× NICE uses cookies to make the site better.  Learn more
A-Z
Topics
Latest

Venous thromboembolism overview

history control tooltip

divider handle tooltip

Venous thromboembolism HAI

About

What is covered

This pathway covers:
  • assessing and reducing the risk of venous thromboembolism (VTE) in patients admitted to hospital
  • diagnosing VTE in primary, secondary and tertiary care, including Wells score, D-dimer measurement, ultrasound and radiological imaging
  • treating VTE
  • investigations for cancer and testing for thrombophilia in patients diagnosed with VTE.
VTE is a condition in which a blood clot (a thrombus) forms in a vein, most commonly in the deep veins of the legs or pelvis; this is called deep vein thrombosis (DVT). The thrombus can dislodge and travel in the blood, particularly to the pulmonary arteries, where it is known as pulmonary embolism (PE). The term 'VTE' includes both DVT and PE. Venous thromboembolic diseases cover a spectrum ranging from asymptomatic calf vein thrombosis to symptomatic DVT.
Thrombophilia is a major risk factor for VTE. It is an inherited or acquired prothrombotic state that predisposes to VTE. Other major risk factors for VTE include a history of DVT, age over 60 years, surgery, obesity, prolonged travel, acute medical illness, cancer, immobility and pregnancy.
Failure to diagnose and treat VTE correctly can result in fatal PE, in which the blood supply to the lungs is badly blocked by the thrombus. Non-fatal VTE can cause serious long-term conditions such as post-thrombotic syndrome. However, diagnosis of VTE is not always straightforward.

Updates

Updates to this pathway

16 December 2014 Dabigatran etexilate for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism (NICE technology appraisal guidance 327) added to pharmacological interventions.
24 June 2014 The geko device for reducing the risk of venous thromboembolism (NICE medical technology guidance 19) added to choice of VTE prophylaxis.
12 May 2014 Minor maintenance update.
28 April 2014 Minor maintenance update.
19 February 2014 Minor maintenance update.
13 September 2013 Minor maintenance update.
2 July 2013 'Rivaroxaban for treating pulmonary embolism and preventing recurrent venous thromboembolism' (NICE technology appraisal guidance 287) added to pharmacological interventions.
3 May 2013 Minor maintenance updates.
28 March 2013 Diagnosis and management of venous thromboembolic diseases quality standard (QS29) added.
29 January 2013 Minor maintenance updates.
24 August 2012 Minor maintenance updates.
31 July 2012 'Venous thromboembolism (treatment and long term secondary prevention) – rivaroxaban' (NICE technology appraisal guidance 261) added to pharmacological interventions.
6 July 2012 Minor maintenance updates.
3 July 2012 Repeat proximal ultrasound scan after positive D-dimer test added to deep vein thrombosis likely based on two-level Wells score.
27 June 2012 'Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing' (NICE clinical guideline 144) added.
27 June 2012 'Renal failure' replaced with severe renal impairment or established renal failure throughout reducing the risk of venous thromboembolism in hospital patients, in line with treating venous thromboembolism in this pathway and stages of CKD and frequency of eGFR testing in the chronic kidney disease pathway.
27 June 2012 Clarification of anti-embolism stocking calf pressure added to using mechanical prophylaxis.
27 June 2012 'Venous thromboembolism – apixaban (hip and knee surgery)' (NICE technology appraisal guidance 245) added to elective hip or knee replacement.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Short Text

Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital
The management of venous thromboembolic diseases and the role of thrombophilia testing

