Thromboprophylaxis in Adult General Medical Patients - Guidelines for Management Adapted from the Worcestershire Acute Hospitals NHS Trust Guideline WAHT-MED-010 Version: Final Ratified by: Provider Quality and Safety Committee Date ratified: July 2010 Name of originator/author: Sue Lunec, Head of Medicine Management for Provider Services Date issued for publication: September 2010 Review date: November 2012 Expiry date: September 2013 Target audience: WPCT community hospitals clinical staff and contracted clinical staff If you would like this document in other languages or formats (i.e. large print), please contact the Communications Team on 01905 760020 or email communications@worcestershire.nhs.uk WPCT Thromboprophylaxis guideline adapted from WHAT guideline WHAT-MED-010 Page 1 of 9
Acute Trust Guideline development Dr S Shafeek Approved by both Medical Directorates and by Medicines Safety Committee on Consultant Haematologist, WAHT 29 th July 2008 Community Hospital Guideline Development Key individuals involved in adapting the Acute Trust Guidelines for use in community hospitals Name Dr S Shafeek Ruth Prince Sue Lunec Designation Consultant Haematologist, WAHT Clinical Pharmacist for Community Hospitals Head of Medicines Management Circulated to the following individuals for consultation Name Dr Sumit Bhaduri Finbarr Costigan Lisa Levy Maria Wilday Sue LaHiff Ginny Snape Karen Young Linda Ingles Della Lewis Carole Clive Vicky Preece Lesley Way Rosemary Pickford Sue Chauhan Designation Joint Medical Director Joint Medical Director Associate Director of Provider Services Matron/Hospital Manager PWCH Matron Evesham CH Matron Tenbury CH Matron Pershore CH Matron Malvern CH Clinical Governance Team Manager Consultant Nurse Infection Control Associate Director of Nursing and Therapies Patient Safety Manager Clinical Pharmacist for Community Hospitals Clinical Pharmacist for Community Hospitals WPCT Thromboprophylaxis guideline adapted from WHAT guideline WHAT-MED-010 Page 2 of 9
Guideline for thromboprophylaxis in adult (18yrs and older) general medical patients INTRODUCTION Venous thrombosis is a condition in which a blood clot (thrombus) forms in a vein. This can reduce the blood flow through the affected vein, sometimes but not always causing swelling and pain. Venous thrombosis most commonly occurs in the deep veins in the legs, thighs, or pelvis. It is usually referred to as deep vein thrombosis (DVT). An embolism is created if all or part of a clot is dislodged from its original site and travels through the venous system. If the clot lodges in the lung, a very serious condition, pulmonary embolism (PE), arises and can easily cause sudden death. Up to 10% of all hospital deaths could be caused by a PE 1. Venous thrombosis can form in any part of the venous system but DVT and PE are the most common and are known as venous thromboembolism (VTE). Each year over 25,000 people in England alone die from VTE contracted in hospital. This has been the subject of a recent Government Health Select Committee report 2. Historically VTE has been considered to be a problem only in surgical patients. This is not the case as available data confirm that acutely ill medical patients are at the same risk, if not more, than surgical patients 3,4. This situation requires a deliberate and ongoing strategy to educate and inform healthcare professionals of the need for adequate risk assessment and actions to promote VTE prevention in all adult inpatients 2,5.. VTE is a condition that can be reduced, provided that an adequate risk assessment forms part of our day to day routine. DVT/PE are to be included in the Healthcare Commissions annual inspection. GUIDELINE VTE is largely preventable and in surgical patients prophylaxis with LMWH has been proven to be safe and cost-effective. Randomised trials have consistently demonstrated that appropriate use of pharmacological thromboprophylaxis can also reduce the risk of VTE in medical patients. 