Venous thromboembolism (VTE) policy

Contents

1 Policy summary

This policy aims to help clinical staff identify people most at risk of venous thromboembolism (VTE) and describes interventions that can be used to reduce the risk of VTE. The recommendations are based on NICE guidance and quality standards. The policy is relevant to all inpatient clinical staff and the care of all inpatients.

Patients admitted to hospital, whether related to their mental and, or physical health, are more likely to have reduced mobility making them at higher risk of VTE. VTE most frequently occurs in the deep veins of the legs or pelvis (a deep vein thrombosis [DVT]). It can dislodge and travel to the lungs, known as a pulmonary embolism (PE), which in some cases can be fatal. VTE is an important cause of death in hospital. It can also cause long-term morbidity for patients and is associated with considerable cost to the health service. However, though common, VTE is potentially preventable. The risk of VTE can be reduced by early identification of those at high risk, reviewing the risk of developing VTE over the course of the admission and offering appropriate VTE prophylaxis.

2 Introduction

The trust will adhere to the following NICE guidance around VTE where the recommendations and standards are applicable:

• NG089 Venous thromboembolism in over 16s reducing the risk of hospital acquired deep vein thrombosis or pulmonary embolism (opens in new window)
• NG158 Venous thromboembolic diseases diagnosis, management and thrombophilia testing (opens in new window)
• QS201 Venous thromboembolism in adults (opens in new window)

VTE is a condition in which a blood clot (thrombus) forms in a vein. It most commonly occurs in the deep veins of the legs; this is called DVT. The thrombus may dislodge from its site of origin to travel in the blood, a phenomenon called embolism.

VTE is an important cause of death in hospital patients and treatment of nonfatal symptomatic VTE and related long-term morbidities is associated with considerable cost to the health service.

The risk of developing VTE depends on the condition and, or procedure for which the patient is admitted and on any predisposing risk factors.

This policy makes recommendations on assessing and reducing the risk of VTE in patients in hospital. The recommendations take into account the potential risks of the various options for prophylaxis and patient preferences.

3 Purpose

The purpose of this document is to set out the organisational arrangements for implementing national best practice in relation to VTE. This policy offers best practice advice on reducing the risk of VTE in patients admitted to hospital and provides guidance for the prevention of VTE based on recommendations in NICE clinical guidelines and pathways.

4 Scope

This policy applies to all staff within the inpatient areas who undertake VTE risk assessments and staff involved in the care of patients at risk of VTE.

5 Procedure or implementation

5.1 Quick guide

5.1.1 Assess

• All inpatients over 16 years must undergo a mandatory risk assessment for the prevention of VTE.
• The VTE risk assessment and clinical decision must be completed by a doctor or suitably trained qualified nurse in the patients records as soon as possible within 14 hours after admission.

5.1.2 VTE prophylaxis

• Consider pharmacological VTE prophylaxis with low molecular weight Heparin (LMWH) for patients admitted to an inpatient service whose risk of VTE outweighs their risk of bleeding
• Consider pharmacological VTE prophylaxis with Fondaparinux sodium if LMWH is contraindicated for patients admitted to an inpatient service whose risk of VTE outweigh their risk of bleeding.

5.1.3 Reduce risk

• Continue pharmacological VTE prophylaxis for people admitted to an inpatient service until the patient is no longer at risk of VTE.
• A care plan will be put into place giving clear guidance to clinical staff as to how the VTE risk is to be managed.

5.1.4 Monitoring

• Routine monitoring or dose adjustment of LMWH prophylaxis is not required for once daily treatment regimen and not generally necessary for twice daily regimen treatment. If patient condition changes baseline investigations and VTE risk reassessed.

5.1.5 Discharge

• As part of the discharge plan, ensure that the VTE information leaflet has been given to patients and, or carers.
• Ensure that patient who are discharged with pharmacological and, or mechanical BTE prophylaxis can use it correctly, or have arrangements made for someone to be available who will be to help them.
• Notify the patient’s GP if the patient has been discharged with pharmacological and, or mechanical BTE prophylaxis to be used at home.

5.2 Guidance

The following guidance is based on the best available evidence.

Throughout this policy significantly reduced mobility is used to denote patients who are unable to leave their bed, unable to walk unaided or likely to spend a substantial proportion of the day in bed or in a chair.

