MMP016 POLICY FOR PRIMARY THROMBOPROPHYLAXIS FOR PATIENTS ADMITTED TO NHFT

MMP016 POLICY FOR PRIMARY THROMBOPROPHYLAXIS FOR PATIENTS ADMITTED TO NHFT MMP016 Policy for primary thromboprophylaxis for patients admitted to NHFT (rev Sept 2020) Page 1 of 21

Table of Contents Why we need this Policy... 3 What the Policy is trying to do... 3 Which stakeholders have been involved in the creation of this Policy... 3 Any required definitions/explanations... 3 Key duties... 3 Medical Staff... 3 Nursing staff... 4 RISK ASSESSMENT, PROPHYLAXIS AND MANAGEMENT OF VTE... 4 For all patients... 4 Risk assessment... 5 Patient Information... 6 Preventive Measures... 6 Patients with Suspected Venous Thromboembolism... 10 Training requirements associated with this Policy... 11 Mandatory Training... 11 Specific Training not covered by Mandatory Training... 11 How this Policy will be monitored for compliance and effectiveness... 12 Equality considerations... 13 Document control details... 15 APPENDIX 1 RISK ASSESSMENT FOR VTE (DVT & PE) IN ALL PATIENTS > 18 YEARS... 16 APPENDIX 2 - PATIENT INFORMATION LEAFLET RE THROMBOPROPHYLAXIS... 18 APPENDIX 3 - MEDICINES INCREASING RISK OF VTE... 21 MMP016 Policy for primary thromboprophylaxis for patients admitted to NHFT (rev Sept 2020) Page 2 of 21

Why we need this Policy An estimated 25,000 people in the UK die from preventable hospital acquired VTE every year. Treatment of non-fatal symptomatic VTE and related long term morbidities is associated with considerable cost to the Health Service. What the Policy is trying to do The purpose of this policy is to aid clinical decision-making regarding primary thromboprophylaxis for VTE. Patients admitted to NHFT inpatient areas must be risk assessed on admission and when changes to patient status occur for risk of VTE and need for thromboprophylaxis. This guidance covers recommendations for assessing and managing risk of VTE in adult patients (those aged 18 years and over) admitted for inpatient care on NHFT wards. It excludes those aged under 18 years, service users attending as outpatients and those receiving care in their own homes For advice regarding palliative patients see MMG015 Guidelines for the use of Primary Thromboprophylaxis in the Palliative Care Setting Which stakeholders have been involved in the creation of this Policy Physical Health Group Medicines Management Committee Any required definitions/explanations NHFT - Northamptonshire Healthcare NHS Foundation Trust VTE Venous Thromboembolism KGH Kettering General Hospital NHS Foundation Trust NGH Northampton General Hospital. LFT s Liver Function Tests PE pulmonary embolism DVT Deep vein thrombosis Key duties Medical Staff Are responsible for: Undertaking the initial risk assessment of the patient on admission Assessing the risk of bleeding in patients considered for VTE prophylaxis Documenting the assessment in the patient s clinical record Prescribing appropriate VTE prophylaxis MMP016 Policy for primary thromboprophylaxis for patients admitted to NHFT (rev Sept 2020) Page 3 of 21

