Venous Thrombo-Embolism Policy
Version No 3.1.
Author(s) Consultant Haematologist
Ratified PARC: September 2015
Next Review date September 2018
POLICY NAME: / VENOUS THROMBOSIS – REDUCING THE RISK IN PATIENTS ADMITTED TO HOSPITALPOLICY REFERENCE: / TW10-049
VERSION NUMBER : / 3.1
APPROVING COMMITTEE: / Medicine Governance and Risk
DATE THIS VERSION APPROVED: / September 2015
RATIFYING COMMITTEE: / PARC (Policy Approval and Ratification Committee)
DATE THIS VERSION RATIFIED: / September 2015
AMENDMENTS MADE / Added sections 2.3, 2.4 and amendment to 3.1.1 July 2016
AUTHOR(S)
(JOB TITLE) / CONSULTANT HAEMATOLOGIST
DIVISION/DIRECTORATE: / Medicine
TRUST WIDE POLICY (YES/NO) / Yes
Links to other Strategies, Policies, SOP’s, etc. / Venous thrombo-embolism guidance, All Party Parliamentary Thrombosis Group, NICE Clinical Guideline 92, Patient Information – Thromboprophylaxis
Medicine Management Policy
Date(s) previous version(s) approved:
(if known) / Version:1
2 / Date :2010
2012
DATE OF NEXT REVIEW: / September 2018
Manager responsible for review:
N.B. This should be the Author’s line manager / MEDICAL DIRECTOR
CONTENTS / PAGE NO.
1 / INTRODUCTION / 2
2 / POLICY STATEMENT / 2
3 / KEY PRINCIPLES / 2
4 / RESPONSIBILITIES / 3
5 / REPORTING TO EXTERNAL AGENCIES / 5
6 / HUMAN RIGHTS ACT / 5
7 / EQUALITY & DIVERSITY / 5
8 / MONITORING AND REVIEW / 5
9 / ACCESSIBILITY STATEMENT / 5
APPENDICES
1 / References and further information / 6
2 / Glossary of Terms used / 7
3 / Thrombosis Committee Terms of Reference / 18
4 / Audit Tool / 10
5 / VTE Assessment Flow Chart / 12
6 / VTE Patient Leaflet / 13
7 / Assessment Use of Anti embolism Stockings / 14
8 / Equality Impact Assessment Form / 16
9 / Monitoring & Review template / 19
1. INTRODUCTION
1.1 Venous thromboembolism (VTE) is a condition in which a thrombus – a blood clot – forms in a vein. Usually, this occurs in the deep veins of the legs and pelvis and is known as deep vein thrombosis (DVT). The thrombus or its part can break off, travel in the blood system and eventually block an artery in the lung. This is known as a pulmonary embolism (PE). VTE is a collective term for both DVT and PE. With an estimated incidence rate of 1-2 per 1,000 of the population, VTE is a significant cause of mortality and disability in England with thousands of deaths directly attributed to it each year.
1.2 One in twenty people will have VTE during their lifetime and more than half of those events are associated with prior hospitalisation. At least two thirds of cases of hospital-associated thrombosis are preventable through VTE risk assessment and the administration of appropriate thromboprophylaxis.
2. POLICY STATEMENT
2.1 This policy represents NICE Guidance and recommendations from the All-Party Parliamentary thrombosis Group, which, when implemented, will help reduce the risk to a patient of developing a VTE.
2.2 VTE prevention is a government priority. The national VTE prevention strategy, led by the Chief edical Officer, has the potential to save many thousands of lives, each year in hospitals across the country. Wrightington, Wigan and Leigh NHS Foundation Trust is committed to implementing the department of health policy that all patients receive a risk assessment for VTE on admission to hospital and as a result receive timely and appropriate prophylaxis.
2.3 This policy applies to all adult patients admitted as inpatients to Wrightington, Wigan and Leigh NHS Foundation Trust (WWL).