What is covered

This pathway covers:
  • assessing and reducing the risk of venous thromboembolism (VTE) in patients admitted to hospital
  • diagnosing VTE in primary, secondary and tertiary care, including Wells score, D-dimer measurement, ultrasound and radiological imaging
  • treating VTE
  • investigations for cancer and testing for thrombophilia in patients diagnosed with VTE.
VTE is a condition in which a blood clot (a thrombus) forms in a vein, most commonly in the deep veins of the legs or pelvis; this is called deep vein thrombosis (DVT). The thrombus can dislodge and travel in the blood, particularly to the pulmonary arteries, where it is known as pulmonary embolism (PE). The term 'VTE' includes both DVT and PE. Venous thromboembolic diseases cover a spectrum ranging from asymptomatic calf vein thrombosis to symptomatic DVT.
Thrombophilia is a major risk factor for VTE. It is an inherited or acquired prothrombotic state that predisposes to VTE. Other major risk factors for VTE include a history of DVT, age over 60 years, surgery, obesity, prolonged travel, acute medical illness, cancer, immobility and pregnancy.
Failure to diagnose and treat VTE correctly can result in fatal PE, in which the blood supply to the lungs is badly blocked by the thrombus. Non-fatal VTE can cause serious long-term conditions such as post-thrombotic syndrome. However, diagnosis of VTE is not always straightforward.

Updates

Updates to this pathway

16 December 2014 Dabigatran etexilate for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism (NICE technology appraisal guidance 327) added to pharmacological interventions.
24 June 2014 The geko device for reducing the risk of venous thromboembolism (NICE medical technology guidance 19) added to choice of VTE prophylaxis.
12 May 2014 Minor maintenance update.
28 April 2014 Minor maintenance update.
19 February 2014 Minor maintenance update.
13 September 2013 Minor maintenance update.
2 July 2013 'Rivaroxaban for treating pulmonary embolism and preventing recurrent venous thromboembolism' (NICE technology appraisal guidance 287) added to pharmacological interventions.
3 May 2013 Minor maintenance updates.
28 March 2013 Diagnosis and management of venous thromboembolic diseases quality standard (QS29) added.
29 January 2013 Minor maintenance updates.
24 August 2012 Minor maintenance updates.
31 July 2012 'Venous thromboembolism (treatment and long term secondary prevention) – rivaroxaban' (NICE technology appraisal guidance 261) added to pharmacological interventions.
6 July 2012 Minor maintenance updates.
3 July 2012 Repeat proximal ultrasound scan after positive D-dimer test added to deep vein thrombosis likely based on two-level Wells score.
27 June 2012 'Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing' (NICE clinical guideline 144) added.
27 June 2012 'Renal failure' replaced with severe renal impairment or established renal failure throughout reducing the risk of venous thromboembolism in hospital patients, in line with treating venous thromboembolism in this pathway and stages of CKD and frequency of eGFR testing in the chronic kidney disease pathway.
27 June 2012 Clarification of anti-embolism stocking calf pressure added to using mechanical prophylaxis.
27 June 2012 'Venous thromboembolism – apixaban (hip and knee surgery)' (NICE technology appraisal guidance 245) added to elective hip or knee replacement.

Quality standards

Venous thromboembolism (VTE) prevention quality standard

These quality statements are taken from the VTE prevention quality standard. The quality standard defines clinical best practice in preventing VTE and should be read in full.

Quality statements

VTE and bleeding risk assessment

This quality statement is taken from the VTE prevention quality standard. The quality standard defines clinical best practice in preventing VTE and should be read in full.

Quality statement

All patients, on admission, receive an assessment of VTE and bleeding risk using the clinical risk assessment criteria described in the national tool.

Quality measure

Structure
Evidence that patients receive a risk assessment for VTE and bleeding that uses the clinical risk assessment criteria described in the national tool.
Process
Proportion of patients assessed on admission for VTE and bleeding risk using the clinical risk assessment criteria described in the national tool.
Numerator: the number of patients assessed on admission for VTE and bleeding risk using the clinical risk assessment criteria described in the national tool.
Denominator: the number of inpatients and day cases admitted to hospital.