3 key trials, MEDENOX 4, PREVENT 6 and ARTEMIS 7 have shown risk reduction of DVT of 50-65% with appropriate use of thromboprophylaxis in medical patients. Combined results of these trials show that medical patients are at high risk of VTE when immobilised with acute medical illnesses, and this risk can be reduced by the use of pharmacological prophylaxis with LMWHs. Medical thromboprophylaxis is a grade 1 recommendation in the ACCP 3 guidelines and is recommended in both SIGN 8 and THRIFT II 9 consensus group guidelines and ther Department of Health. These guidelines all recommend the use of pharmacological thromboprophylaxis in acutely ill medical patients who exhibit risk factors for VTE in whom there is no contraindication. SCOPE This guideline should be used by Worcestershire PCT medical and nursing staff and people contracted to work for the PCT including GPs, involved in the care of adult inpatients with an acute medical condition. WPCT Thromboprophylaxis guideline adapted from WHAT guideline WHAT-MED-010 Page 3 of 9
ASSESSMENT OF PATIENTS The Department of Health assessment sheet should be completed by the doctor, for each patient and filed in their notes. For those patients in community hospital settings for long periods of time there is potential for their medical condition to deteriorate from stable to acutely unwell. In cases where the initial acute medical condition has been treated and resolved, staff must be aware of the possibility that a patient s medical condition may deteriorate, and in these cases the risk of thrombosis may increase. In such cases it may be appropriate to restart enoxaparin, and monitor the patient s progress closely. RISK FACTORS for VTE Active cancer or cancer treatment Active heart or respiratory failure Acute medical illness Age over 60 years Antiphospholipid syndrome Behcet s disease Central venous catheter in situ Immobility (for example, paralysis or limb in plaster) Inflammatory bowel disease (for example, Crohn s disease or ulcerative colitis) Myeloproliferative diseases Risk Factors for VTE 10 Nephrotic syndrome Obesity (body mass index 30 kg/m2) Paraproteinaemia Paroxysmal nocturnal haemoglobinuria Personal or family history of VTE Pregnancy or puerperium Recent myocardial infarction or stroke Severe infection Use of oral contraceptives or hormonal replacement therapy Varicose veins with associated phlebitis Inherited thrombophilias WPCT Thromboprophylaxis guideline adapted from WHAT guideline WHAT-MED-010 Page 4 of 9
The following flowchart should be used when deciding whether a medical patient should be prescribed enoxaparin for thromboprophylaxis: Is the patient an adult who is acutely ill (likely to be immobilised for 3 or more days) with one or more VTE risk factors? YES Is low molecular weight heparin contraindicated? NO YES Give enoxaparin (Clexane) 40mg* once daily s/c (* review dose at extremes of body weight) Consider mechanical thromboprophylaxis with graduated compression stockings (GCS) Contraindications to enoxaparin Creatinine clearance <30ml/min (consider s/c unfractionated heparin (UFH) or a reduced dose of enoxaparin High risk of bleeding A known bleeding disorder/ thrombocytopenia History of heparin induced thrombocytopenia On oral anticoagulants with a therapeutic INR (INR > 2.0) Recent spinal or epidural analgesia. Hemorrhagic stroke or risk of CNS bleed. Ischaemic stroke within one week of onset Aortic aneurysm Acute bacterial endocarditis hypersensitivity to either enoxaparin sodium, heparin or its derivatives including other Molecular Weight Heparins WPCT Thromboprophylaxis guideline adapted from WHAT guideline WHAT-MED-010 Page 5 of 9
Continuation of thromboprophylaxis Thromboprophylaxis once commenced should be continued until the patient is fully ambulant. It should be regularly reviewed and only continued after ambulation if the risk of VTE is still high. Please note that enoxaparin is only licensed for use for 14 days. There is positive evidence for use longer than 14 days but the benefit of a reduction in venous thromboembolic events has to be balanced against an increase in the risk of bleeding. The patient should therefore be re-assessed and this should be documented in the patient s notes Monitoring of LMWH The standard prophylactic regimen