2.4 In addition to this Policy there is also a specific Orthopaedic Guideline (THrombophrophylaxis in Orthopaedic Surgery CG15-015) available on the Trust Intranet Policy Library.
3. KEY PRINCIPLES
3.1 Assessing the risks of VTE and Bleeding
3.1.1 All patients admitted to hospital will be assessed for VTE and bleeding risk on admission according to current NICE guidance.
3.1.2 All patients will be re-assessed for risk of bleeding and VTE within 24 hours of admission and whenever the clinical situation changes to:
3.1.2.1 Ensure that the methods of VTE prophylaxis being used are suitable
3.1.2.2 Ensure that VTE prophylaxis is being used correctly
3.1.2.3 Identify adverse events resulting from VTE prophylaxis (Appendix 5).
3.2 Reducing the risk of VTE
3.2.1 Patients at increased risk of VTE who have no contraindications, will be offered pharmacological prophylaxis as soon as possible after their risk assessment has been completed.
3.2.2 VTE prophylaxis will be continued until the patient is no longer at increased risk of VTE or the risk of bleeding exceeds the risk of thrombosis.
3.3 Patient Information and Planning for discharge
3.3.1 Prior to commencing on VTE prophylaxis, patients and/or their families will be offered verbal and written information on:
3.3.1.1 The risks and possible consequences of VTE
3.3.1.2 The correct use of VTE prophylaxis and its possible side effects
3.3.1.3 How patients can help reduce their risk of developing a VTE.
3.3.2 As part of the discharge plan, patients and/or their families/carers will be provided with verbal and written information on:
3.3.2.1 The signs and symptoms of deep vein thrombosis (DVT) and pulmonary embolism (PE)
3.3.2.2 The correct and recommended duration of VTE prophylactic use at home (if patient is discharged with prophylaxis
3.3.2.3 The importance of seeking help and who to contact if they have any problems using prophylaxis
3.3.2.4 The importance of seeking medical help and who to contact if VTE is suspected
4. RESPONSIBILITIES
4.1 Responsibility of the Trust Board
4.1.1 It is accepted that ultimate responsibilities lie with the Chief Executive and the Trust Board.
4.1.2 The Trust Board delegates authority for approving this policy to the Thrombosis Committee.
4.1.3 The Trust Board will ensure, through line management structures, that this policy is fully applied and consistently adhered to. The Medical Director is the Quality and Safety lead for Wrightington, Wigan and Leigh NHS Foundation Trust.
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4.1.4 The Trust Board will receive a monthly VTE compliance report as part of the performance report (quality and safety section).
4.2 Responsibilities of the Medical Director
4.2.1 To ensure that monitoring data is presented to the Trust Board.
4.2.2 To be responsible for this Policy and for allocating responsibility for writing the appropriate procedures etc.
4.2.3 To ensure that this Policy is reviewed within its appropriate time frame and is then taken to the Thrombosis Committee for approval.
4.2.4 To ensure that the current version of this policy is accessible to all staff via the policy library on the Trust intranet.
4.3 Responsibilities of the VTE Committee
The responsibilities of the VTE Committee are set out in the Terms of References (Appendix 3).
4.4 Responsibility of /Divisional Medical Director/ Managers/Heads of Nursing
4.4.1 To ensure that all staff are fully aware of this policy and the accompanying procedure(s) which will be available via the policy library on the Trust intranet.
4.4.2 To ensure that all relevant clinical staff receive adequate training to implement VTE Management.
4.4.3 To ensure that all clinical staff work within the local Policy.
4.4.4 To take local decisions within the defined parameters of Trust Policies.
4.4.5 To ensure that compliance to this policy is monitored using the audit tool provided (Appendix 4).
4.5 Responsibility of all staff
4.5.1 All staff have a duty to read and work within current policies.
4.5.2 All staff should know how to gain access to the Policy Library if a member of staff identifies that any part of a policy is no longer relevant, they have a responsibility to inform both the person responsible for writing or reviewing the Policy and the Policy Management Co-ordinator.