Description of what the quality statement means for each audience

Service providers ensure patients, on admission, are assessed for risk of VTE and bleeding using the clinical risk assessment criteria described in the national tool.
Healthcare professionals assess all patients for risk of VTE and bleeding on admission using the clinical risk assessment criteria described in the national tool.
Commissioners ensure services assess all patients for risk of VTE and bleeding on admission using the clinical risk assessment criteria described in the national tool.
Patients can expect to have their risk of VTE and bleeding assessed when admitted to hospital using the clinical risk assessment criteria described in the national tool.

Definitions

This statement applies to all patients admitted to hospital.
If the assessment for VTE and bleeding has been done at a pre-admission clinic, it should be reviewed for changes on admission using the clinical risk assessment criteria described in the national tool.
A day case is defined as a patient admitted electively during the course of a day with the intention of receiving care who does not require the use of a hospital bed overnight and who returns home as scheduled. If this original intention is not fulfilled and the patient stays overnight, such a patient should be counted as an ordinary admission.
The national tool is the Department of Health's Risk assessment for venous thromboembolism (March 2010).

Data source

Structure
Local data collection.
Process
Mandatory national data collection on VTE risk assessment to achieve compliance with the national VTE Commissioning for Quality and Innovation goal set for 2010/11.

Verbal and written information on VTE prevention

This quality statement is taken from the VTE prevention quality standard. The quality standard defines clinical best practice in preventing VTE and should be read in full.

Quality statement

Patients/carers are offered verbal and written information on VTE prevention as part of the admission process.

Quality measure

Structure
Evidence of written patient/carer information on VTE prevention being available to patients/carers as part of the admission process.
Process
Proportion of patients/carers who are offered verbal and written information on VTE prevention as part of the admission process.
Numerator: the number of patients/carers who are offered verbal and written information on VTE prevention as part of the admission process.
Denominator: the number of inpatients and day cases admitted to hospital.

Description of what the quality statement means for each audience

Service providers ensure verbal and written patient/carer information on VTE prevention is offered as part of the admission process.
Healthcare professionals offer all patients/carers verbal and written information on VTE prevention as part of the admission process.
Commissioners ensure services provide all patients/carers verbal and written information on VTE prevention as part of the admission process.
Patients/carers can expect to be offered verbal and written information on VTE prevention as part of the admission process to hospital.

Definitions

Information should be provided on:
  • the risks and possible consequences of VTE
  • the importance of VTE prophylaxis and its possible side effects
  • the correct use of VTE prophylaxis (for example, anti-embolism stockings, intermittent pneumatic compression devices or foot impulse devices)
  • how patients can reduce their risk of VTE (such as keeping well hydrated and, if possible, exercising and becoming more mobile).
Information about NICE guidance written specifically for patients can be found in Venous thromboembolism – reducing the risk: information for the public (NICE clinical guideline 92, 2010).

Data source

Structure
Local data collection.
Process

Anti-embolism stockings

This quality statement is taken from the VTE prevention quality standard. The quality standard defines clinical best practice in preventing VTE and should be read in full.

Quality statement

Patients provided with anti-embolism stockings have them fitted and monitored in accordance with NICE guidance.

Quality measure

Structure
(a) Evidence of local arrangements to ensure patients provided with anti-embolism stockings have them fitted and monitored in accordance with NICE guidance.
(b) Evidence of local arrangements to ensure that staff are trained in the use and monitoring of anti-embolism stockings.
Process
(a) Proportion of patients with anti-embolism stockings fitted and monitored in accordance with NICE guidance.
Numerator: the number of patients with anti-embolism stockings fitted and monitored in accordance with NICE guidance.
Denominator: the number of patients provided with anti-embolism stockings.
(b) Proportion of staff responsible for fitting and monitoring anti-embolism stockings who have received training on their use.
Numerator: the number of staff who have received training in the use and monitoring of anti-embolism stockings.
Denominator: the number of staff responsible for fitting and monitoring anti-embolism stockings.