Monitoring and reviewing the need for treatment as the patient s condition changes. Reassessing the patient as the patient condition changes Liaison with acute trusts for patients identified with potential signs and symptoms of VTE Nursing staff Are responsible for: Monitoring the patient for change in mobility and notifying the doctor of any significant change Administering thromboprophylaxis as prescribed. Measuring, fitting and monitoring of anti-embolism stockings RISK ASSESSMENT, PROPHYLAXIS AND MANAGEMENT OF VTE For all patients Ensure adequate fluid intake and do not allow to become dehydrated unless clinically indicated Encourage to mobilise as soon as possible Do not regard aspirin or other anti-platelet agents as adequate prophylaxis for VTE. The risk of the patient developing a VTE must be balanced with the risk of a patient bleeding when prescribed pharmacological prophylaxis This includes patients that are prescribed therapeutic anticoagulants prior to admission. If such a patient has no additional risk factors that would increase risk of VTE and warrant a change in dose of anticoagulant then assessment is complete at this point a. General medical (malignant and non-malignant) Regard medical patients at being at increased risk of VTE if they: have had or are expected to have significantly reduced mobility for three days or more or are expected to have ongoing reduced mobility relative to their normal state and have one or more risk factors mentioned below: o Active cancer or cancer treatment o Age above sixty years o Dehydration o Known thrombophilias o Obesity (BMI more than 30kg/m 2 ) o One or more significant medical co-morbidities (heart disease/metabolic/ endocrine/respiratory pathologies/acute infectious disease/inflammatory conditions) o Personal history or first degree relative with a history of VTE o Use of hormone replacement therapy or oestrogen-containing contraceptive therapy o Varicose veins with phlebitis b. Patients after a stroke (management led by local stroke service) c. Patients undergoing orthopaedic/general surgery, both elective and non-elective MMP016 Policy for primary thromboprophylaxis for patients admitted to NHFT (rev Sept 2020) Page 4 of 21

Post-surgical patients should be regarded as high risk if: Total anaesthetic plus surgery time more than 90 minutes If surgery involves pelvic/lower limb surgery and anaesthesia and surgery time exceeding 60 minutes If surgical admission with inflammatory or intra-abdominal condition If expected to have significant reduction in mobility With other VTE risk factors present as described in a) above Risk assessment Assessing the Risk of VTE All patients aged 18 or over should be assessed on admission to hospital by the admitting doctor to identify those at risk of VTE. Mobility should be assessed on an ongoing basis and whenever clinical status changes Step 1- Assess Mobility Assess all patients admitted to hospital for current level of mobility. All patients with significantly reduced mobility should be considered for further risk assessment (step 2 below). If the patient is not expected to have significantly reduced mobility relative to normal state then the risk assessment would be considered to be complete- the risk assessment proforma (appendix 1/electronic form on systmone ) should still be signed and included in the patient s notes Remember to repeat risk assessment at least every 7 days or when the patient s mobility or clinical situation changes - this is a simple process of the nursing staff observing changes in mobility, documenting the outcome of this observation and notifying the doctor of any change. A record of reassessment of risk must be made in the clinical record each time the patient is reassessed. Step 2 Assess risk factors for VTE Review the patient using the assessment sheet (Appendix 1/systmOne form) for thrombosis risk, ticking each box that applies (more than one box can be ticked) Any tick for thrombosis risk indicates HIGH RISK OF VTE. If no box is ticked for thrombosis risk then the patient is at LOW RISK OF VTE in this case encourage early mobilisation The list of risk factors is not exhaustive; clinicians may consider additional risks in individual patients and offer thromboprophylaxis. Assessing the risk of bleeding in high risk patients for VTE Consider the risk of bleeding: Active bleeding Acquired bleeding disorders, e.g. liver failure Concurrent use of anti-coagulants, e.g. Warfarin with INR 2 MMP016 Policy for primary thromboprophylaxis for patients admitted to NHFT (rev Sept 2020) Page 5 of 21