4.5.3 Nursing staff to complete Anti Embolic Stockings assessment on admission and to repeat if required (Appendix 8a and b).
4.5.4 The VTE risk assessment shall be performed by the admitting doctor on admission and subsequently by a doctor within the team responsible for continuing care (Appendix 5).
4.5.5 To ensure that patients are provided with Trust approved Patient Information on VTE (Appendix 6).
4.5.6 Adverse drug reactions should be reported immediately as per the Medicine Management policy.
4.5.7 All clinical incidents involving VTE management of inpatients should be reported via the Trust Incident Reporting mechanism and an incident review undertaken. Reportable incidents include: failure to undertake a VTE risk assessment; failure to commence timely VTE prophylaxis; diagnosis of VTE event (PE/DVT) during hospital stay; suspected/confirmed death resulting for VTE.
4.5.8 Medical staff are required to report all suspected/confirmed VTE deaths to the Coroner.
4.6 Responsibilities of the Pharmacist
4.6.1 The Pharmacist will review and advise on prescribed VTE prophylaxis.
4.6.2 Pharmacist will deliver VTE training to FY1 and FY2 doctors.
4.7 Responsibility of the Bereavement officer
4.7.1 When a patient has died as a result of a suspected or confirmed VTE, the bereavement officer will provide support and guidance to medical staff on the necessary reporting requirements to the Coroner.
4.8 Responsibilities of the Stakeholders
4.8.1 All those involved in producing the document (policy, guideline, strategy etc) have a responsibility to ensure that consultation has taken place with the appropriate stakeholders.
4.8.2 Anyone who is asked for comments or to make a contribution to the document has a responsibility to respond to the request within the identified time frame, even if it is only to confirm that they are satisfied with the document as it stands.
4.9 Responsibility of Policy Management Co-ordinator
4.9.1 To be responsible for publishing all Policies/Procedures/Guidelines to the Intranet “Policy Library”..
4.9.2 To notify the author that the Policy is due to expire three months before the review date.
5 REPORTING TO EXTERNAL AGENCIES
5.1 NHS England will be informed when a VTE event occurs within the Trust and a Root Cause Analysis will be undertaken.
5.2 Serious Adverse Events (SAE/SUI) will be reported strategically using the Strategic Executive Information Systems (StEIS).
5.3 Medical Staff are required to report all suspected or confirmed deaths to the Coroner
6 HUMAN RIGHTS ACT
Implications of the Human Rights Act have been taken into account in the formulation of this policy and they have, where appropriate, been fully reflected in its wording.
7 EQUALITY AND DIVERSITY
The Policy has been assessed against the Equality Impact Assessment Form from the Trust’s Equality Impact Assessment Guidance and, as far as we are aware, there is no impact on any Equality Target Group.
8 MONITORING AND REVIEW:
8.1 The processes contained within the policy (TW10/049) will be audited in line with the audit monitoring template contained in Appendix 4.
8.2 The results of audits will be monitored by Divisional Governance Leads.
8.3 This policy will be reviewed in 3 years.
9 ACCESSIBILITY STATEMENT:
This document can be made available in a range of alternative formats e.g. large print, Braille and audio cd.
For more details, please contact the HR Department on 01942 77 (3766) or email
APPENDIX 1
REFERENCES AND FURTHER INFORMATION:
References and further Information:
Nice Clinical Guideline 92 Venous Thromboembolism, Reducing the risk: Jan 2010 This guideline updates NICE clinical guideline 46 and replaces it. https://www.nice.org.uk/guidance/cg92/resources/guidance-venous-thromboembolism-in-adults-admitted-to-hospital-reducing-the-risk-pdf
All-Parliamentary Thrombosis Group: Feb 2010.
NHS Operating Framework 2010/11, VTE in the Quality Framework
DOH Commissioning for Quality and innovation (CQUIN): an addendum to the 2008 policy guidance for 2010/11.
