Venous thromboembolism prevention policy and procedure



Ref: FOI/GS/ID 6480

Please reply to:

FOI Administrator

Trust Management

Maidstone Hospital

Hermitage Lane

Maidstone, Kent

ME16 9QQ

Email: mtw-tr.f[email protected]

www.mtw.nhs.uk

12 January 2021

Freedom of Information Act 2000

I am writing in response to your request for information made under the

Freedom of Information Act 2000 in relation to the policy for the prevention of

blood clots for inpatients.

You asked:

I am aware that the Trust has a policy for the prevention of blood clots for

inpatients.

Could you please advise me on how to obtain a copy of the policy?

Trust response:

Please find attached below a copy of the requested policy.

Venous thromboembolism prevention

policy and procedure

Requested/

Required by: Thrombosis Committee to comply with NICE Clinical

Guidance 92

Author: VTE Lead Nurse

Other contributors: Consultant Haematologist

Owner: Medical Director

Directorate: Corporate

Specialty: Venous Thromboembolism (VTE)

Supersedes: Venous Thromboembolism Prevention Policy and

Procedure, Version 3.0 (June 2013)

Venous Thromboembolism Prevention Policy and

Procedure, Version 3.1 (April 2014)

Venous Thromboembolism Prevention Policy and

Procedure, Version 4.0 (May 2016)

Venous Thromboembolism Prevention Policy and

Procedure, Version 4.1 (September 2016)

The policies below are now incorporated into this

policy and have been archived on Q-pulse.

Anti-embolism stockings (AES), Policy and Procedure

for the use of, Version 1.0 (February 2013)

Intermittent Pneumatic Compression Devices (IPCD),

Policy and Procedure for the use of, Version 1.0

(June 2013)

Approved by: Thrombosis Committee, 10

March 2016

Ratified by: Policy Ratification Committee, 12

May 2016

Review date: May 2019 [Extension to June 2021 approved by the

Chair of the Thrombosis Committee on 8

December

2020, following the arrangements for extension as set

out in the ‘Policy and procedure for the production,

approval and ratification of Trust-wide policies and

procedures ('Policy for policies') - RWF-OPPPCS-NC-

CG25]

This policy has been written for implementation during periods of

standard functioning within the Trust. Outside of those periods

(such as major incidents or national emergencies) other

‘emergency’ policies may be written to supersede or run alongside

this policy.

Disclaimer: Printed copies of this document may not be the most recent version.

The master copy is held on Q-Pulse: Organisational Wide Documentation database

This copy – REV4.2

Document history

Requirement

for

document:

 To comply with national guidance on the prevention of

venous thromboembolism in hospitalised patients.

Cross

references

(external):

1. NICE. (2010). Venous thromboembolism: reducing the risk

of venous thromboembolism (deep vein thrombosis and

pulmonary embolism) in patients admitted to hospital.

NICE Clinical Guidance 92 (2010)

2. NICE. (2012). Venous thromboembolic diseases: the

management of venous thromboembolic diseases and the

role of thrombophilia testing. NICE Clinical Guidance 144

(2012)

3. Department of Health. (2007). Report of the independent

expert working group on the prevention of venous

thromboembolism in hospitalised patients. London:

Department of Health

4. Department of Health. (2008). Risk Assessment for

Venous Thromboembolism. London: Department of Health

5. National Patient Safety Agency. (2009). Patient Safety

Alert. WHO Surgical Safety Checklist.

6. The NHS Confederation (2009). Briefing paper: Reducing

Deaths from Blood Clots in Hospitals.

Associated

documents

(internal):

 Acute Stroke Policy and Procedure (RWF-OPPPES-C-

SM11)

 Blood clots (thrombosis), Preventing hospital acquired

[LARGE PRINT LEAFLET] [RWF-OPLF-PES92]

 Blood clots (thrombosis), Preventing hospital acquired

[STANDARD PRINT LEAFLET] [RWF-OPLF-PES89]

 Blood clots (thrombosis), Preventing hospital acquired;

information for maternity patients [STANDARD PRINT

LEAFLET] [RWF-OPLF-PES90]

 Blood clots (thrombosis), Preventing hospital acquired;

information for maternity patients [LARGE PRINT

LEAFLET] [RWF-OPLF-PES94]

 Consent to Examination or Treatment, Policy and

Procedure for [RWF-OPPPES-C-SM5]

 Medical Devices Policy and Procedure [RWF-OPPPCS-NC-

EST2]

 Pharmacy anti-coagulation guidance [available on the

pharmacy pages of the staff intranet]

 Policy and Procedure for the Safe Management of

Anticoagulant Therapy [RWF-OPPPCSS-C-CAN3] –

 Protocol for the use of Intermittent Pneumatic Compression

Devices (IPCD) for patients with Haemorrhagic Stroke (or

other contraindication to LMWH) (RWF-OPPM-ES6)

 Venous Thromboembolism (VTE) in Pregnancy and

Puerperium: prophylaxis, diagnosis and management

[RWF-OPPPW&C-C-O&G2]

 Venous Thromboembolism (VTE): diagnosis and

management in adults policy and procedure [RWF-

OPPPES-C-SM15]

Version control:

Issue:

Description of changes:

Date:

1.0

First iteration of the policy/procedure

July 2010

1.1

Amendment to Appendix 4 Risk Assessment

July 2010

1.2

Amendment to Appendix 4 Risk Assessment

January 2011

2.0

Revision of the policy/procedure

October 2011

3.0

Revision of the policy/procedure

June 2013

3.1

Added section 7.9 and appendix 11 to

policy/procedure; removed references to NHSLA

standards, which have ceased to exist

April 2014

4.0

Revision of the policy / procedure

Merge of this policy with Anti-embolism stockings

P&P and Intermittent Pneumatic Compression

Devices P&P

May 2016

4.1

Amended appendix table to reflect printed

stationary

September

2016

4.2

Extension to June 2021 approved by the Chair of

the Thrombosis Committee on 8

December 2020

Policy statement for

Venous thromboembolism prevention

policy

The purpose of this policy is to ensure that all adult in-patients are appropriately and regularly assessed

for risk of venous thromboembolism (VTE) and if appropriate receive VTE prophylaxis according to that

risk throughout their stay at Maidstone and Tunbridge Wells NHS Trust (MTW).