Acute stroke Thrombocytopenia (platelets less than 75 x 10 9 /l) Uncontrolled systolic hypertension (more than 230/120) Untreated inherited bleeding disorders Significant risk of falls Outcome Patient s risk of VTE should be weighed against their risk of bleeding and the outcome clearly documented. Consider whether the patient s risk of bleeding precludes pharmacological intervention and consider mechanical prophylaxis e.g. anti-embolism stockings. Where the risk of VTE outweighs the risk of bleeding commence VTE prophylaxis at the earliest opportunity. Outcome of this risk assessment should be clearly documented in the patient notes and VTE prophylaxis prescribed on the drug chart Reassess the risk status within 24 hours of admission and whenever the clinical situation changes, at least every 7 days. Patient Information Patients should be provided with both written and verbal information on the risk of VTE and the signs and symptoms which should be reported to nursing and medical staff. See Appendix 2 Preventive Measures Every patient should be encouraged to mobilise as soon as possible Hydration status should be assessed, both clinically and be guided by the latest available blood results, e.g. urea and electrolytes in high risk patients and haemoglobin and LFT s in patients at risk of bleeding Mechanical Prophylaxis Consider mechanical VTE prophylaxis e.g. anti-embolism stockings Do not offer anti-embolism stockings to patients with: suspected or proven peripheral arterial disease peripheral arterial bypass grafting peripheral neuropathy or other causes of sensory impairment local conditions, e.g. fragile skin/dermatitis/gangrene, etc cardiac failure allergy to material of manufacture severe leg oedema or pulmonary oedema from heart failure unusual leg shape or size major limb deformity Use caution and clinical judgement when applying anti-embolism stockings over venous ulcers or wounds MMP016 Policy for primary thromboprophylaxis for patients admitted to NHFT (rev Sept 2020) Page 6 of 21

Patients requiring anti-embolism stockings should have their legs measured and the correct size of stocking provided. Staff who fit stockings should be trained in their use and should show patients how to use them where possible. Patients should be encouraged to wear the stockings day and night until they return to normal mobility. Patients who are able to use stockings themselves should be monitored regularly and assistance offered where they are not being worn correctly. Remove stockings daily for hygiene purposes and to inspect skin condition. If the patient has significantly reduced mobility, poor skin integrity or sensory loss, inspect skin two or three times daily paying particular attention to heels and bony prominences. Discontinue stockings if there is marking, blistering or discolouration of the skin or if the patient has pain or discomfort. Pharmacological Prophylaxis Pharmacological prophylaxis should be considered for all patients whose risk of venous thromboembolism outweighs the risk of bleeding. Enoxaparin is the agent of choice, except for patients admitted post elective hip or knee replacement, see below. The usual dose for adults is 40mg daily. For patients with severe renal failure, creatinine clearance 30ml/min the dose should be reduced to 20mg. Although no dosage adjustments are recommended in patients with moderate (creatinine clearance 30-50 ml/min) and mild (creatinine clearance 50-80 ml/min) renal impairment, careful clinical monitoring is advised. Dosing in extremes of bodyweight There is no evidence for the use of low doses in patients with low bodyweight. The SPC for enoxaparin states that there may be an increase in enoxaparin exposure in low body weight (<45kg women, <57kg men) and this may lead to a higher risk of bleeding. Careful clinical monitoring is required in these patients however lower doses are not specifically recommended in these guidelines, individual clinical judgement is required. In obese patients the risk of VTE increases significantly, however this is taken into account in the risk assessment process. A systematic review of studies showed that enoxaparin once or twice daily was a suitable dose for prophylaxis in obese medical and surgical patients. The suggested dose increases are (assuming normal renal function): >100kg increase enoxaparin to 40mg bd >150kg increase enoxaparin to 60mg bd Contra-indications Active major bleeding including recent haemorrhagic stroke Severe thrombocytopenia (platelets <50) Active gastric or duodenal ulceration Acute bacterial endocarditis Hypersensitivity to Enoxaparin MMP016 Policy for primary thromboprophylaxis for patients admitted to NHFT (rev Sept 2020) Page 7 of 21