Description of what the quality statement means for each audience

Service providers ensure that services and protocols are in place to ensure that patients provided with anti-embolism stockings are fitted and monitored in accordance with NICE guidance by appropriately trained staff.
Healthcare professionals follow local protocols and are trained in fitting and monitoring patients with anti-embolism stockings in accordance with NICE guidance.
Commissioners ensure services are in place so that patients provided with anti-embolism stockings are fitted and monitored in accordance with NICE guidance.
Patients who require anti-embolism stockings can expect to have them fitted and monitored in accordance with NICE guidance by appropriately trained staff.

Data source

Structure
Local data collection.
Process
Local data collection.

Re-assessment

This quality statement is taken from the VTE prevention quality standard. The quality standard defines clinical best practice in preventing VTE and should be read in full.

Quality statement

Patients are re-assessed within 24 hours of admission for risk of VTE and bleeding.

Quality measure

Structure
Evidence of local arrangements to ensure patients admitted for more than 24 hours are re-assessed for risk of VTE and bleeding within 24 hours of admission.
Process
Proportion of patients with a length of stay greater than 24 hours who are re-assessed within 24 hours of admission for risk of VTE and bleeding.
Numerator: the number of patients who are re-assessed for risk of VTE and bleeding within 24 hours of admission.
Denominator: the number of patients with a length of stay greater than 24 hours.

Description of what the quality statement means for each audience

Service providers ensure all patients with a length of stay greater than 24 hours are re-assessed within 24 hours of admission for risk of VTE and bleeding.
Healthcare professionals re-assess patients within 24 hours of admission for risk of VTE and bleeding.
Commissioners ensure services re-assess patients' risk of VTE and bleeding within 24 hours of admission.
Patients can expect to have their risk of VTE and bleeding re-assessed within 24 hours of admission.

Data source

Structure
Local data collection.
Process

VTE prophylaxis

This quality statement is taken from the VTE prevention quality standard. The quality standard defines clinical best practice in preventing VTE and should be read in full.

Quality statement

Patients assessed to be at risk of VTE are offered VTE prophylaxis in accordance with NICE guidance.

Quality measure

Structure
Evidence of local arrangements ensuring that the provision of VTE prophylaxis is in accordance with NICE guidance.
Process
Proportion of patients assessed to be at increased risk of VTE who are offered VTE prophylaxis in accordance with NICE guidance.
Numerator: the number of patients who are offered thromboprophylaxis in accordance with NICE guidance.
Denominator: the number of patients assessed to be at increased risk of VTE.

Description of what the quality statement means for each audience

Service providers ensure VTE prophylaxis is offered in accordance with NICE guidance having regard for the complications of thromboprophylaxis.
Healthcare professionals offer VTE prophylaxis to all patients assessed as being at risk of VTE in accordance with NICE guidance having regard for the complications of thromboprophylaxis.
Commissioners ensure services comply with NICE guidance on the provision of VTE prophylaxis having regard for the complications of thromboprophylaxis.
Patients assessed as being at risk of VTE can expect to be offered VTE prophylaxis in accordance with NICE guidance having regard for the complications of thromboprophylaxis.

Definitions

This statement applies to all patients admitted to hospital.

Data source

Structure
Local data collection.
Process
Local data collection.

Information for patients and carers

This quality statement is taken from the VTE prevention quality standard. The quality standard defines clinical best practice in preventing VTE and should be read in full.

Quality statement

Patients/carers are offered verbal and written information on VTE prevention as part of the discharge process.

Quality measure

Structure
Evidence of written patient/carer information on VTE prevention being available to patients as part of the discharge process.
Process
Proportion of patients/carers who receive verbal and written information on VTE prevention as part of the discharge process.
Numerator: the number of patients/carers who receive verbal and written information on VTE prevention as part of the discharge process.
Denominator: the number of inpatient and day case discharges.