Patients admitted to the Trust should have the opportunity to make informed decisions

about their care and treatment, in partnership with their health care professionals and

the Trust will offer best practice advice on reducing the risk of VTE in patients admitted

to hospital.

Venous thromboembolism prevention

procedure

Contents

Page

1.0 Introduction and scope 6

2.0 Definitions 7

3.0 Duties 8

4.0 Training / competency requirements 8

5.0 Care pathway 9

6.0 Patient risk assessment 10

7.0 Thromboprophylaxis 10

7.1 VTE prophylaxis in surgical patients 11

7.2 VTE prophylaxis in orthopaedic patient 11

7.3 VTE prophylaxis in medical patients 11

7.4 VTE prophylaxis in acute stroke patients 12

7.5 VTE prophylaxis in cancer patients 12

7.6 VTE prophylaxis in end of life patients 13

7.7 Patients already on anti-platelet or anticoagulant therapy 13

7.8 VTE prophylaxis in pregnancy and up to 6 weeks post-partum 13

7.9 Lower limb immobilisation and LMWH 13

8.0 Patient information and consent

9.0 Discharge

10.0 Anti-embolism stockings (AES)

11.0 Intermittent pneumatic compression devices (IPCD)

12.0 Monitoring and audit

Appendices

1 Process requirements

2 Consultation table

3 Equality impact assessment table

List of further appendices – separate documents on Q-Pulse

1.0 Introduction

The House of Commons Health Committee reported in 2005 that an

estimated 25,000 people a year in the UK die from preventable hospital-

acquired venous thromboembolism (VTE). This includes patients admitted

to hospital for medical care and surgery. The inconsistent use of prophylactic

measures for VTE in hospital patients has been widely reported. A UK

survey suggested that 71% of patients assessed to be at medium or high

risk of developing deep vein thrombosis (DVT) did not receive any form of

mechanical or pharmacological VTE prophylaxis.

VTE encompasses a range of clinical presentations. Venous thrombosis is

often asymptomatic; less frequently it causes pain and swelling in the leg.

Part or all of the thrombus can come free and travel to the lung as a

potentially fatal pulmonary embolism. The patient typically suffers chest

pain, breathlessness and collapse. Deep vein thrombosis carries a

considerable burden of morbidity, including long-term morbidity because of

chronic venous insufficiency. This in turn can cause venous ulceration and

development of a post-thrombotic limb (characterised by chronic pain,

swelling and skin changes). Pulmonary embolism can leave a legacy of

pulmonary hypertension.

VTE is an important cause of death in hospital patients, and treatment of

non-fatal symptomatic VTE and related long-term morbidities is associated

with considerable cost to the health service.

The purpose of this policy is to enable healthcare practitioners at MTW to

identify patients at risk of developing VTE and select the appropriate therapy

to reduce the associated mortality and morbidity risks associated with this

disease.

The diagnosis and treatment of VTE (DVT and PE) is covered in the MTW

Policy and Procedure for the Diagnosis and Management of VTE and the

MTW Policy and Procedure for the Safe Management of Anticoagulation

Therapy.

1.1 Scope

The policy applies to:

All those 18 years and older admitted to hospital as inpatients or formally

admitted to a hospital for day-case procedures, including:

surgical and medical inpatients

orthopaedic and trauma inpatients

patients admitted to Intensive Care Units

cancer inpatients

people undergoing long-term rehabilitation in hospital

patients admitted to a hospital bed for day-case medical or surgical

procedures.

Please note: Appendix 8 - this applies to patients 16 and over and is relevant

to both outpatients and inpatients with lower limb casts.

The policy does not apply to:

 People younger than 18 years (but please use clinical judgement for

teenage inpatients) (exception please see Appendix 8 for lower limb

casts)

 People attending hospital as outpatients (exception - please see Appendix

8 for lower limb casts)

 People presenting to emergency departments without admission.

 Elderly or immobile people cared for at home, or in external residential

accommodation, unless admitted to hospital.

 Women in pregnancy; a separate policy exists relating to women in

pregnancy (Venous Thromboembolism (VTE) in Pregnancy and

Puerperium)

Patients admitted to hospital with a diagnosis of, or suspected diagnosis of,

deep vein thrombosis or pulmonary embolism should follow a treatment plan

and not the prophylactic plan. Please refer to the Trust Policy and Procedure

for the Diagnosis and Management of VTE and the Trust Policy and

Procedure for the Safe Management of Anticoagulation Therapy and this

policy.