Already receiving Warfarin Cautions The following cautions need to be exercised in using LMWH Severe renal impairment- reduce dose, see above Severe liver impairment Platelet count < 70 History of heparin-induced thrombocytopenia Known cerebral metastases Frequent falls or high risk of falls Special Patient Categories For patients already receiving anti-platelet therapy consider offering additional VTE prophylaxis, taking into account the risk of bleeding and co-morbidities e.g. arterial thrombosis. If the risk of VTE outweighs the risk of bleeding consider pharmacological prophylaxis If the risk of bleeding outweighs the risk of VTE offer anti-embolism stockings Elective hip or knee replacement Patients transferred to the inpatient wards following elective hip or knee replacement should receive VTE prophylaxis with dabigatran, unless contraindicated, as follows: Total hip replacement- Adults over 18 110mg (Elderly over 75 years, 75mg) 1-4 hours after surgery then 220mg (elderly over 75 years, 150mg) once daily for 27-34 days Total knee replacement- Adults over 18 110mg (Elderly over 75 years, 75mg 1-4 hours after surgery and then 220mg (elderly over 75 years, 150mg) once daily for 9 days Patients with renal impairment (egfr 30-50ml/minute/1.73m 2 should receive reduced doses of 75mg initially and then 150mg daily, unless receiving concomitant therapy with verapamil or amiodarone when the daily dose should be reduced to 75mg. Dabigatran should be avoided in patients with egfr 30 ml/min/1.73m 2 Where alternative anti-thrombotic agents e.g. rivaroxaban, apixaban, have been commenced by the referring Acute Trust and no contra-indications are identified they should be continued for 10-14 days for knee surgery or 28-35 days for hip surgery. Alternatively patients may be transferred to the inpatient wards on the following: Elective hip replacement - consider non-pharmacological, i.e. anti-embolism stockings followed by LMWH, which should be continued for 28-35 days (LMWH normally started six to twelve hours after surgery) Elective knee replacement similar to the above, LMWH should be for a period of 10-14 days Post stroke There is no place for anti-embolism stockings for VTE prophylaxis MMP016 Policy for primary thromboprophylaxis for patients admitted to NHFT (rev Sept 2020) Page 8 of 21

Consider the use of prophylactic LMWH if a diagnosis of haemorrhagic stroke has been excluded and the risk of bleeding, e.g. haemorrhagic transformation of a large infarct is considered to be low and the patient has one or more of the following: Major restriction of mobility Previous history of VTE Dehydration Comorbidities such as malignant disease Continue therapy until the patient s condition is stable. Non-Orthopaedic Surgery After assessing risk of bleed, the duration of prophylaxis is given until the patient is fully mobile or no longer significantly reduced (generally 5-7 days). The exception is in patients who have had surgery for major cancer, in which case LMWH should be continued for a minimum of 28 days Hip Fracture Offer mechanical prophylaxis, i.e. anti-embolism stockings (thigh or knee length, if no contraindication) LMWH is commenced six to twelve hours post-surgery, which should be continued for 28 35 days depending on the patient s mobility status Other orthopaedic surgery Upper limb surgery patients do not need VTE prophylaxis. The other patients need to be assessed and considered non-pharmacological and pharmacological measures and the duration guided by clinical judgement, e.g. full mobility Patients that fall into the specialist categories above will be initiated on treatment by the acute hospital prior to transfer to NHFT inpatient wards and this treatment should be continued for the appropriate duration as described above provided no contraindications are identified. For pregnant women or women less than 6 weeks post-partum the patient s obstetrician should be consulted regarding prophylaxis or treatment Duration The duration of pharmacological VTE prophylaxis should be guided by clinical judgement depending on patient s level of mobility, except where a minimum period is required in certain special situations discussed above. Monitoring Platelet count There is a risk of antibody mediated heparin induced thrombocytopenia. If this occurs this is generally within 5-21 days of treatment but can be delayed with LWMH, platelets should therefore be checked at 7 days. Patients receiving long term prophylaxis should have a platelet count monthly. MMP016 Policy for primary thromboprophylaxis for patients admitted to NHFT (rev Sept 2020) Page 9 of 21