does not require monitoring 11 Graduated compression stockings (GCS) The decision to fit GCS should be made in collaboration with the medical staff. The patient should be measured accurately in order to ascertain the correct size of the stocking. If they are fitted incorrectly, they may be too tight, restricting the circulation, causing a tourniquet effect and thus predisposing to DVT. If they are too loose they will be completely ineffective. It is important to note that even if GCS are fitted correctly they are not 100% effective at preventing DVT. Other preventative measures such as passive leg exercises should be encouraged where appropriate. Contraindications to compression stockings Gross leg oedema Gross pulmonary oedema Ischaemic vascular disease Local leg conditions e.g. gangrene, dermatitis, skin grafts Extreme leg deformity MONITORING TOOL There will be an audit of medical records to measure compliance with these guidelines. STANDARDS % CLINICAL EXCEPTIONS All medical inpatients (aged >18years) who meet the inclusion criteria will receive appropriate thromboprophylaxis 100% None WPCT Thromboprophylaxis guideline adapted from WHAT guideline WHAT-MED-010 Page 6 of 9
REFERENCES 1. Cooper JW & Groce J III. DVT/PE prophylaxis in medically ill patients: a new avenue of clinical management in the long term care setting.consult pharm 2001; 16 (suppl D):7-17 2. House of Commons Health Select Committee.In :The prevention of venous thromboembolism in hospitalised patients, HC99, The Stationary Office Limited, London, England 2005 3. Geerts WH et al. Prevention of venous thromboembolism. The Seventh ACCP conference on antithrombotic and thrombolytic therapy Chest 2004; 126:338S-400S. 4. Samama MM et al. A comparison of Enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. (MEDENOX) N Eng J Med 1999; 341:793-800 5. Cohen A T et al. Assessment of venous thromboembolism risk and the benefits of thromboprophylaxis in medical patients Thromb Haemo 2005; 94: 750-9 6. Leizorovicz A et al. Randomised, placebo-controlled trial of dalteparin for the prevention of venous thromboembolism in acutely ill medical patients. Circulation 2004; 110:874-879 7. Cohen A T et al. Efficacy and safety of fondaparinux for the prevention of venous thromboembolism in older acute medical patients: Randomised placebo controlled trial. BMJ 2006; 332:325-329 8. Scottish and Collegiate Guideline Network (SIGN). Prophylaxis of Venous Thromboembolism. London. SIGN Publication 2002: no.62. Available at www.sign.ac.uk/guidelines. 9. Thromboembolic Risk Factors (THRIFT II) Consensus Group Guidelines. Available at www.clinicalconsensusreports.com 10. NICE Guideline: CG46 Venous thromboembolism 23 April 2007 11. BNF, September 2007 WPCT Thromboprophylaxis guideline adapted from WHAT guideline WHAT-MED-010 Page 7 of 9
Equality Impact Assessment Report Template Name of policy or function - Guideline for thromboprophylaxis in adult (18yrs and older) general medical patients Responsible Manager - Sue Lunec, Head of Medicine Management Date EIA completed - 2 March 2010 Description of aims of function/policy - To improve the health of patients in the community hospitals; To fulfil the requirement of national guidance o Brief summary of research and relevant data - See references o Methods and outcomes of consultation o Results of Initial Screening or Full Equality Impact Assessment Initial or Full Equality Impact Assessment? Equality Group Race Gender Disability Age Sexual Orientation Religion or Belief Human Rights Initial Assessment of Impact 1. Decisions and or recommendations (including supporting rationale) 2. Equality action plan (if required) 3. Monitoring and review arrangements (include date of next full review) WPCT Thromboprophylaxis guideline adapted from WHAT guideline WHAT-MED-010 Page 8 of 9
Department Medicines Management Directorate Medicines Management Director Dr S Bhaduri Report produced by and job title Sue Lunec, Head of Medicines Management Date report produced March 2010 Date report published September 2010 WPCT Thromboprophylaxis guideline adapted from WHAT guideline WHAT-MED-010 Page 9 of 9