2.0 Definitions

Venous Venous thrombosis is a condition in which a blood clot

Thromboembolism (thrombosis) forms in a deep vein. Blood flow along

the

(VTE) affected vein can be limited by the clot, causing

swelling and pain. Venous thrombosis most

commonly occurs in the 'deep veins' in the leg or

pelvis. This is known as a deep vein thrombosis

(DVT). An embolism is created if a part or all of the

thrombosis in the deep vein breaks off from the site

where it is created and travels along the venous

system. A leg DVT can travel to the lungs, known as

pulmonary embolism (PE). DVT and PE are the most

common manifestations of venous thrombosis. Both

conditions can be asymptomatic. DVT and PE are

known collectively as venous thromboembolism

(VTE).

Deep Vein A thrombosis occurring in a deep vein, most

commonly

Thrombosis (DVT) a deep vein of the leg or pelvis but can affect any

deep vein.

Pulmonary If the clot lodges in the lung a very serious condition,

Embolism (PE) pulmonary embolism (PE) arises.

Thromboprophylaxis Thromboprophylaxis is the treatment to prevent blood

clots forming in veins – this may be chemical or

mechanical.

Chemical Pharmaceutical agents (oral or parenteral) used to

decrease

thromboprophylaxis the clotting ability of the blood.

Mechanical Devices including anti-embolism stockings (AES) and

thromboprophylaxis intermittent pneumatic compression devices (IPCD)

can be used to increase venous blood flow and

reduce stasis within the leg veins.

Significantly reduced Used to denote patients who are bedbound, unable to

walk

mobility unaided or likely to spend a substantial proportion of

the day in bed or in a chair.

Major bleeding Refers to bleeding events that result in one or more of

the following:

 death

 a decrease in haemoglobin concentration of 2g/dl

or more

 transfusion of two or more units of blood

 bleeding into a retroperitoneal, intracranial or

intraocular site

 a serious or life-threatening clinical event

 a surgical or medical intervention.

Thrombosis The Thrombosis Committee was established under

the committee auspices of the Medical Director to

lead on the prevention, reduction and treatment of

VTE. It ensures best practice for the prevention and

management of VTE, based on national guidance and

other examples of best practice.

3.0 Duties (roles and responsibilities)

 Chief Executive has overall responsibility and accountability for the

implementation of this policy.

 Medical Director has delegated responsibility for the implementation of

this policy.

 Clinical Directors will be responsible for ensuring that the clinical staff

within their area follow this policy. They will also review any audits

undertaken to ensure highlighted actions are completed and implemented

in a timely manner.

 VTE Lead Nurse will be responsible for providing the education and

training to assist in the implementation of this policy, ensuring audits are

undertaken to monitor the effectiveness of the policy and ensure the policy

is revised when necessary.

 Clinical staff (Medical/Nursing/Midwifery) will be responsible for

undertaking appropriate and timely risk assessments on patients (as

detailed in this policy) and entering these onto Patient Centre, as well as

ensuring that necessary prophylactic treatment is prescribed as necessary.

This applies to all patients admitted whether emergency or planned.

 Theatre staff should ensure that the nursing pre-operative checklist is

performed ensuring that appropriate VTE risk assessments have been

undertaken as necessary. If no appropriate risk assessment has been

undertaken the surgical procedure should not proceed unless a life-

threatening situation.

 Pharmacists: Pharmacists are responsible for checking chemical

prophylaxis is appropriately prescribed and administered. Any

discrepancies should be recorded in the patient’s healthcare record and

discussed with the prescriber and / or the patient’s medical team.

4.0 Training / competency requirements

All medical, nursing and midwifery staff are made aware of the VTE risk

assessment tool, thromboprophylaxis and patient information documents in

conjunction with this policy at local induction.

Doctors, nurses and midwives will undertake VTE training either through e-

learning or the mandatory update study day VTE session and this will be

monitored as part of their annual appraisal.

Pharmacists will undertake VTE training either through e-learning or the

mandatory update study day VTE session and this will be monitored as part of

their annual appraisal.

The above training will be monitored via the AT-Learning training database.

The training should take place every two years (see Appendix 6 for ‘Training

matrix’).

All clinical staff (Medical/Nursing/Midwifery) will be made aware of the AES

care pathway, AES patient information and the AES manufacturer’s

guidelines.

They should receive training in AES and a declaration of their competency

should be documented (see Appendix 11).

All clinical staff (medical / nursing / midwifery) will be made aware of the IPCD

care pathway and IPCD manufacturer’s guidelines. They must receive training

in IPCD and a declaration of their competency should be documented. See

Appendix 14 (IPCD competency).

5.0 Care pathway

Venous thromboembolism (VTE)

risk assessment

Thrombosis risk?

Yes

Bleeding risk?

No intervention

required

Yes

Mechanical prophylaxis

(if not contraindicated)

Assign patient to

intervention group and

treat as per actions on

risk assessment form

6.0 Patient risk assessment

 All patients admitted to Maidstone and Tunbridge Wells Trust must be

screened within two hours of admission for risk of VTE and considered

for thromboprophylaxis using the screening tool. Please refer to the VTE

Risk Assessment form: Appendix 4.

 All patients must be assessed for risk of bleeding before being offered

chemical VTE prophylaxis. Patients with any of the risk factors for

bleeding will not be offered chemical prophylaxis unless the risk of VTE

outweighs the risk of bleeding. See Appendix 4.

 The patient's VTE risk will be recorded on the risk assessment form and

if appropriate, thromboprophylaxis (chemical, mechanical or a

combination of both) will be commenced. See Appendix 5 for

‘Thromboprophylaxis summary’.

 The risk of VTE and bleeding must be reassessed within 24 hours of

admission and whenever the clinical situation changes and treatment

adjusted accordingly, taking into account the need for extended

thromboprophylaxis in certain cases.

 Treatment must take into account any contraindications to chemical or

mechanical therapies. Contraindications must be recorded in the

patient's healthcare record.