Regard patients as being at increased risk of VTE if they either:

• have had or are expected to have significantly reduced mobility for 3 days or more
• are expected to have ongoing reduced mobility relative to their normal state and have one or more of the risk factors as shown below

In addition, the following factors may increase risk:

• age over 60 years
• active cancer or cancer treatment
• acute or chronic lung disease
• acute or chronic inflammatory disease
• chronic heart failure
• acute infectious disease, for example, pneumonia
• dehydration or poor oral intake
• known thrombophilia
• obesity (body mass index (BMI) over 30 kg/m2)
• lower limb paralysis (excluding aortic stroke)
• personal history or first-degree relative with a history of VTE
• use of oestrogen-containing contraceptive therapy or hormone replacement therapy
• varicose veins with phlebitis
• injecting illicit drugs
• antipsychotics
• restraint
• catatonia and other presentations associated with reduced mobility and, or poor fluid intake
• neuromuscular syndrome

Assess patient’s risks of bleeding and VTE within 14 hours of admission and reassess whenever the clinical situation changes to:

• ensure that the methods of VTE prophylaxis being used are suitable
• ensure that VTE prophylaxis is being used correctly
• identify adverse events resulting from VTE prophylaxis Prescribers should consult the summary of product characteristics for the pharmacological VTE prophylaxis being used or planned for further details

5.3 Assessing the risk of VTE inpatient services

5.3.1 Interim COVID-19 related assessment for VTE

Staff should refer to COVID-19 rapid guideline: managing COVID-19 (opens in new window) for the most up-to-date COVID-19 related NICE guidance.

5.3.2 All trust inpatient wards

• All inpatients over 16 years must undergo a mandatory risk assessment for the prevention of VTE.
• The risk assessment must be signed by a doctor or nurse or other suitably qualified registered professional.
• The clinical decision on how to manage the risk of VTE will be based on an assessment of the risk of VTE against the risks of preventative treatment for each individual patient and the decision will be informed by available published evidence. Following this the pharmacological and mechanical prophylaxis should be prescribed.
• The VTE risk assessment and clinical decision must be completed by a doctor or suitably trained qualified nurse in the patients records as soon as possible within 14 hours after admission.
• Consider pharmacological VTE prophylaxis with low molecular weight Heparin (LMWH) for patients admitted to an inpatient service whose risk of VTE outweighs their risk of bleeding.
• Consider pharmacological VTE prophylaxis with Fondaparinux sodium if LMWH is contraindicated for patients admitted to an inpatient service whose risk of VTE outweighs their risk of bleeding.
• Continue pharmacological VTE prophylaxis for people admitted to an inpatient service until the patient is no longer at risk of VTE.
• A care plan will be put into place giving clear guidance to clinical staff as to how the VTE risk is to be managed.
• The VTE risk assessment is to be reviewed if the patient’s clinical condition changes or at the point of consultant review.

5.3.3 Intermediate care Hazel and Hawthorn

• Step down patients from the acute trust will have had their VTE assessment in the acute trust.
• The professional receiving the referral will check an assessment has been undertaken and ascertain if a management plan is in place, they will document this information on the referral form. They will request that the assessment and any management plan are sent with the patient.

Step up patients received from community will have a VTE assessment within 14 hours undertaken by the nurse. If a risk is identified they will contact the Advanced Nurse Practitioner (ANP) to make the clinical and prescribing decision. If this cannot be actioned immediately by the ANP the admitting 8 nurse will contact the contracted General Practitioner (GP) or out of hour’s service for advice on the appropriate management plan.

5.3.4 Mental health and forensic inpatients including rehabilitation wards

• The risk assessment must be completed by a doctor or suitably trained qualified nurse and filed in the patients records as soon as possible within 14 hours after admission (appendix A).
• Advice is to be sought from the District Nursing team with regard to the management of the identified risk.
• A care plan will be put into place giving clear guidance to clinical staff as to how the risk is to be managed.
• The risk assessment is to be reviewed if the patient’s clinical condition changes or at the point of consultant review.
• A VTE assessment must be completed for all patients prior to electroconvulsive therapy (ECT).
• Consider pharmacological VTE prophylaxis with LMWH for patients admitted to an acute psychiatric ward whose risk of VTE outweighs their risk of bleeding.
• Consider pharmacological VTE prophylaxis with Fondaparinux sodium if LMWH is contraindicated for patients admitted to an acute psychiatric ward whose risk of VTE outweighs their risk of bleeding.
• Continue pharmacological VTE prophylaxis for people admitted to an acute ward until the patient is no longer at risk of VTE.
• Advice is to be sought from the District Nursing team regarding the management of the identified VTE risk.
• A VTE assessment must be completed for all patients prior to ECT.