If the count is significantly reduced (30-50% of the initial value) take further advice from the acute trusts immediately. Potassium Heparin can suppress adrenal secretion of aldosterone causing hyperkalaemia. Patients with diabetes, chronic kidney disease, other potassium sparing medicines are at higher risk. Plasma potassium should be measured before commencing treatment in at risk patients and monitored regularly whilst LWMH continues particularly if treatment is prolonged. Excessive bleeding / overdose/ need for reversal Take advice from acute trust. Patients with Suspected Venous Thromboembolism Patients presenting with the following signs/symptoms should be considered for further investigation for VTE: Localised tenderness along the distribution of the deep venous system Entire leg swollen Calf swollen by more than 3cm when compared with the asymptomatic leg (measured 10cm below tibial tuberosity) Pitting oedema (greater in the symptomatic leg) Collateral superficial veins (non varicose) Where there is no probable alternative diagnosis, consider venous thromboembolism and refer patient to the acute hospital (KGH/NGH) for ultrasound. If there are no contra-indications to treatment discontinue prophylactic dose of low molecular weight heparin (where already prescribed) and commence treatment dose. For adults, with normal renal function the treatment dose of enoxaparin is 1.5mg/kg. For adult patient with severe renal impairment (creatinine clearance 30ml/min) the dose should be reduced to 1mg/kg. If VTE is excluded following ultrasound the treatment dose should be discontinued and prophylactic dose recommenced if appropriate Medical staff should liaise with the relevant acute trust to ascertain the most appropriate route of referral and to arrange admission. Patients will normally be transferred to the relevant acute hospital medical assessment unit for clinical assessment, diagnosis and initiation of treatment as appropriate. Transfer to the acute trust will be within reasonable timescales following liaison with the acute trust Management of confirmed VTE. Where VTE is confirmed by ultrasound the patient should commence treatment as recommended by the Acute Trust. The usual treatment is warfarin, which should be commenced as per local acute hospital (KGH/NGH) protocol unless any contraindications are identified. MMP016 Policy for primary thromboprophylaxis for patients admitted to NHFT (rev Sept 2020) Page 10 of 21

The treatment dose of enoxaparin should be continued until the patient s warfarin level is therapeutic i.e. 2.0. Once the patient s warfarin level reaches therapeutic range the enoxaparin should be stopped. Warfarin should be continued for the following durations unless otherwise recommended by the relevant anticoagulation department: No past history of DVT- 3 months Previous history of DVT or no previous history but with permanent risk factors- 6 months Clear and precise information should be provided to the GP on discharge regarding the recommended duration of anticoagulation therapy where necessary. Patients with the following symptoms should be considered for further investigation for pulmonary embolism: Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of deep veins) Heart rate greater than 100 Previous DVT/PE Haemoptysis PE is the most likely diagnosis Patients with suspected pulmonary embolism should be commenced on treatment doses of low molecular weight heparin as for DVT and liaison undertaken with acute trusts for D-dimer and CT scan as appropriate. A clear treatment plan for patients who require ongoing treatment with warfarin should be in place prior to discharge. The plan should include as a minimum: How, where and by whom follow up blood tests will be undertaken How the outcomes of the blood test and dose changes will be implemented An assessment of the patient s ability to self-medicate and where this is not possible alternative arrangements for administration. Both confirmed and suspected DVT/PE should be reported as clinical incidents. Please refer to CRM002 Policy for management of incidents. Training requirements associated with this Policy Mandatory Training Training required to fulfil this policy will be provided in accordance with the Trust s Training Needs Analysis. Management of training will be in accordance with the Trust s Statutory and Mandatory Training Policy Specific Training not covered by Mandatory Training Ad hoc training sessions based on an individual s training needs as defined within their annual appraisal or job description. E.g. Training in relation to measurement for and fitting of antiembolism stockings. MMP016 Policy for primary thromboprophylaxis for patients admitted to NHFT (rev Sept 2020) Page 11 of 21