7.0 Thromboprophylaxis

 Treatment should continue until the patient is fully mobile. Extended

thromboprophylaxis should be considered in high risk patients (please

refer to extended thromboprophylaxis guidelines within VTE risk

assessment: see Appendices 4 -5).

 All patients who have risk factors for VTE will be prescribed low

molecular weight heparin (LMWH) from admission at 22.00 hours unless

this is contraindicated.

 Patients who are at risk of VTE but who have an absolute

contraindication to LMWH must be prescribed anti-embolism stockings

unless contraindicated.

 Pre-operative LMWH should not be given to elective surgical patients

unless this has been specifically requested and prescribed by the

admitting consultant.

 Trauma list and non-elective surgical patients should where possible be

delayed until at least 12 hours after the last dose of LMWH has been

administered.

 All patients should be adequately hydrated.

 Patients should be mobilised as early as possible. Patients should be

shown how to exercise their legs if they are on bed rest.

 Consider offering temporary inferior vena cava filters to patients who are

at very high risk of VTE (such as patients with a previous VTE event or

an active malignancy) and for whom mechanical and pharmacological

VTE prophylaxis are contraindicated.

 Invasive procedures with a risk of bleeding (e.g. liver biopsy, endoscopy

with biopsy) should where possible be delayed until at least 12 hours

after the last dose of LMWH has been administered.

7.1 VTE prophylaxis in surgical patients

Surgical patients are at high risk if their combined surgical and anaesthetic

time is 60 minutes or longer or they have any additional risk factor as

identified on the MTW VTE risk assessment form. High risk surgical patients

should be prescribed LMWH daily as per actions on MTW VTE risk

assessment form (see Appendix 4) plus AES (unless contraindicated) and/or

intermittent pneumatic compression device.

Patients undergoing major cancer surgery in the abdomen or pelvis should

continue chemical and mechanical thromboprophylaxis for 28 days post-

surgery. Surgical patients with a body mass index of 30 or greater should

have extended chemical and mechanical thromboprophylaxis for 7 days post-

surgery. Other high risk surgical patients (including day surgery patients)

should continue thromboprophylaxis until their mobility is no longer

significantly reduced, including after discharge if necessary.

Surgical patients are at low risk if their combined surgical and anaesthetic

time is less than 60 minutes and they have no additional risk factor. Low risk

surgical patients should mobilise early and AES should be considered (unless

contraindicated).

If a spinal or epidural anaesthesia is used, additional care must be exercised

when placing or removing the catheters. Placement should be delayed until at

least 12 hours after the last LMWH dose to avoid bleeding complications at

the catheter site. Presence of a spinal or epidural catheter is not a

contraindication to LMWH use. At the discretion of the anaesthetist, LMWH

may be started immediately after the catheter is removed, or immediately after

a regional block.

For patients booked on the emergency theatre list, there needs to be a 12

hour gap between chemical thromboprophylaxis and spinal anaesthetic.

Therefore consideration must be given to the timing of the pre-operative dose,

i.e. this should be prescribed at 20.00 hours on the evening pre-surgery as a

stat dose with the 22.00 dose cancelled. Thromboprophylaxis must not simply

be omitted.

7.2 Thromboprophylaxis for orthopaedic patients

Unless contraindicated, patients admitted for elective hip or knee replacement

should have mechanical VTE prophylaxis which should continue until the

patient’s mobility is no longer significantly reduced. The patient should be

commenced on chemical thromboprophylaxis 6-10 hours post operatively.

This should continue for 35 days for hip replacements and 14 days for knee

replacements. Each patient should be reviewed on a case by case basis. Hip

fracture patients should be prescribed LMWH daily as per actions on MTW

VTE risk assessment form (see Appendix 4) plus AES (unless

contraindicated) and/or intermittent pneumatic compression device.

Thromboprophylaxis should be continued for 28 days. Please see Appendix

5 for summary of extended thromboprophylaxis for specific orthopaedic

surgery.

It is acceptable to reduce thromboprophylaxis to 2,500 units subcutaneous

daily for trauma patients with a weight of 49kg or under.

For patients booked on the orthopaedic trauma list, there needs to be a 12

hour gap between chemical thromboprophylaxis and spinal anaesthetic.

Therefore consideration must be given to the timing of the pre-operative dose,

i.e. this should be prescribed at 20.00 hours on the evening pre surgery as a

stat dose with the 22.00 dose cancelled. Thromboprophylaxis must not simply

be omitted.

7.3 VTE prophylaxis in medical patients

Patients expected to have ongoing reduced mobility plus one or more risk

factors and no contraindications identified should be prescribed LMWH daily

as per actions on the MTW VTE risk assessment form.

Patients who have a bleeding risk or an absolute contraindication to LMWH

must be prescribed AES instead unless contraindicated. If AES also

contraindicated (e.g. acute stroke patients) then an intermittent compression

device should be considered.

Please see Appendix 7 for guidance on thromboprophylaxis for patients with

a bleed or suspected bleed.