Description of what the quality statement means for each audience

Service providers ensure verbal and written patient/carer information on VTE prevention is available as part of the discharge process.
Healthcare professionals offer all patients/carers verbal and written information on VTE prevention as part of the discharge process.
Commissioners ensure services provide all patients/carers verbal and written information on VTE prevention as part of the discharge process.
Patients/carers can expect to be offered verbal and written information on VTE prevention as part of their discharge plan.

Definitions

Information should include:
  • the signs and symptoms of deep vein thrombosis and pulmonary embolism
  • 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 VTE prophylaxis
  • the importance of seeking medical help if deep vein thrombosis, pulmonary embolism or other adverse events are suspected.
Information about NICE guidance written specifically for patients can be found in Venous thromboembolism – reducing the risk: information for the public (2010).

Data source

Structure
Local data collection.
Process

Extended VTE prophylaxis

This quality statement is taken from the VTE prevention quality standard. The quality standard defines clinical best practice in preventing VTE and should be read in full.

Quality statement

Patients are offered extended (post hospital) VTE prophylaxis in accordance with NICE guidance.

Quality measure

Structure
Evidence of local arrangements to comply with NICE guidance on prescription of extended (post hospital) VTE prophylaxis.
Process
Proportion of patients offered extended (post hospital) VTE prophylaxis in accordance with NICE guidance.
Numerator: The number of patients offered VTE prophylaxis in accordance with NICE guidance.
Denominator: The number of patients eligible for extended (post hospital) VTE prophylaxis.

Description of what the quality statement means for each audience

Service providers ensure patients are offered extended (post hospital) VTE prophylaxis in accordance with NICE guidance.
Healthcare professionals offer extended (post hospital) VTE prophylaxis to patients in accordance with NICE guidance.
Commissioners ensure services comply with NICE guidance on the provision of extended (post hospital) VTE prophylaxis.
Patients can expect to be offered extended (post hospital) VTE prophylaxis in accordance with NICE guidance.

Definitions

This statement applies to patients who need extended (post hospital) prophylaxis to continue after the end of their hospital stay.

Data source

Structure
Local data collection.
Process
Local data collection.

Interim therapeutic dose of anticoagulation therapy for suspected deep vein thrombosis

This quality statement is taken from the diagnosis and management of venous thromboembolic diseases quality standard. The quality standard defines clinical best practice in diagnosing and managing venous thromboembolic diseases in adults and should be read in full.

Quality statement

People with suspected deep vein thrombosis (DVT) are offered an interim therapeutic dose of anticoagulation therapy if diagnostic investigations are expected to take longer than 4 hours from the time of first clinical suspicion.

Rationale

It is important that people with suspected DVT are treated promptly. In line with NICE guidance, people with suspected DVT should be offered interim anticoagulation therapy if diagnostic investigations are expected to take longer than 4 hours from the time of first clinical suspicion. This is to avoid adverse effects if a quick confirmation test is not available or possible because there is risk of pulmonary embolism (PE).

Quality measure

Structure
Evidence of local arrangements to ensure people with suspected DVT are offered an interim therapeutic dose of anticoagulation therapy if diagnostic investigations are expected to take longer than 4 hours from the time of first clinical suspicion.
Process
The proportion of people with suspected DVT whose diagnostic investigations take longer than 4 hours from the time of first clinical suspicion who receive an interim therapeutic dose of anticoagulation therapy.
Numerator – the number of people in the denominator who receive an interim therapeutic dose of anticoagulation therapy.
Denominator – the number of people with suspected DVT whose diagnostic investigations were not completed within 4 hours from the time of first clinical suspicion.
Outcome
Incidence of PE in people who have undergone diagnostic tests for DVT.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with suspected DVT to be offered an interim dose of anticoagulation therapy if diagnostic investigations are expected to take longer than 4 hours from the time of first clinical suspicion.
Healthcare professionals ensure they offer people with suspected DVT an interim dose of anticoagulation therapy if diagnostic investigations are expected to take longer than 4 hours from the time of first clinical suspicion.
Commissioners ensure they commission services that offer people with suspected DVT an interim dose of anticoagulation therapy if diagnostic investigations are expected to take longer than 4 hours from the time of first clinical suspicion.
People who may have deep vein thrombosis and whose confirmation test is expected to take longer than 4 hours from the time an appropriate healthcare professional requests it are offered a dose of an anticoagulant (a drug that helps to stop blood clots forming or enlarging, and makes it less likely that a blood clot will come loose and travel to the lungs).

