NICE Pathways bring together all NICE guidance, quality standards and other NICE information on a specific topic.

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1 Reducing venous thromboembolism risk: medical patients bring together all NICE guidance, quality standards and other NICE information on a specific topic. are interactive and designed to be used online. They are updated regularly as new NICE guidance is published. To view the latest version of this pathway see: Pathway last updated: 26 April 2016 This document contains a single pathway diagram and uses numbering to link the boxes to the associated recommendations. All rights reserved

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3 1 Medical patient No additional information 2 General medical patients Pharmacological prophylaxis Offer pharmacological VTE prophylaxis to general medical patients assessed to be at increased risk of VTE (see assessment on admission in this pathway). Choose any one of: fondaparinux sodium LMWH 1 UFH (for patients with severe renal impairment or established renal failure). Start pharmacological VTE prophylaxis as soon as possible after risk assessment has been completed. Continue until the patient is no longer at increased risk of VTE. Mechanical prophylaxis Consider offering mechanical VTE prophylaxis to medical patients in whom pharmacological VTE prophylaxis is contraindicated. Choose any one of: anti-embolism stockings (thigh or knee length) foot impulse devices intermittent pneumatic compression devices (thigh or knee length). For further information see using mechanical prophylaxis in this pathway. Quality standards The following quality statements are relevant to this part of the interactive flowchart. Venous thromboembolism in adults: reducing the risk in hospital quality standard 1. VTE and bleeding risk assessment 3. Anti-embolism stockings Page 3 of 16

4 1 At the time of publication (June 2015) some types of LMWH do not have UK marketing authorisation for VTE prophylaxis in medical patients. Prescribers should consult the summary of product characteristics for the individual LMWH. Informed consent for off label use should be obtained and documented. Page 4 of 16

5 4. Re-assessment 5. VTE prophylaxis 3 Patients with cancer Offer pharmacological VTE prophylaxis to patients with cancer who are assessed to be at increased risk of VTE (see assessment on admission in this pathway). Choose any one of: fondaparinux sodium LMWH 1 UFH (for patients with severe renal impairment or established renal failure). Start pharmacological VTE prophylaxis as soon as possible after risk assessment has been completed. Continue until the patient is no longer at increased risk of VTE. Do not routinely offer pharmacological or mechanical VTE prophylaxis to patients with cancer having oncological treatment who are ambulant. Quality standards The following quality statements are relevant to this part of the interactive flowchart. Venous thromboembolism in adults: reducing the risk in hospital quality standard 1. VTE and bleeding risk assessment 4. Re-assessment 5. VTE prophylaxis 4 Patients with central venous catheters Do not routinely offer pharmacological or mechanical VTE prophylaxis to patients with central venous catheters who are ambulant. 1 At the time of publication (June 2015) some types of LMWH do not have UK marketing authorisation for VTE prophylaxis in medical patients. Prescribers should consult the summary of product characteristics for the individual LMWH. Informed consent for off label use should be obtained and documented. Page 5 of 16

6 Consider offering pharmacological VTE prophylaxis with LMWH 1 (or UFH for patients with severe renal impairment or established renal failure) to patients with central venous catheters who are at increased risk of VTE (see assessment on admission in this pathway). Quality standards The following quality statements are relevant to this part of the interactive flowchart. Venous thromboembolism in adults: reducing the risk in hospital quality standard 1. VTE and bleeding risk assessment 4. Re-assessment 5. VTE prophylaxis 5 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 benefits and the views of patients and their families and/or carers. Choose any one of: fondaparinux sodium LMWH 2 UFH (for patients with severe renal impairment or established renal failure). 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 views of patients, their families and/or carers and the multidisciplinary team. NICE has published a guideline on care of dying adults in the last days of life. Quality standards The following quality statements are relevant to this part of the interactive flowchart. Page 6 of 16