7.4 VTE prophylaxis in acute stroke patients

Patients admitted with an acute stroke should have a VTE risk assessment on

admission. LMWH should be withheld until CT imaging has excluded a

haemorrhage and the size of any infarct has been able to be assessed. Once

haemorrhage has been excluded and the patient has been reviewed by the

stroke/medical consultant to assess the size of the infarct, the VTE risk

assessment should be repeated within 24 hours. Unless there are further

contraindications, prophylactic LMWH should be prescribed within the first 72

hours of admission. Care should be taken if there are large territorial infarcts,

if there is a risk of haemorrhagic transformation or if there is a high risk of intra

or extra cranial haemorrhage (this decision will be made the Stroke

Consultant).Patients who have received thrombolysis should not be

prescribed LMWH until they have undergone a follow up CT brain imaging

after 24 hours. A second VTE risk assessment should take place following

the repeat CT head scan. It is expected that the majority of patients will be

able to commence VTE chemical prophylaxis following this assessment but

there will be some patients where this will not be appropriate due to possible

post thrombolysis complications such as haemorrhagic conversion or due to

the size or location of the established infarct. These patients should be

reviewed by the responsible stroke consultant for a decision and future

management in relation to VTE prevention including consideration of using

IPCD after the initial 12 hours if not already commenced. This decision will be

documented in the patient’s record.

All patients with a bleeding risk e.g. haemorrhagic stroke or other

contraindication to LMWH and who have reduced mobility must be assessed

for the use of an intermittent pneumatic compression device (IPCD) using the

IPCD proforma (see Appendix 15). All patients commenced on the IPCD’s

must have the care plan completed within the stroke integrated care pathway

document. Any removal of the IPCDs for anything other than physical therapy

or brief inspection and care of the legs for longer than 2 hours must be

documented on the IPCD monitoring sheet within the stroke integrated care

pathway. If the IPCD have been left off for more than 2 hours the patient’s

legs must be checked carefully for any signs of DVT before reapplying IPCD.

Please see Acute Stroke Policy and Procedure for stroke integrated care

pathway.

If the use of an IPCD is indicated the IPCD will be prescribed on the patient’s

prescription chart by the doctor or appropriate non-medical prescriber. Do

NOT offer AES for VTE prophylaxis to patients who are admitted for stroke.

7.5 VTE prophylaxis in cancer patients

Definition: active cancer should be considered to be:

1. A diagnosis of cancer (other than basal cell or squamous cell

carcinoma of the skin) within the previous six-month period

2. Any treatment for cancer within the previous six-month period

3. Recurrent or metastatic cancer

7.5.1 Patients with active cancer should receive thromboprophylaxis

throughout their hospital admission unless contraindicated.

7.5.2 Extended surgical thromboprophylaxis should be offered to those

requiring surgery for the management of abdominal and pelvic cancer (NICE

2010).

7.5.3 Thromboprophylaxis is not routinely recommended to prevent catheter-

related thrombosis.

Please refer to the Cancer Thrombosis Guideline within the Policy and

Procedure for the Safe Management of Anticoagulant Therapy for further

information.

7.6 VTE prophylaxis in end of life patients

Patients in palliative care, who have potentially acute reversible pathology,

should be considered for LMWH. However, if the patient is in terminal care or

on an end-of-life care pathway, pharmacological or mechanical VTE

prophylaxis should not routinely be offered. In both cases, decisions about

VTE prophylaxis should be reviewed daily, taking into account potential risks

and benefits and views of the patient, family and/or carers and

multidisciplinary team.

7.7 Patients already on anti-platelet or anticoagulant therapy

Consider offering additional mechanical or pharmacological VTE prophylaxis if

the patient is at risk of VTE. Take into account the risk of bleeding and of co-

morbidities such as arterial thrombosis.

If the risk of VTE outweighs the risk of bleeding, consider offering

pharmacological VTE prophylaxis according to the reason for admission.

If the risk of bleeding outweighs the risk of VTE, offer mechanical VTE

prophylaxis.

Do not offer additional pharmacological or mechanical VTE prophylaxis to

patients who are taking vitamin K antagonists (warfarin) and who are within

their therapeutic range, or direct oral anticoagulants (rivaroxaban, apixaban,

dabigatran, edoxaban), providing anticoagulant therapy is continued.

Do not offer additional pharmacological or mechanical VTE prophylaxis to

patients who are having full anticoagulant therapy (for example, Fondaparinux

sodium, LMWH or UFH).

7.8 VTE prophylaxis in pregnancy and up to six weeks post-partum

Please refer to separate policy for Obstetrics: Maidstone and Tunbridge

Wells NHS Trust. Venous Thromboembolism (VTE) in Pregnancy and

Puerperium

7.9 Lower limb immobilisation and LMWH

Immobilisation is defined as rigid immobilisation in plaster or fibre-glass. This

specifically excludes removable devices such as walking boots or cricket-pad

splints as there is no evidence for VTE prophylaxis in these patients. There is

no evidence for VTE prophylaxis in upper limb injuries.

The use of prophylactic LMWH is effective at reducing incidence of VTE in

ambulatory patients with lower limb immobilisations. If commenced,

prophylactic LMWH should be given for the duration of immobilisation. The

use of LMWH is associated with low rates of heparin induced

thrombocytopenia (HIT) and major bleeding when used for

thromboprophylaxis in ambulatory patients with cast immobilisation.

See Appendix 8 for the Lower limb immobilisation and LMWH pathway.

8.0 Patient information and consent

Treatment and care should take into account patients’ needs and preferences.

People admitted to hospital should have the opportunity to make informed

decisions about their care and treatment, in partnership with their healthcare

professionals. If patients do not have the capacity to make decisions,

healthcare professionals should follow the Policy and Procedure for Consent

to Examination or Treatment written with regard to the Department of Health’s

advice on consent and the Mental Capacity Act.

Good communication between healthcare professionals and patients is

essential. It should be supported by evidence-based written information

tailored to the patient’s needs. Treatment and care, and the information

patients are given about it, should be culturally appropriate. It should also be

accessible to people with additional needs such as physical, sensory or

learning disabilities, and to people who do not speak or read English.