Source guidance references

NICE clinical guideline 144 recommendations 1.1.1 (key priority for implementation), 1.1.2, 1.1.3 (key priority for implementation) and 1.1.4 (key priority for implementation).

Data source

Structure
Local data collection.
Process
Local data collection. Contained within NICE clinical guideline 144 clinical audit tool (diagnosis of deep vein thrombosis), standards 6 and 15.
Outcome
Local data collection.

Definitions

Suspected DVT NICE clinical guideline 144 recommendations 1.1.1 and 1.1.2 describe the features of suspected DVT and how to estimate clinical probability (two-level DVT Wells score).
Diagnostic tests NICE clinical guideline 144 recommendations 1.1.3 and 1.1.4 recommend diagnostic testing for people with suspected DVT according to clinical probability.
First clinical suspicion Clinical suspicion of DVT by an appropriate healthcare professional in community or hospital settings.

Diagnosis of deep vein thrombosis

This quality statement is taken from the diagnosis and management of venous thromboembolic diseases quality standard. The quality standard defines clinical best practice in diagnosing and managing venous thromboembolic diseases in adults and should be read in full.

Quality statement

People with suspected deep vein thrombosis (DVT) have all diagnostic investigations completed within 24 hours of first clinical suspicion.

Rationale

It is important that all diagnostic investigations for suspected DVT are completed within 24 hours to ensure prompt treatment if the diagnosis is confirmed, and to avoid unnecessary repeat doses of anticoagulants if the diagnosis is excluded.

Quality measure

Structure
Evidence of local arrangements to ensure people with suspected DVT have all diagnostic investigations completed within 24 hours of first clinical suspicion.
Process
The proportion of people who have all diagnostic investigations completed within 24 hours of first clinical suspicion.
Numerator – the number of people in the denominator who have all diagnostic investigations completed within 24 hours of first clinical suspicion.
Denominator – the number of people with suspected DVT.
Outcome
Incidence of pulmonary embolism (PE) in people who have undergone all diagnostic tests for DVT.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with suspected DVT to have all diagnostic investigations completed within 24 hours of first clinical suspicion.
Healthcare professionals ensure people with suspected DVT to have all diagnostic investigations completed within 24 hours of first clinical suspicion.
Commissioners ensure they commission services for people with suspected DVT to have all diagnostic investigations completed within 24 hours of first clinical suspicion.
People who may have deep vein thrombosis have all their diagnostic tests done within 24 hours of the tests being requested by an appropriate healthcare professional.

Source guidance references

NICE clinical guideline 144 recommendations 1.1.1 (key priority for implementation), 1.1.2, 1.1.3 (key priority for implementation), 1.1.4 (key priority for implementation) and 1.1.14. See also diagnosing venous thromboembolism in primary, secondary and tertiary care in this pathway.

Data source

Structure
Local data collection.
Process
Local data collection.
Outcome
Local data collection.

Definitions

Suspected DVT NICE clinical guideline 144 recommendations 1.1.1 and 1.1.2 describe the features of suspected DVT and how to estimate clinical probability (two-level DVT Wells score).
Diagnostic investigations completed are outlined in diagnosing venous thromboembolism in primary, secondary and tertiary care in this pathway.
NICE clinical guideline 144 recommendations 1.1.3 and 1.1.4 recommend arranging diagnostic testing for people with suspected DVT according to clinical probability.
First clinical suspicion Clinical suspicion of DVT by an appropriate healthcare professional in community or hospital settings.

