Title Use of rivaroxaban in suspected DVT in the Emergency Department Standard Operating Procedure. Author s job title. Pharmacist.

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1 Document Control Title Use of rivaroxaban in suspected DVT in the Emergency Department Author Pharmacist Directorate Clinical Support Services Version Date Issued Status 0.1 Oct Draft Dec Final Jan Final 2016 Main Contact Pharmacist North Devon District Hospital Raleigh Park Barnstaple, EX31 4JB Lead Director Director of Document Class Distribution List Senior Management Author s job title Pharmacist Department Initial version for consultation Approved by DTC Comment / Changes / Approval Changed nomenclature. Amendment to DVT unlikely pathway Target Audience Emergency Department Distribution Method Trust s internal website Superseded Documents None Issue Date Review Date November 2015 November 2018 Consulted with the following stakeholders Emergency Medicine Clinical Lead Anticoagulation lead Pathology Improvement Team Haematology lead Review Cycle Three years Contact responsible for implementation and monitoring compliance: Emergency Medicine Clinical Lead Education/ training will be provided by: Emergency Medicine Clinical Lead Approval and Review Process DTG Medicines Governance Use of rivaroxaban in suspected DVT in the Emergency Department SOP V1.1 JAN16 Page 1 of 7

2 Local Archive Reference G:\\Policies Filename Use of rivaroxaban in suspected DVT in the Emergency Department SOP V1.1 JAN16 Policy categories for Trust s internal website (Bob) Emergency Department Tags for Trust s internal website (Bob) Anticoagulation, NOAC, DVT, A&E, ED Use of rivaroxaban in suspected DVT in the Emergency Department SOP V1.1 JAN16 Page 2 of 7

3 2. Contents Document Control Purpose Scope Location Procedure Anticoagulation References Associated Documentation... 6 Appendix A: Two Level Wells Score... 7 Use of rivaroxaban in suspected DVT in the Emergency Department SOP V1.1 JAN16 Page 3 of 7

4 3. Purpose 3.1. The (SOP) has been written to: Outline the actions required for ED staff managing a patient presenting with a suspected DVT. 4. Scope 4.1. This (SOP) relates to the following staff groups who may be involved in the assessment and delivery of care in the emergency department: Registered nurses Support workers Medical staff 5. Location 5.1. This can be implemented in the emergency department Staff undertaking this procedure must be able to demonstrate continued competence as per the organisations policy on assessing and maintaining competence. Use of rivaroxaban in suspected DVT in the Emergency Department SOP V1.1 JAN16 Page 4 of 7

5 6. Procedure SECONDARY CARE ASSESSMENT OF SUSPECTED DVT THIS PATHWAY SHOULD ONLY BE USED WHERE A DVT IS THE MOST LIKELY CLINICAL DIAGNOSIS Patient presents with clinically likely DVT Exclude other likely causes Consider heart failure, cellulitis, or muscular tear. Two level Wells score must be done DVT Likely based on 2 level Wells Score Two-level DVT Wells score 2 or more points DVT Unlikely Two-level DVT Wells score 1 point or less Contact MAU clinic to find availability of next scan. Is an ultrasound available the same day? D-dimer taken to rule out DVT Ultrasound available same day Send patient to MAU clinic for scan Ultrasound not available same day D-DIMER MUST BE TAKEN D-dimer will be used by MAU if ultrasound scan is negative. Positive: refer to MAU clinic for scan Negative: advise the patient a DVT is unlikely but to seek further medical help if symptoms persist or worsen. D-dimer cannot be taken if anticoagulation already initiated. Start anticoagulation. (See Section 4) Top Tip: D-dimer tests have a high false positive rate and are non-specific. It should only be used as part of a structured decision making process when a DVT is clinically suspected. A D-dimer should not be used to rule in if there is low suspicion of a DVT. Notes: All patients presenting with VTE should have a full clinical history provided with the aim of detecting underlying conditions contributing to the development of thrombosis and assessing suitability for antithrombotic therapy Unless already taken as part of low risk pathway Use of rivaroxaban in suspected DVT in the Emergency Department SOP V1.1 JAN16 Page 5 of 7

6 7. Anticoagulation If an ultrasound scan is not available the same day then take a D-dimer and prescribe interim anticoagulation. Rivaroxaban Initiate 15mg orally twice daily with food. Supply 1 dose for each 12 hours until scan. Give 1 st dose in ED and supply FP10 for remaining doses or TTA pack where available. Patients should not be prescribed anticoagulant medication if already on anticoagulation therapy including warfarin or other vitamin K antagonist, low molecular weight heparin, apixaban, dabigatran, edoxaban or rivaroxaban. Patients with severe renal impairment (less than 30ml/min) may need alternative therapy. Use with caution in patients with hepatic disease with coagulopathy, pregnancy or breast feeding. Consult advice for patients with cancer (may need enoxaparin). MAU process and follow up Patients will receive an ultrasound scan to investigate a thrombus. If positive the patient will be continued on rivaroxaban 15mg twice daily for 21 days which will be supplied by the hospital pharmacy. After 21 days the patient s GP will need to initiate them on 20mg once daily of rivaroxaban for the time period specified by the discharging team. A negative scan will be rescanned 6-8 days later. A D-dimer taken prior to referral can reduce the need for follow up scan by 10%. A further negative scan will be referred for an alternative diagnosis but advice will be given to contact the surgery if symptoms worsen. 8. References NICE QS29: Venous thromboembolism in adults: diagnosis and management Rivaroxaban (Xarelto ) Summary of Product Characteristics 9. Associated Documentation 9.1. Northern Devon Healthcare NHS Trust Policies for : managing suspected DVT in primary care Use of rivaroxaban in suspected DVT in the Emergency Department SOP V1.1 JAN16 Page 6 of 7

7 Appendix A: Two Level Wells Score A Two Level Wells Score must be completed before referral. Two Level Wells Score - please complete Clinical feature Points Active cancer (treatment ongoing, within 6 months, or palliative) 1 Paralysis, paresis or recent plaster immobilisation of the lower extremities 1 Recently bedridden for 3 days or more or major surgery within 12 weeks requiring general or regional anaesthesia 1 Localised tenderness along the distribution of the deep venous system 1 Entire leg swollen 1 Calf swelling at least 3 cm larger than asymptomatic side 1 Pitting oedema confined to the symptomatic leg 1 Collateral superficial veins (non-varicose) 1 Previously documented DVT 1 An alternative diagnosis is at least as likely as DVT 2 Clinical probability simplified score: DVT likely Refer to MAU clinic DVT unlikely Refer to flow diagram 2 points or more 1 point Use of rivaroxaban in suspected DVT in the Emergency Department SOP V1.1 JAN16 Page 7 of 7

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