All patients admitted to hospital will receive a patient information document,

produced by the Trust, relating to the prevention of thromboembolism, i.e. one

of the following:

 Blood clots (thrombosis), Preventing hospital acquired [STANDARD PRINT

LEAFLET] [RWF-OPLF-PES89]

 Blood clots (thrombosis), Preventing hospital acquired [LARGE PRINT

LEAFLET] [RWF-OPLF-PES92]

 Blood clots (thrombosis), Preventing hospital acquired; information for

maternity patients [STANDARD PRINT LEAFLET] [RWF-OPLF-PES90]

 Blood clots (thrombosis), Preventing hospital acquired; information for

maternity patients [LARGE PRINT LEAFLET] [RWF-OPLF-PES94]

This information will be used to obtain verbal consent from the patient allowing

healthcare staff to assess and where necessary provide prophylactic

treatment to the patient to reduce the risk of VTE.

Ward medical and nursing staff must be completely familiar with the patient

information provided, enabling them to answer general questions that may

arise while obtaining verbal consent.

9.0 Discharge

On discharge, all patients and/or their families / carers will be informed of the

signs and symptoms of DVT and PE and the importance of seeking medical

help if this is suspected.

If discharged with VTE prophylaxis (pharmacological and/or mechanical),

patients and/or their families or carers will be given verbal and written

information on the correct use and duration of VTE prophylaxis at home and

who to contact if problems occur.

If VTE prophylaxis is either pharmacological or mechanical, the patient and/or

their family should be shown how to use it. The patient’s GP must be notified

that the patient is being discharged with VTE prophylaxis.

Patients should be advised to wear their anti-embolism stockings until they

regain their usual mobility or longer if advised. When patients are discharged

with anti-embolism stockings, it should be ensured that they are able to

remove and replace the stockings for daily hygiene needs or that they have

someone who can do this for them. Patients should also be informed to check

for skin marking, blistering or discolouration, particularly over heels and bony

prominences.

10.0 Anti-embolism stockings (AES)

Anti-embolism stockings (AES) exert graduated circumferential pressure from

distal (below knee) to proximal (above knee) regions of the leg. They work to

help prevent the formation of thrombosis (blood clot) by promoting increased

blood flow velocity in the leg veins by compression of the deep venous

system, and by reducing venous dilatation.

One of the purposes of this Policy is to ensure that anti-embolism stockings

are correctly supplied, applied and utilised, and that their use is not

contraindicated.

Correctly applied, in the absence of contra-indications, anti-embolism

stockings are a safe and non-invasive therapy for reducing the incidence of

venous thromboembolism by the promotion of venous blood flow.

Anti-embolism stockings can be used as a therapy on their own or as an

adjunct to low molecular weight heparin in patients who have been clinically

assessed as having a risk of venous thromboembolism. AES can be used in

conjunction with IPCD.

It is important to ensure safe application through assessment, measurement

and application to ensure patients receive the correct management.

Patients should be informed of decisions about their care and treatment.

10.1 Indications for AES

Indication for use of AES - All patients admitted to hospital are eligible for anti-

embolism stockings as part of their thromboprophylaxis based on an up to

date VTE risk assessment.

Surgical patients: All surgical patients with a risk of VTE (unless anti-embolism

stockings contraindicated).

Medical patients: Medical patients with a risk of VTE and for whom

anticoagulation therapy (chemical thromboprophylaxis) is contraindicated

(unless anti-embolism stockings are also contraindicated).

Obstetric patients: All obstetric patients with a risk of VTE (unless anti-

embolism stockings are contraindicated).

Patients admitted to hospital with a diagnosis of, or suspected

diagnosis of, deep vein thrombosis or pulmonary embolism should

follow the Policy and Procedure for Diagnosis and Management of VTE

and not this prophylactic plan.

10.2 Contraindications for AES

 Acute stroke patients

 Patients with suspected or confirmed peripheral arterial disease

 Patients who are receiving high dose vasopressor inotropes

 Patients with severe dermatitis

 Patients with very fragile ‘tissue paper’ skin

 Patients who have recently undergone skin grafting

 Patients with an allergy to the stocking fabric

 Patients with peripheral neuropathy

 Patients with cardiac failure

 Patients with massive leg oedema

 Patients who have an unusual leg size or shape or deformity preventing

correct fit

 Venous ulcers or wounds

10.3 Caution for use of AES

Use caution in patients with sensory impairment e.g. patients undergoing

mechanical ventilation, sedated patients or those with an epidural – check

skin integrity twice daily.

Use caution in patients with diabetes mellitus and assess for sensory

impairment.

10.4 Pre requisites for practitioners

Registered Nurse / Midwife / Doctor with appropriate training and experience.

Clinical Support Workers (CSW) with appropriate training and experience.

Student nurse / midwife under the supervision of a registered nurse / midwife.

Use in accordance with manufacturer’s guidelines.

Please see Appendix 9 for standard operating procedure (SOP) for the use of

AES. Please see Appendix 10 for care plan for a patient with AES.

11.0 Intermittent pneumatic compression devices (IPCD)

Intermittent pneumatic compression devices (IPCD) work by augmenting

venous blood flow velocity, thus reducing venous stasis and by enhancing

early fibrinolytic activity to reduce the risk of clot formation.

The garments, which can be either leg sleeves or foot cuffs, compress the

limbs to enhance venous blood movement. After the compression and then

release, the controller waits for a period of time before the next compression

is initiated.