How this Policy will be monitored for compliance and effectiveness The table below outlines the Trusts monitoring arrangements for this document. The Trust reserves the right to commission additional work or change the monitoring arrangements to meet organisational needs. Monthly census monitoring of VTE is undertaken via the NHS Safety Thermometer which is mandated for all NHS organisations Aspect of compliance or effectiveness being monitored Method of monitoring Individual responsible for the monitoring Monitoring frequency Group or committee who receive the findings or report Group or committee or individual responsible for completing any actions Duties To be addressed by the monitoring activities below. How patients are assessed for their risk of developing venous thromboembolism (VTE) including timescales Audit of documentation of VTE risk assessment in patient records. Information in safety thermometer Medical Director Head of Quality Improvemen t Annually in September Monthly census MMC Physical health group/safer Hospitals group MMC Physical health group/safer Hospitals group Prophylactic treatment regime for high risk patients Audit of prescriptions of patients identified as being at risk of VTE following risk assessment Chief Pharmacist Annually MMC MMC Procedure to be followed if VTE suspected Review of incident reports and subsequent investigations Medical Director Quarterly Medicines Safety Group Medicines Safety Group MMP016 Policy for primary thromboprophylaxis for patients admitted to NHFT (rev Sept 2020) Page 12 of 21

Management of the patient once a positive diagnosis has been made Review of prescriptions for those patients identified through incident reports and investigations. Medical Director 6 monthly Medicines Safety Group Medicines Safety Group Staff have completed training associated with this policy in line with Training Needs Analysis Training will be monitored in line with the Statutory and Mandatory Training Policy. Equality considerations Please refer to MMP001 Control of Medicines Policy. Reference Guide National Institute for Clinical Excellence (2010) Venous Thromboembolism: Reducing the Risk for patients in hospital, Clinical Guideline 92 London :NICE available at https://www.nice.org.uk/guidance/cg92 National Patient Safety Agency (2011) How to guide to Venous Thromboembolism risk assessment available at http://www.nrls.npsa.nhs.uk/resources/?entryid45=94727 National Institute for Clinical Excellence (2008) Dabigatran Etexilate for the prevention of venous thromboembolism after hip and knee surgery in adults. Technology appraisal guidance 157 London: NICE available at https://www.nice.org.uk/guidance/ta157 Institute for Clinical Systems Improvement 2011 Risk assessment for venous thromboembolism. (VTE). Department of Health. 2010 Zornberg GL, Jick H (2000). Antipsychotic drug use and risk of first-time idiopathic venous thromboembolism: a case-control study. Lancet; 356: 1219-23. Tapson VF (2000). Risk of venous thromboembolism with use of antipsychotic drugs. Lancet; 356: 1206. Parker C, Coupland C, Hippisley-Cox J. (2010) Antipsychotic drugs and risk of venous thromboembolism: nested case-control study. BMJ; 341: c4245. Paton C. (2005 )Editorial. SSRI and gastrointestinal bleed. BMJ; 331: 529 MMP016 Policy for primary thromboprophylaxis for patients admitted to NHFT (rev Sept 2020) Page 13 of 21

Prophylaxis of Venous Thromboemolism SIGN Publication No. 62 ISBN 899893 02 Published October 2002 MMP016 Policy for primary thromboprophylaxis for patients admitted to NHFT (rev Sept 2020) Page 14 of 21

Document control details Author: Senior Community Services Pharmacist Chief Pharmacist Approved by and date: 21.09.17 Trust Policy Board Responsible committee: Medicines Management Committee Any other linked Policies: CRM002 Policy for management of incidents. CLP049 Standard for minimum level of physical examination Policy number: MMP016 Version control: 2 Version No. Date Ratified/ Amended Date of Implementation Next Review Date 1 05.12.16 01.01.17 31.01.20 Review Reason for Change (eg. full rewrite, amendment to reflect new legislation, updated flowchart, minor amendments, etc.) 2 21.09.17 22.09.17 21.09.20 Minor amendments MMP016 Policy for primary thromboprophylaxis for patients admitted to NHFT (rev Sept 2020) Page 15 of 21