7 1 At the time of publication (June 2015) some types of LMWH do not have UK marketing authorisation for VTE prophylaxis in medical patients. Prescribers should consult the summary of product characteristics for the individual LMWH. Informed consent for off label use should be obtained and documented. 2 At the time of publication (June 2015) some types of LMWH do not have UK marketing authorisation for VTE prophylaxis in medical patients. Prescribers should consult the summary of product characteristics for the individual LMWH. Informed consent for off-label use should be obtained and documented. Page 7 of 16

8 Venous thromboembolism in adults: reducing the risk in hospital quality standard 1. VTE and bleeding risk assessment 4. Re-assessment 5. VTE prophylaxis 6 Patients admitted for stroke Do not offer anti-embolism stockings for VTE prophylaxis to patients who are admitted for stroke. Consider offering prophylactic-dose LMWH 1 (or UFH for patients with severe renal impairment or established renal failure) if: a diagnosis of haemorrhagic stroke has been excluded, and the risk of bleeding (haemorrhagic transformation of stroke or bleeding into another site) is assessed to be low, and the patient has one or more of: major restriction of mobility previous history of VTE dehydration comorbidities (such as malignant disease). Continue until the acute event is over and the patient's condition is stable. Do not offer foot impulse or neuromuscular electrical stimulation devices for VTE prophylaxis to patients who are admitted for stroke, except in the context of research. Consider intermittent pneumatic compression for VTE prophylaxis in immobile patients who are admitted within 3 days of acute stroke. Explain to the patient or their family members or carers (as appropriate) that: it reduces the risk of deep vein thrombosis and may provide an increase in survival it will not help them recover from stroke, and there may be an associated increased risk of surviving with severe disability (see table below). When using intermittent pneumatic compression for patients who are admitted for stroke, provide it for 30 days or until the patient is mobile or discharged, whichever is sooner. Page 8 of 16

9 1 At the time of publication (June 2015) some types of LMWH do not have UK marketing authorisation for VTE prophylaxis in medical patients. Prescribers should consult the summary of product characteristics for the individual LMWH. Informed consent for off-label use should be obtained and documented. Page 9 of 16

10 Average comparative outcomes with and without intermittent pneumatic compression per 1000 patients who are immobile when admitted for stroke Standard best medical care (cases per 1000 patients) Standard best medical care plus intermittent pneumatic compression (IPC) 1 (cases per 1000 patients, with 95% confidence interval) Outcomes in hospital Skin breaks (range between 18 and 49) Deep vein thrombosis that will cause symptoms and need treatment (range between 34 and 62) Deep vein thrombosis that may or may not cause symptoms (range between 94 and 136) OHS 4 Outcomes at 6 months 2,5 0 4 Alive and not severely disabled (range between 517 and 590) 5 Alive but severely disabled (range between 187 and 252) 6 Dead (range between 204 and 259) Page 10 of 16

11 1 Absolute risk: number of cases per 1000 patients (95% confidence interval). 2 Data from CLOTS3 trial (Dennis 2013, 2014). 3 Data from Lacut (2005) and CLOTS3 trial (Dennis 2013, 2014). 4 The Oxford Handicap Scale is a categorical scale for measuring functional outcome after a stroke. Key: 0 = Healthy survival fully independent; 1 = Minor symptoms independent, no interference; 2 = Minor disability independent, some restrictions but able to self-care; 3 = Moderate disability significant restriction, unable to lead a totally independent existence (requires some assistance); 4 = Moderate-to-severe disability unable to live independently but does not require constant attention; 5 = Severe disability totally dependent, requires constant attention day and night; 6 = Death. 5 These are average outcomes at 6 months after stroke, assessed using the Oxford Handicap Scale 4. However, death rate and functional outcomes will vary depending on the severity of the initial stroke. 6 The difference between the 2 groups on this outcome is not statistically significant. 7 The difference between the 2 groups on this outcome is not statistically significant. However, when 6-month all-cause mortality data from the CLOTS3 trial are pooled with 3-month data from the Lacut (2005) trial, the survival effect favouring IPC is statistically significant (see outcome 8 and figure 8 in Appendix I of the full guideline). NICE has produced a pathway on stroke. Quality standards The following quality statements are relevant to this part of the interactive flowchart. Venous thromboembolism in adults: reducing the risk in hospital quality standard 1. VTE and bleeding risk assessment 4. Re-assessment 5. VTE prophylaxis Page 11 of 16