Correctly applied, in the absence of contra-indications, intermittent pneumatic

compression devices are a safe and non-invasive therapy for reducing the

incidence of venous thromboembolism by the promotion of venous blood flow.

Intermittent pneumatic compression devices are useful as a therapy on their

own in VTE prevention for both medical and surgical patients where there is

an identified risk of VTE together with a risk of bleeding. They can be also

used as an adjunct to low molecular weight heparin in patients who have been

clinically assessed as having a risk of venous thromboembolism. IPCD can

be used in conjunction with AES.

It is important to ensure safe application through assessment, measurement

and application to ensure patients receive the correct management.

Patients should be informed of decisions about their care and treatment and

their consent obtained prior to use wherever possible. This should be

documented in the healthcare record

11.1 Indications for use of IPCD

Indication for use of IPCD - All patients admitted to hospital are indicated for

(and eligible for) intermittent pneumatic compression devices as part of their

thromboprophylaxis based on an up to date VTE risk assessment.

11.1.1 Surgical patients

IPCD are used widely within the operating department for surgical patients

with a risk of VTE who will be on the operating table for 30 minutes or more

(unless IPCD contraindicated), either alone or in conjunction with chemical

thromboprophylaxis and/or another form of mechanical thromboprophylaxis,

for example anti-embolism stockings.

IPCD are also used in the immediate post-operative period (unless IPCD

contraindicated), particularly in orthopaedic hip and knee joint replacements,

gynaecology surgery and obstetric caesarean section surgery, either alone or

in conjunction with chemical thromboprophylaxis and/or another form of

mechanical thromboprophylaxis, for example anti-embolism stockings.

11.1.2 General medical patients

IPCD are indicated for medical patients with a risk of VTE, where both

anticoagulation and anti-embolism stockings are contraindicated (unless IPCD

are also contraindicated).

11.1.3 Acute stroke medical patients

Please refer to earlier section on acute stroke patients (7.4).

Patients admitted to hospital with a diagnosis of, or suspected

diagnosis of, deep vein thrombosis or pulmonary embolism should

follow the Policy and Procedure for the Diagnosis and Management of

VTE. IPCD should not be applied until resolution of the clot has been

confirmed with diagnostic testing. The time frame for this is individual

to each patient.

11.2 Contraindications for use of IPCD

 Patients with an acute or suspected DVT or PE (see above)

 Patients with suspected or confirmed peripheral arterial disease

 Patients with severe dermatitis

 Patients with a leg wound

 Patients with very fragile ‘tissue paper’ skin

 Patients who have recently undergone skin grafting

 Patients with an allergy to the fabric of the sleeve

 Patients with peripheral neuropathy

 Patients with massive oedema of the legs or pulmonary oedema from

congestive heart failure

 Patients who have an unusual leg size or shape or deformity preventing

correct fit

This is not an exhaustive list.

11.3 Cautions for the use of IPCD

Use caution in patients with sensory impairment e.g. patients undergoing

mechanical ventilation, sedated patients or those with an epidural – check

skin integrity twice daily.

Use caution in patients with diabetes mellitus and assess for sensory

impairment.

Use caution in patients who are receiving high dose vasopressor inotropes.

11.4 Pre-requisites for practitioners

 Registered nurse / midwife / doctor with appropriate training and

experienced

Clinical Support Workers (CSW) with appropriate training and experience.

 Student nurse / midwife under the supervision of a registered nurse /

midwife.

 Use in accordance with manufacturer’s guidelines

 See Appendix 14 (IPCD competency).

Please see Appendix 12 for standard operating procedure (SOP) for the use

of IPCD. Please see Appendix 13 for care plan for a patient with IPCD.

12.0 Monitoring and audit

 Completion of VTE risk assessments will be entered onto the Patient

Administration System and data is extracted and available daily.

Retrospective periods can also be viewed. Data is submitted via Unify as

required by the Department of Health.

 Audits of VTE risk assessment and thromboprophylaxis will be

undertaken and data submitted to local commissioners if requested.

Frequency of audits will be determined by the Thrombosis Committee.

Auditors will vary, audits may be delegated to directorates to complete or

completed centrally by the VTE Lead Nurse.

 Other formal audits of VTE risk assessment and thromboprophylaxis

may be undertaken with support from the audit department.

 Random spot check audits will be carried out ad hoc to ensure that VTE

risk assessment, prescription of chemical thromboprophylaxis and data

capture processes are being followed. The results of which will be

shared appropriately.

 Information from formal audits and the data capture will be reported at

ward level and to the Directorates, Thrombosis committee and trust

executives.

 The VTE Prevention policy and procedure document will be reviewed

every three years.

All hospital acquired VTE incidents should be reported either verbally to the

VTE Lead Nurse or by using the e-reporting system. Investigation and root

cause analysis (RCA) will be undertaken on all hospital acquired VTE

incidents. Actions arising from VTE RCA and / or VTE serious incident

investigations will be added to the VTE trust wide action plan. 12.1

APPENDIX ONE

Process requirements

1.0 Implementation and awareness

 Once ratified the document lead or author will submit this

policy/procedural document to the Clinical Governance Assistant who

will activate it on the Trust approved document management database

on the intranet, under ‘Trust policies, procedures and leaflets’.

 A monthly publications table is produced by the Clinical Governance

Assistant which is published on the Trust intranet under “Policies”;

notification of the posting is included on the intranet “News Feed” and

in the Chief Executive’s newsletter.

 On reading of the news feed notification all managers should ensure

that their staff members are aware of the new publications.

 The policy will be disseminated to all clinical staff and ward areas.