Interim therapeutic dose of anticoagulation therapy for suspected pulmonary embolism

This quality statement is taken from the diagnosis and management of venous thromboembolic diseases quality standard. The quality standard defines clinical best practice in diagnosing and managing venous thromboembolic diseases in adults and should be read in full.

Quality statement

People with suspected pulmonary embolism (PE) are offered an interim therapeutic dose of anticoagulation therapy if diagnostic investigations are expected to take longer than 1 hour from the time of first clinical suspicion.

Rationale

The consequences of missing a diagnosis of PE are severe and if a PE is left untreated there is a high risk of mortality. Immediate interim treatment with an anticoagulant is recommended if PE is suspected and a confirmatory test is not immediately available.

Quality measure

Structure
Evidence of local arrangements to ensure people with suspected PE are offered an interim therapeutic dose of anticoagulation therapy if diagnostic investigations are expected to take longer than 1 hour from the time of first clinical suspicion.
Process
The proportion of people with suspected PE whose diagnostic investigations take longer than 1 hour from the time of first clinical suspicion who receive an interim therapeutic dose of anticoagulation therapy.
Numerator – the number of people in the denominator who receive an interim therapeutic dose of anticoagulation therapy.
Denominator – the number of people with suspected PE whose diagnostic investigations take longer than 1 hour from the time of first clinical suspicion.
Outcome
Mortality from PE.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with suspected PE to be offered an interim therapeutic dose of anticoagulation therapy if diagnostic investigations are expected to take longer than 1 hour from the time of first clinical suspicion.
Healthcare professionals ensure people with suspected PE are offered an interim therapeutic dose of anticoagulation therapy if diagnostic investigations are expected to take longer than 1 hour from the time of first clinical suspicion.
Commissioners ensure they commission services in which people with suspected PE are offered an interim therapeutic dose of anticoagulation therapy if diagnostic investigations are expected to take longer than 1 hour from the time of first clinical suspicion.
People who may have a pulmonary embolism whose test results are expected to take longer than 1 hour from the time the tests are requested by an appropriate healthcare professional are offered a dose of an anticoagulant (a drug that helps to stop blood clots forming or enlarging, and makes it less likely that a blood clot will come loose and travel to the lungs)l.

Source guidance references

NICE clinical guideline 144 recommendations 1.1.7 and 1.1.8 and 1.1.9 and 1.1.10 (key priorities for implementation).

Data source

Structure
Local data collection.
Process
Outcome
Local data collection.

Definitions

Suspected PE NICE clinical guideline 144 recommendations 1.1.7 and 1.1.8 describe the features of suspected PE and how to estimate clinical probability (two-level PE Wells score).
Diagnostic investigations are outlined in diagnosing venous thromboembolism in primary, secondary and tertiary care in this pathway.
NICE clinical guideline 144 recommendations 1.1.9 and 1.1.10 recommend immediate diagnostic testing for people with suspected PE according to clinical probability with appropriate use of anticoagulant.
First clinical suspicion Clinical suspicion of PE by an appropriate healthcare professional in community or hospital settings.

Mechanical interventions

This quality statement is taken from the diagnosis and management of venous thromboembolic diseases quality standard. The quality standard defines clinical best practice in diagnosing and managing venous thromboembolic diseases in adults and should be read in full.

Quality statement

People with proximal deep vein thrombosis (DVT) are offered below-knee graduated compression stockings within 3 weeks of diagnosis.

Rationale

The use of stockings can help prevent post-thrombotic syndrome. It is important that stockings are applied within 3 weeks of diagnosis to ensure they are effective. The timeframe of 3 weeks allows for swelling to reduce in order for stockings to be fitted.