Balance the persons individual risk of VTE against their risk of bleeding when deciding whether to offer pharmacological thromboprophylaxis to patients.

5.4 All patients

Offer mechanical or pharmacological VTE prophylaxis to patients assessed to be at increased risk of VTE

Start pharmacological VTE prophylaxis if indicated as soon as possible after risk assessment has been completed. Continue until the patient is no longer at increased risk of VTE or as indicated in NICE guidance.

5.4.1 Patients with central venous catheters

Do not routinely offer pharmacological or mechanical VTE prophylaxis to patients with central venous catheters who are ambulant.

Consider offering pharmacological VTE prophylaxis to patients with central venous catheters who are at increased risk of VTE.

5.4.2 Patients in palliative care

Consider offering pharmacological VTE prophylaxis to patients in palliative care who have potentially reversible acute pathology. Take into account potential risks and benefit and the views of patients and their families and, or carers.

Do not routinely offer pharmacological or mechanical VTE prophylaxis to patients admitted for terminal care or those commenced on an end of life care pathway.

Review decisions about VTE prophylaxis for patients in palliative care daily, taking into account the view of patients, their families and, or carers and the multidisciplinary team.

5.4.3 VTE Prophylaxis and actions to be taken if patients taking antiplatelet and anticoagulants for other conditions

5.4.4 Patients with uncontrolled bleeding

In the event of uncontrolled bleeding contact the 999 ambulance service and arrange transfer to the local acute hospital.

5.5 Reducing the risk of VTE

The prescriber and clinical decision maker will advise and discuss with ward staff and patient how to reduce risk.

Do not allow patients to become dehydrated unless clinically indicated.

Encourage patients to mobilise as soon as possible.

Patients already having antiplatelet agents or anticoagulant therapy to treat other medical conditions. For patients admitted on dual antiplatelet therapy, for example, Aspirin and Ticagrelor seek advice from consultant cardiologist.

Consider VTE prophylaxis for patients who are having antiplatelet agents for other conditions and whose risk of VTE outweighs their risk of bleeding. Take into account the risk of bleeding and of co-morbidities such as arterial thrombosis.

Consider VTE prophylaxis for patients at increased risk of VTE who are interrupting anticoagulant therapy.

5.6 Using VTE prophylaxis

5.6.1 Anti-embolism stockings

Anti-embolism stockings can only be issued via a prescription.

Do not offer anti-embolism stockings to patients who have:

• suspected or proven peripheral arterial disease
• peripheral arterial bypass grafting
• peripheral neuropathy or other causes of sensory impairment
• any local conditions in which anti-embolism stockings may cause damage, for example fragile “tissue paper” skin, dermatitis, gangrene or recent skin graft
• known allergy to material or manufacture
• severe leg oedema
• unusual leg size or shape
• major limb deformity preventing correct fit

Use caution and clinical judgement when applying anti-embolism stockings over venous ulcers or wounds.

Ensure that patients who need anti-embolism stockings have their legs measured and that the correct size of stocking is provided. Anti-embolism stockings should be fitted and patients shown how to use them by staff trained in their use.

Ensure that patients who develop oedema or post-operative swelling have their legs re-measured and anti-embolism stockings re-fitted.

If arterial disease is suspected, seek expert opinion before fitting antiembolism stockings. Referral process may differ in different parts of the inpatient areas within the organisation.

Use anti-embolism stockings that provide graduated compression and produce a calf pressure of 14 to 15 mmHg (this relates to a pressure of 14 to 18 mm Hg at the ankle and is in line with British Standards BS 6612:1985 specification for graduated compression hosiery and BS 7672:1993 specification for compression, stiffness and labelling of anti-embolism hosiery.

Encourage patients to wear their anti-embolism stockings day and night until they no longer have significantly reduced mobility.

Remove anti-embolism stockings daily for hygiene purposes and to inspect skin condition. In patients with a significant reduction in mobility, poor skin integrity or any sensory loss, inspect the skin two or three times per day, particularly over the heels and bony prominences. Patients should have two pairs prescribed to facilitate a change of stocking.

Discontinue the use of anti-embolism stockings if there is marking, blistering or discoloration of the skin, particularly over the heels and bony prominences, or if the patient experiences pain or discomfort.

Show patients how to use anti-embolism stockings correctly and ensure they understand that this will reduce their risk of developing VTE.

Monitor the use of anti-embolism stockings and offer assistance if they are not being worn correctly.