Medicine Management Policy: Version 8, Sept 2013.
Policy and Procedure for the Implementation of National Institute for Health and Clinical Excellence (NICE) Guidance: Version 9, June 2012.
Policy and Procedure for the reporting of Near Miss, Adverse Events and Serious Untoward Incidents: Version 10, April 2015.
NICE VTE pathways:
http://pathways.nice.org.uk/pathways/venous-thromboembolism/reducing-the-risk-of-venous-thromboembolism-in-hospital-patients
APPENDIX 2
GLOSSARY OF TERMS
Glossary of Terms (relevant to Policy)
BMI: body mass index
Dabigatran: dabigatran etexilate
DVT: deep vein thrombosis
Fondaparinux: fondaparinux sodium
HRT: hormone replacement therapy
INR: international normalised ratio (standardised laboratory measure of blood coagulation)
LMWH: low molecular weight heparin
PE: pulmonary embolism
UFH: unfractionated heparin
VTE: venous thrombo-embolism
DEFINITIONS:
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
Renal failure: estimated glomerular filtration rate (eGFR) < 30 ml/min/1.73 m2
Significantly reduced mobility:
– bedbound
– unable to walk unaided
– likely to spend a substantial proportion of the day in bed or in a chair
Appendix 3Terms of Reference
Committee Name: / Thrombosis Committee
Chairperson / Haematology Consultant
Deputy Chairperson / Acute Medical Physician
Date: / 23rd January 2015
Version: / 4.1
Reports to: / Corporate Quality Executive Committee
Divisional Quality Executive Committees
Divisional Safety Committees
Receives reports/ minutes from: / · Divisional Prophylaxis Leads
· VTE Unit
· Anticoagulation Unit
· Pharmacy
· Governance Leads
Meeting and attendance Frequency: / Every 4 months
Definition of Quorum: / Chair or Deputy plus five other core members
Membership: / Core Members
· Haematology Consultant
· Acute Care Physician
· Divisional Prophylaxis Lead for Specialist Services
· Divisional Prophylaxis Lead for Surgery
· VTE Department Nurse Specialist
· Anticoagulation Specialist Pharmacist
· Anticoagulant Nurse Specialist
· Vascular Department representative
· VTE Compliance Nurse
· A Head of Nursing
Additional Members
· Consultant Paediatrician
· Consultant Radiologist
· Consultant Obstetrician
· Surgical Consultant
· Specialist Services representative
· Emergency Care Centre representative
· Anaesthetics representative
· Unscheduled Care representative
In Attendance: (to support the committee) / · Business Intelligence
· Junior Dr representation
· Divisional Governance Leads
· NHSLA lead
Authority: / · To promote a mechanism for engaging active participation of Divisions in service development and improvement of anticoagulation and VTE services.
· To ensure effective communication through the divisions and specialities and ensure partnership working.
· To submit chairperson’s reports to the Divisional Quality Executive Committee’s (DQEC)
Scope of Responsibilities (duties) / 1. To promote best practice through based on National Guidelines and other examples of best available for the treatment of VTE disease and anticoagulation
2. Introduce protocols and appropriate changes to practice in consultation with the relevant interested parties
3. Promote the education and training of all clinical and support staff
Key Strategies:
1. To generate ideas and provide the impetus for the management of VTE throughout the Trust.
2. To establish and implement systems to evaluate and manage the diagnosis and treatment of patients with VTE disease. The systems should be determined in consultation with senior Clinical personnel working within the Trust.
3. Ensure that policies are communicated appropriately and effectively across the trust.
4. To advise on criteria and standards for clinical audit to monitor the effectiveness within the Trust and make recommendations for further action as necessary.
5. To evaluate new treatments and prepare formulary and funding applications as necessary
6. To provide an annual report for presentation to the Quality Improvement Committee each year
Review Date: / May 2018
Monitoring of ToR: / Trust Medical Director.
Appendix 4