12 7 Planning for discharge See Venous thromboembolism/reducing venous thromboembolism risk in hospital patients /Discharge Page 12 of 16

13 Glossary APTT activated partial thromboplastin time CTPA computed tomography pulmonary angiogram D-dimer test D-dimer is a product formed in the body when a blood clot (such as those found in DVT or PE) is broken down. A laboratory or point of care test can be done to assess the concentration of D- dimer in a person's blood. The threshold for a positive result varies with the type of D-dimer test used and is determined locally. The result of the D-dimer test can be used as part of probability assessment when DVT or PE is suspected. DVT deep vein thrombosis Fondaparinux fondaparinux sodium HRT hormone replacement therapy INR international normalised ratio (a standardised laboratory measure of blood coagulation used to monitor the adequacy of anticoagulation in patients who are having treatment with a vitamin K antagonist) LMWH Low molecular weight heparin Page 13 of 16

14 Major bleeding a bleeding event that results in one or more of the following: death, a decrease in haemoglobin concentration of 2 g/dl, transfusion of 2 units of blood, bleeding into a retroperitoneal, intracranial or intraocular site, a serious or life-threatening clinical event, a surgical or medical intervention PE pulmonary embolism Proximal in the popliteal vein or above; sometimes referred to as 'above-knee' Provoked occurring in a patient with an antecedent (within 3 months) and transient major clinical risk factor for venous thromboembolism for example surgery, trauma, significant immobility (bedbound, unable to walk unaided or likely to spend a substantial proportion of the day in bed or in a chair), pregnancy or puerperium or in a patient who is having hormonal therapy (oral contraceptive or hormone replacement therapy) Renal impairment Reduced renal function that may be acute or chronic. An estimated glomerular filtration rate (egfr) < 90 ml/min/1.73 m 2 indicates a degree of renal impairment in chronic kidney disease. For NICE guidance on the classification of chronic kidney disease see stages of CKD and frequency of egfr testing in the NICE pathway on chronic kidney disease. Severe renal impairment or established renal failure estimated glomerular filtration rate of less than 30 ml/min/1.73m 2 Significantly reduced mobility bedbound, unable to walk unaided or likely to spend a substantial proportion of the day in bed or in a chair Page 14 of 16

15 UFH unfractionated heparin Unprovoked occurring in a patient with: no antecedent major clinical risk factor for venous thromboembolism for example surgery, trauma, significant immobility (bedbound, unable to walk unaided or likely to spend a substantial proportion of the day in bed or in a chair), pregnancy or puerperium who is not having hormonal therapy (oral contraceptive or hormone replacement therapy) or active cancer, thrombophilia or a family history of venous thromboembolism, because these are underlying risks that remain constant in the patient V/Q SPECT ventilation/perfusion single photon emission computed tomography VTE venous thromboembolism Wells score a clinical prediction rule for estimating the probability of deep vein thrombosis (DVT) or pulmonary embolism (PE). There are a number of versions of Wells scores available. This pathway recommends the two-level DVT Wells score and the two-level PE Wells score Sources Venous thromboembolism: reducing the risk for patients in hospital (2010 updated 2015) NICE guideline CG92 Your responsibility The guidance in this pathway represents the view of NICE, which was arrived at after careful consideration of the evidence available. Those working in the NHS, local authorities, the wider public, voluntary and community sectors and the private sector should take it into account when carrying out their professional, managerial or voluntary duties. Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are Page 15 of 16

16 reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties. Copyright Copyright National Institute for Health and Care Excellence All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE. Contact NICE National Institute for Health and Care Excellence Level 1A, City Tower Piccadilly Plaza Manchester M1 4BT nice@nice.org.uk Page 16 of 16

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