5.6.2 Pharmacological VTE prophylaxis

5.6.2.1 Principles of pharmacological VTE prophylaxis

Assess all patients for risk of bleeding before offering pharmacological VTE prophylaxis. Prescribers should consult the summary of product characteristics for the pharmacological VTE prophylaxis being used or planned for further details and individual drug contra-indications.

Do not offer pharmacological VTE prophylaxis to patients with any of the risk factors for bleeding below, unless the risk of VTE outweighs the risk of bleeding:

• untreated inherited bleeding disorders (such as haemophilia and von Willebrand’s disease
• acute stroke in previous month (haemorrhagic or ischaemic)
• uncontrolled systolic hypertension (230/120mmHg or higher)
• severe liver disease (prothrombin time above normal or known varices)
• major bleeding risk, existing anticoagulant therapy
• thrombocytopenia (platelets less than 75 x 109/l)
• active bleeding

5.6.2.2 Choice of low molecular weight Heparin (LMWH)

Different LMWH has been chosen by the acute trusts working in the different localities of RDaSH. The following are the first choice LMWH in each of the localities (as at February 2015):

• Doncaster area, Dalteparin
• Rotherham area, Tinzaparin
• Scunthorpe area, Tinzaparin 12
• Fondaparinux Sodium should be used in individuals who are allergic to Heparin

5.6.2.3 Dose recommendations

5.6.2.3.1 Dalteparin

• Prophylaxis for patients assessed as at risk of VTE.
• Patients whose weight is between 45kg to 100 kg.

This lower dose should also be used in all those with evidence of acute kidney injury (oliguria over 12 hours or doubling or serum creatinine), including obese patients.

Prophylaxis in extremes of body weight (unlicensed).

5.6.2.3.1 Tinzaparin

It is administered subcutaneously once daily until patients no longer significantly immobile, generally 5 to 7 days.

Extended duration is recommended after some surgical procedures, for example, Orthopaedic (hip and knee replacement and hip fracture) and patients undergoing abdominal and pelvic surgery for cancer. This should be initiated by the acute trust.

Contraindications to Tinzaparin.

See risk assessment form (appendix A)

Consider 50 units per kg at extremes of weight, for example, less than 30kg or more than 130kg.

All LMWH are derived from animal origin. Alternatives may be considered following discussion with the haematologists.

Fondaparinux 2.5 mg once daily.

5.6.2.4 Monitoring requirements

5.6.2.4.1

Investigations prior to initiating a LMWH

Before prescribing a LMWH the following baseline investigations should be checked:

• weight
• full blood count (FBC)
• urea and electrolytes (U and E), estimated glomerular filtration rate (eGFR) and platelet count

5.6.2.4.2 Ongoing monitoring

LMWH’s can cause hyperkalemia. The risk appears to increase with increased duration of therapy. Patients at increased risk include: Patients with diabetes mellitus, chronic renal failure, acidosis, raised plasma potassium, or those on potassium sparing diuretics, ACE Inhibitors.

Routine monitoring or dose adjustment of LMWH prophylaxis is not required for once daily treatment regimen and not generally necessary for twice daily regimen treatment. If patients condition changes baseline investigations and VTE risk reassessed.

5.7 Patient information and planning for discharge

5.7.1 Patient information

Good communication between health and social care professionals and patients is essential. Treatment and care, and the information given about it, should be culturally appropriate. It should also be accessible to patients with additional needs such as physical, sensory, or learning disabilities, and to patients who do not speak or read English.

Staff should be mindful that heparins are of animal origin and this may be of concern to some patients with certain preferences and religious beliefs, to not accept medications containing animal products (see Religion or belief, a practical guide for the NHS 2009 (opens in new window)). For patients who have concerns about using animal products, consider offering synthetic alternatives (Fondaparinux sodium) based on clinical judgement and after discussing their suitability, advantages and disadvantages with the patient. This should be documented in the patient’s record.

Patients (and relatives and carers as appropriate) should have the opportunity to be involved in decisions regarding prophylaxis for the prevention of VTE.

Before starting VTE prophylaxis, patients and, or their families or carers must be offered the VTE information leaflet (appendix B).

5.8 Planning for discharge

As part of the discharge plan, ensure that the VTE information leaflet has been given to patients and, or carers which provides written information on:

• the signs and symptoms of DVT and PE
• 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 DVT, PE or other adverse events are suspected
• how patients can reduce their risk of VTE (such as keeping well hydrated and, if possible, exercising and becoming more mobile)

Ensure that patients who are discharged with anti-embolism stockings:

• understand the benefits of wearing them
• understand the need for daily hygiene removal
• can 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
• understands the importance of wearing them correctly
• know when to stop wearing them

Ensure that patients who are discharged with pharmacological and, or mechanical VTE prophylaxis can 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.