APPENDIX 1 RISK ASSESSMENT FOR VTE (DVT & PE) IN ALL PATIENTS > 18 YEARS Risk assessment is required for all patient > 18 years on admission to hospital During in patient stay, an assessment of mobility should be repeated if there is a significant change and the patient is not already on prophylaxis and the responsible doctor should reassess the patient s thrombosis risk All patients should be kept well hydrated and encouraged to mobilise as soon as possible STEP 1: ASSESS MOBILITY If expected to have ongoing reduced mobility relative to normal state plus at least one VTE risk factor (see below) Not expected to have significantly reduced mobility relative to normal state Risk assessment now complete. Repeat if patient condition or mobility changes. STEP 2: Assess for thrombosis risk below Thrombosis risk Patient related Tick Admission related Tick Active cancer or cancer treatment Significantly reduced mobility for 3 days Age >60 Hip or knee replacement Dehydration Known thrombophilias / myeloproliferative disorder Obesity (BMI >30kg/m²) One or more significant medical comorbidities (eg 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 HRT/COC/Tamoxifen Hip fracture Acute surgical admission with inflammatory or intraabdominal condition Surgery with significant reduction in mobility Varicose veins with phlebitis Pregnancy or < 6 weeks post-partum (see additional guidance) Risk factors listed are not exhaustive. Clinicians may consider additional risk in individual patients and offer thromboprophylaxis as appropriate. There is recent evidence that patients receiving antipsychotic drugs may have an increased risk of VTE. Evidence also exists for risk of GI bleed with SSRIs/SNRIs. Please turn over and complete Step 3.

STEP 3: ASSESS RISK FACTORS FOR BLEED Patient related Active bleeding or risk of GI bleed Tick Acquired bleeding disorders (eg acute liver failure) Concurrent use of anticoagulants known to increase the risk of bleeding (eg Warfarin with INR >2) Acute stroke Thrombocytopaenia (platelets <75x10 9 /l) Uncontrolled systolic hypertension (230/120 mmhg or higher) Untreated bleeding disorder (eg haemophilia and von Willebrand disease) Significant risk of falls If patients risk of VTE outweighs risk of bleeding STEP 4: VTE PROPHYLAXIS (tick box) No contraindications. Prescribe Enoxaparin 40mg sc once daily (if renal failure: GFR <30ml/min then reduce dose to 20mg once daily) REVIEW NEED IF PATIENT S CONDITION CHANGES Enoxaparin contraindicated. Peripheral pulses intact anti-embolic stockings prescribed (see section 6.3) Patient information leaflet on preventing blood clots given? ADMISSION ASSESSMENT DATE: NAME: SIGNED: Risk assessment must be done on admission ASSESSMENT DURING ADMISSION DATE: NAME: SIGNED: PLEASE NOTE THESE ARE GUIDELINES AND DO NOT REPLACE GOOD CLINICAL JUDGEMENT

APPENDIX 2 - PATIENT INFORMATION LEAFLET RE THROMBOPROPHYLAXIS

KEY POINTS: Patients in hospital are at risk of getting a blood clot in their legs or lungs (VTE). This can lead to significant problems and can sometimes lead to death There are many things that can be done to prevent VTE. Ask your GP or ward doctor for further advice. For more information go to: Your General Practice www.nice.org.uk www.nhsdirect.uk www.dh.gov.uk Created from DVT Prevention Leaflet Ealing Hospital DVT PREVENTION (Thromboprophylaxis) Information Leaflet for Patients

