a special inflatable sleeve or cuff around your legs while you are in bed this will inflate automatically and provide pressure at regular intervals, increasing blood flow in your legs Drug therapy The anticoagulant medications (enoxaparin and rivaroxaban) increase the time it takes your blood to clot (blood thinners) and can make you bleed and bruise more easily your risk of bleeding will be assessed together with your risk of VTE Tell your doctor or nurse if you experience any of the following side effects: long or excessive bleeding unexplained bruising unusual headaches If you need to take anticoagulant medication, you should take your enoxaparin injections or rivaroxaban tablets correctly every day What can I do to help reduce my risk of developing blood clots in hospital and at home? The risk of developing DVT or PE can continue for four weeks (or more) after you have gone home. It is important to: Keep mobile (move around) Exercise Keep well hydrated by drinking plenty of water How can I help reduce my risk of blood clots? Here is a simple exercise you can do, even when you are lying in bed, to help your blood to move around your body. 1. Lie on your back or sit 2. Bend and straighten your ankles quickly If you keep your knees straight during the exercise you will stretch your calf muscles.

76 Patient Advice & Liaison Service (PALS) If you require information, support or advice about our services, you can contact the PALS office on the Ground Floor of the hospital just behind the main reception. Alternatively, you can feedback your comments/suggestions on one of our comment cards, available at the PALS office, or on a feedback form on our website We value your opinion and invite you to provide us with feedback. T: E: pals@chelwest.nhs.uk

77 369 Fulham Road London SW10 9NH Main Switchboard Website August 2014 Español Lietuviškai Polski Português Русский Soomaali Speak to your clinician

78 Preventing deep vein thrombosis and pulmonary embolism (Blood clots) Information for patients, relatives and carers on Hospital-Acquired thrombosis (HAT) Date Produced: June 2010 Date for review: June 2011 Lead: Mallika Sekhar A first class hospital for our community

79 This leaflet has been provided to help answer some of the questions you may have about HOSPITAL ACQUIRED THROMBOSIS (HAT). What is hospital acquired thrombosis? Admission to hospital either for surgery or for a medical problem is associated with an increased risk of blood clots in the veins, also known as venous thrombosis. These blood clots tend to occur in the deep veins of the legs (deep vein thrombosis or DVT) or in the lungs (pulmonary emboli or PE). Thrombosis can occur while you are in hospital but also when you go home. How can my risk of thrombosis be reduced? Please read the list of risk factors for thrombosis at the back of this leaflet and tell your hospital doctor if any of them apply to you (for example a previous history of thrombosis). Discuss stopping hormone supplements before surgery with either your hospital doctor or GP. For example the oral contraceptive pill, HRT (hormone replacement therapy) or tamoxifen can increase your risk of thrombosis.

80 The exact recommendation will depend on your risk of thrombosis and your risk of bleeding as determined by the medical staff around the time of your admission. You will find a list of risk factors for bleeding at the back of this leaflet. It is essential that you tell your doctor if any of them apply to you. You must also inform the hospital team in charge of your care if you have had an allergy/reaction to heparin in the past. Please note that a blood thinning tablet has been recently licensed for certain groups of patients having hip or knee surgery. In some cases, this tablet may be offered instead of injections. When you go home If you are at particularly high risk of thrombosis, we will advise you to continue to take blood-thinning injections or tablets when you leave hospital and will give you a supply to take home. However, for the majority of patients, moving around and getting back to normal activities as soon as possible will be enough to reduce the risk of thrombosis when discharged home.

81 Is there anything I should look out for at home? Yes. If you develop any of the symptoms listed below, it is important that you contact your GP or the hospital immediately for advice. You may need to attend your nearest A & E for assessment. Unexplained swelling or discomfort in your legs from the calf upwards Chest pain Breathing difficulties Painful cough If tests confirm that there is a blood clot, you will be given anticoagulation (blood thinning) medication, which is a very effective treatment.

82 Am I at increased risk of thrombosis? If any of the following risk factors apply to you, please tell your doctor, as it may affect your treatment plan. o You have had deep vein thrombosis or pulmonary embolism in the past o Other members of your family have had blood clots in their veins o Previous blood tests have suggested that you are at increased risk of thrombosis o You are having treatment for cancer such as chemotherapy or radiotherapy, OR you have cancer which is not in remission o You are taking hormone treatment (such as the Pill, HRT or tamoxifen) o You have a chronic illness, for example lung disease, heart failure, or inflammatory disease such as ulcerative colitis o You are pregnant

83 Am I at increased risk of bleeding? If any of the following apply to you, please tell your doctor. We will need to tailor the anti-coagulation medication to your needs. o You are taking anticoagulant drugs such as warfarin o You are taking medication which affects blood clotting, such as aspirin or clopidrogel, and some pain killers o You have haemophilia or another known bleeding disorder o You have a low platelet count o You have a past history of major bleeding or bleeding peptic ulcer o A family history of major bleeding o You have had a stroke recently o You have very high blood pressure o You have severe liver or kidney disease

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