6 Training implications

6.1 VTE prevention in primary care, all in patient non-medical staff including registered and non-registered nurses

• How often should this be undertaken: Annually.
• Length of training: 30 mins.
• Delivery method: E-learning.
• Training delivered by whom: ESR training.
• Where are the records of attendance held: Electronic staff record system (ESR).

6.2 VTE prevention in secondary care, all prescribers involved in assessment, informing and prescribing (this excludes medical staff), this is for inpatient areas only

• How often should this be undertaken: Annually.
• Length of training: 45 mins.
• Delivery method: E-learning.
• Training delivered by whom: ESR training.
• Where are the records of attendance held: Electronic staff record system (ESR).

7 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

7.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

7.1.1 How this will be met

No issues have been identified in relation to this policy.

7.2 Mental Capacity Act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

7.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005).

8 Links to any other associated documents

• Consent to care and treatment policy
• Infection prevention and control
• MCA Mental Capacity Act 2005 policy
• Non-medical prescribing policy
• Healthcare record keeping policy

9 References

• British National Formulary (on line) 2022 British Pharmaceutical Society and British Medical Journal.
• Diagnosing Venous Thromboembolism in Primary, Secondary and Tertiary care NICE pathway updated March (2018).
• Guideline for the Management of Venous Thromboembolism (Medicines Formulary) Doncaster and Bassetlaw NHS Foundation Trust (2022).
• Treating Venous Thromboembolism NICE pathway updated March (2018).
• Venous Thromboembolism in over 16s Reducing the risk of hospital acquired deep vein thrombosis or pulmonary embolism 2018 NICE guideline NG89.
• Venous Thromboembolic diseases: diagnosis, management and thrombophilia testing. (2020) (NG89).
• Venous thromboembolism in adults Quality Standard (QS201).

10 Appendices

10.1 Appendix A Risk assessment for venous thromboembolism (VTE)

• Appendix A Risk assessment for venous thromboembolism (VTE) (staff access only) (opens in new window)

10.2 Appendix B Venous thromboembolism (VTE) information leaflet

• Appendix B Venous thromboembolism (VTE) information leaflet (staff access only) (opens in new window)

10.3 Appendix C Responsibilities, accountabilities and duties

10.3.1 Chief executive

The chief executive is accountable for having policies and procedures in place to support best practice, effective management, service delivery, management of associated risks and meeting national and local legislation and, or requirements.

10.3.2 Medical director

The medical director is responsible for the implementation and monitoring of this policy.

10.3.3 Medical staff or advance nurse practitioners

Consultants, medical staff and advance nurse practitioners are responsible for the safe and effective implementation and monitoring of this policy. In addition:

• ensuring VTE risk assessments are completed within 14 hours of admission to the ward and as the patient’s condition changes

10.3.4 Matron or ward manager

The matron or ward managers are responsible for the safe and effective implementation of this policy. In addition:

• monitoring compliance with VTE risk assessment within their service area
• monitoring compliance relating to staff training and competency outlined in this policy

10.3.5 All staff

All qualified nursing and medical staff are responsible for:

• ensuring that patients in their care have been assessed for their risk of VTE
• ensure VTE documentation is accurate and up-to-date
• ensure patients receive verbal and written information on their risk of VTE and methods of prevention on admission and as part of the discharge process
• ensure escalation to the appropriate medical staff and, or senior nursing staff regarding any omissions in VTE risk assessment and treatment

10.4 Appendix D Monitoring arrangements

10.4.1 Completion of VTE risk assessment compliance

• How: Report on re-portal.
• Who by: Service manager.
• Reported to: Quality meeting.
• Frequency: Monthly.

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Document control

• Version: 5.
• Unique reference number: 36.
• Approved by: Clinical policy review and approval group.
• Date approved: 6 September 2022.
• Name of originator or author: Julie Hall, Complex Care Practitioner, Raegan Cartlidge, Pharmacist.
• Name of responsible individual: Director of nursing and allied health professionals.
• Date issued: 20 September 2022.
• Review date: September 2025.
• Target audience: Trust wide, all staff in inpatient areas.

Page last reviewed: November 19, 2024
Next review due: November 19, 2025

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