This guide is for patients admitted to NHFT inpatient areas. Most patients who come into hospital for treatment have a straight forward in-patient stay and leave hospital after medical or surgical treatment, feeling better than when they came in. There are however risks attached to being in hospital. Your health care team will assess your risk of venous blood clots (called venous thromboembolism or VTE for short) which can form in your body after illness or surgery. You may wish to discuss VTE with your doctor and ask about the best way to reduce the likelihood of getting this condition. What is VTE? VTE is the name given to a deep-vein thrombosis (DVT) or a pulmonary embolism (PE). A DVT is a blood clot that forms in a deep vein, most commonly in your legs or pelvis. This can cause pain, tenderness, swelling, warmth or redness in the leg, most commonly the calf. A DVT can cause long term problems such as swelling and ulcers. If a clot becomes dislodged and passes through your circulation to your lungs this is called a PE and can cause coughing (sometimes with blood stained phlegm), chest pain and breathlessness. If you develop any of these symptoms either in hospital or after discharge please seek medical advice immediately. Who is at risk of VTE? You are at an increased risk of a VTE if you have any of the following risk factors: Increased age, immobility, obesity, diagnosis of cancer or heart failure, pregnancy, medications such as the pill or hormone replacement therapy, conditions that cause the blood to clot more easily, recent surgery or an acute infection. This list is not exhaustive. Will my risk of VTE be assessed? The Department of Health recognizes that VTE is a common and important problem in hospitals and has advised that all patients coming into hospital must have their risk assessed. If you are at risk then your doctor will discuss with you what can be done to reduce your risks. What can I do to reduce my risk of VTE before hospital admission? If your hospital admission has been planned several weeks in advance there are some precautions which you can take to reduce your risks of VTE: Talk to your doctor about your medications. Certain medications such as contraceptive/hormone replacement medication may need to be stopped before your admission. Avoid travelling for more than three hours in the months before your operation if possible. What can I do to reduce my risk of VTE when in hospital? Keep moving/walking during your stay in Hospital (leg exercises available) Ask your doctor what is being done to reduce my risk of VTE? Drink plenty of fluids to keep yourself well hydrated. In hospital what will be done to reduce my risks of VTE Anti-embolism stockings may be considered by your doctor. These are stockings, usually of thigh length which are given to you depending on your leg measurements. You will be shown how to wear them and are advised to report any new symptoms in your feet or legs when wearing them. The clinical team 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 out of your legs. Alternatively, the clinical team may consider an anticoagulant injection or tablets. These medications reduce the chance of your blood clotting and can stop a DVT from forming. What happens after I have been discharged from hospital Anti-embolism stockings should be worn from admission until the clinical team feel you are mobile enough. If you have been advised to continue anti-coagulation medication at home then you should make sure you know how to take these tablets or injections before discharge. If you develop any signs or symptoms of VTE at home seek medical advice immediately. Is VTE common? VTE occurs in one in 500 of the general population. You may have heard in the news about people getting DVT from flying for long periods of time-commonly known as the economy class syndrome. However, you are more likely to get a VTE if you are in hospital due to illness or surgery

APPENDIX 3 - MEDICINES INCREASING RISK OF VTE The following gives examples of medicines which can increase risk of VTE. For further advice consult latest edition of BNF or contact Pharmacy for further information. Medicine Oral contraceptives / Hormone Replacement therapy / hormone therapy Progesterone only contraception High Dose progestogens Combined oral contraceptives and HRT Tamoxifen (oestrogen receptor antagonist) Aromatase inhibitors e.g. anastrazole Risk Oestrogen containing oral contraceptives and HRT confer an increased risk of VTE in all patients. Management remains controversial see further advice below No increased risk VTE Evidence exists of association of increased VTE risk with high dose progestogens General advice is to stop before elective surgery due to increased risk of VTE. Assess risk for non-surgical patients Increased risk of VTE by between 2 5 fold. If being used for breast cancer only stop tamoxifen if risk outweighs benefit. All patients should receive appropriate prophylaxis. Associated with approximately half the risk of tamoxifen. No additional risk factors from medicines perspective, but note patients will have a malignancy