 The policy/procedure will be launched via cascade through directorate

nurse managers.

2.0 Review

This policy/procedure will be reviewed once every three years, as a minimum;

however, if changes in legislation or Trust practice require, amendments will

be made following Trust consultation and approval procedures.

3.0 Archiving

The Trust approved document management database on the intranet retains

all superseded files in an archive directory (obsolete register) in order to

maintain document history.

APPENDIX TWO

CONSULTATION ON: Revision of the Venous Thromboembolism Prevention Policy

and Procedure combining with the Anti-embolism Stocking policy and procedure and

the Intermittent Pneumatic Compression Device policy and procedure

Consultation process – Use this form to ensure your consultation has been

adequate for the purpose.

Please return comments to: VTE Lead Nurse

By date: 9

March 2016

The Thrombosis Committee has representation from all directorates except

paediatrics. The revision and merger of these three policies was managed

under the Thrombosis Committee. Separate sections were discussed with the

relevant departments e.g. surgical section discussed at a surgical clinical

governance meeting, stroke section discussed with all stroke consultants. The

AES and IPCD sections were discussed with the relevant company

representatives.

Job title:

Date sent

Date reply

received

Modification

suggested?

Y/N

Modification

made?

Y/N

Chief Nurse

Deputy Director of Nursing (Deputy

Chief Nurse)

ADNS

Matrons

Ward / Theatre Managers

Head of Quality and Governance

Senior Nurses Practice

Development

Thrombosis Committee

01/03/16

Discussed

at meeting

Medical Director

Standards Committee (no longer

exists)

Patient Safety and Risk Manager

The role of those staff being consulted upon as above is to ensure that they have shared the

policy for comments with all staff within their sphere of responsibility who would be able to

contribute to the development of the policy.

APPENDIX THREE

Equality Impact Assessment

In line with race, disability and gender equalities legislation, public bodies like MTW are

required to assess and consult on how their policies and practices affect different

groups, and to monitor any possible negative impact on equality. The completion of the

following Equality Impact Assessment grid is therefore mandatory and should be

undertaken as part of the policy development and approval process.

Title of Policy or Practice

Venous Thromboembolism Prevention Policy and

Procedure

What are the aims of the policy or

practice?

To ensure that all inpatients are appropriately and

regularly assessed for risk of venous

thromboembolism (VTE) and treated according to

that risk throughout their stay at MTW. Patients

admitted to the Trust should have the opportunity to

make informed decisions about their care and

treatment, in partnership with their health care

professionals and the Trust will offer best practice

advice on reducing the risk of VTE in patients

admitted to hospital.

Identify the data and research used to

assist the analysis and assessment

NICE Guidance, VTE Exemplar Centres

Analyse and assess the likely impact on

equality or potential discrimination with

each of the following groups.

Is there an adverse impact or potential

discrimination (yes/no).

If yes give details.

Males or Females

People of different ages

Policy does not apply to those under the age of 18 -

based on NICE guidance

People of different ethnic groups

People of different religious beliefs

People who do not speak English as a first

language

N interpreting services available; leaflets to be made

available in different languages

People who have a physical disability

People who have a mental disability

Women who are pregnant or on maternity

leave

Single parent families

People with different sexual orientations

People with different work patterns (part

time, full time, job share, short term

contractors, employed, unemployed)

People in deprived areas and people from

different socio-economic groups

Asylum seekers and refugees

Prisoners and people confined to closed

institutions, community offenders

Carers

If you identified potential discrimination

is it minimal and justifiable and therefore

does not require a stage 2 assessment?

When will you monitor & review the EIA?

Alongside this policy/procedure when it is reviewed.

Where do you plan to publish the results

of your Equality Impact Assessment?

As Appendix 3 of this policy/procedure on the Trust

document management database (on Intranet, under

‘Trust policies, procedures and leaflets’).

FURTHER APPENDICES

The following appendices are published as related links to the main policy

/procedure on the Trust approved document management database on the

intranet (Trust policies, procedures and leaflets):

No.

Title

Unique ID

VTE risk assessment form

This document is a proof of printed stationary which

should only be accesses in hard copy from clinical

areas.

RWF-OWP-APP220

Thromboprophylaxis summary

RWF-NUR-NUR-GUI-1

Training matrix

RWF-OWP-APP226

Guideline for thromboprophylaxis and patients with a

bleed or suspected bleed

RWF-OPG-ES7

Lower limb immobilisation and LMWH pathway

RWF-OPPM-ES8

Standard operating procedure for the use of AES

RWF-NUR-NUR-GUI-2

Care plan for a patient with AES

RWF-OPF-ES-C-SM2

AES competency

RWF-OPF-ES-C-SM1

Standard operating procedure for the use of IPCD

RWF-NUR-NUR-GUI-3

Care plan for a patient with IPCD

RWF-OPF-ES-C-SM4

IPCD competency

RWF-OPF-ES-C-SM3

Protocol for the use of IPCD for patients with

haemorrhagic stroke

RWF-OPPM-ES6

IPCD sizing chart for leg sleeves

RWF-OPG-ES5

IPCD with leg sleeves ‘Quick Guide’

RWF-OPPM-ES4

IPCD with leg sleeves ‘User Manual’

RWF-OPPM-ES3

IPCD sizing chart for foot cuffs

RWF-OPG-ES4

IPCD with foot cuffs ‘User Manual’

RWF-OPPM-ES5

IPCD trouble shooting guide

RWF-OPG-ES6

Patient leaflet: Kendall / SCD Express - Sequential

Compression System (Covidien)

RWF-OPLF-PES115