Quality measure

a) Structure
Evidence of local arrangements to ensure people with proximal DVT are offered below-knee graduated compression stockings within 3 weeks of diagnosis.
Process
The proportion of people with proximal DVT who receive below-knee graduated compression stockings within 3 weeks of diagnosis.
Numerator – the number of people in the denominator who receive below-knee graduated compression stockings within 3 weeks of diagnosis.
Denominator – the number of people with proximal DVT eligible for below-knee compression stockings.
b) Structure
Evidence of local arrangements to ensure people with proximal DVT are offered below-knee graduated compression stockings within 1 week of diagnosis.
Process
The proportion of people with proximal DVT who receive below-knee graduated compression stockings within 1 week of diagnosis.
Numerator – the number of people in the denominator who receive below-knee graduated compression stockings within 1 week of diagnosis.
Denominator – the number of people with proximal DVT eligible for below-knee graduated compression stockings.
Outcome
The incidence of post-thrombotic syndrome.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with proximal DVT to be offered below-knee graduated compression stockings within 3 weeks of diagnosis.
Healthcare professionals ensure they offer people with proximal DVT below-knee graduated compression stockings within 3 weeks of diagnosis.
Commissioners ensure they commission services that offer people with proximal DVT below-knee graduated compression stockings within 3 weeks of diagnosis.
People with deep vein thrombosis above the knee are offered below-knee graduated compression stockings within 3 weeks of their deep vein thrombosis being diagnosed.

Source guidance references

NICE clinical guideline 144 recommendation 1.2.9 (key priority for implementation)

Data source

Structure
Local data collection.
Process
Outcome
Local data collection.

Definitions

Below-knee graduated compression stockings NICE clinical guideline 144 recommendation 1.2.9 recommends that below-knee graduated compression stockings should have an ankle pressure of greater than 23 mmHg. Below-knee graduated compression stockings are recommended unless there are contraindications. The full NICE clinical guideline 144 describes contraindications that include:
  • swelling if not reduced sufficiently to fit the stockings
  • peripheral arterial disease
  • arteriosclerosis
  • severe peripheral neuropathy
  • massive leg oedema or pulmonary oedema
  • oedema secondary to congestive cardiac failure
  • local skin or soft tissue diseases such as recent skin graft or dermatitis
  • extreme deformity of the leg
  • gangrenous limb
  • ankle:brachial pressure index less than 0.8
  • cellulitis.
Proximal DVT DVT in the popliteal vein or above; proximal DVT in this context refers to ‘above-knee DVT’.

Equality and diversity considerations

Some people may have difficulty putting the stocking on themselves. These people may need assistance and/or an application aid.

Investigations for cancer

This quality statement is taken from the diagnosis and management of venous thromboembolic diseases quality standard. The quality standard defines clinical best practice in diagnosing and managing venous thromboembolic diseases in adults and should be read in full.

Quality statement

People with unprovoked deep vein thrombosis (DVT) or pulmonary embolism (PE) who are not already known to have cancer are offered timely investigations for cancer.

Rationale

A significant proportion of people with a new unprovoked DVT or PE may have an undiagnosed cancer. In addition, the occurrence of cancer-related venous thromboembolic disease is associated with a poorer prognosis. Therefore it is critical for the optimal management of unprovoked DVT or PE (in a person in whom no obvious risk factors for DVT or PE have been identified) to establish whether they may have an underlying cancer.

Quality measure

Structure
Evidence of local arrangements to ensure people with unprovoked DVT or PE who are not already known to have cancer are offered investigations for cancer.
Process
The proportion of people with unprovoked DVT or PE who are not already known to have cancer who receive investigations for cancer.
Numerator – the number of people in the denominator who receive investigations for cancer.
Denominator – the number of people with unprovoked DVT or PE who are not already known to have cancer.
Outcome
The incidence of cancer detected after unprovoked DVT or PE.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with unprovoked DVT or PE who are not already known to have cancer to be offered investigations for cancer.
Healthcare professionals ensure people with unprovoked DVT or PE who are not already known to have cancer are offered investigations for cancer.
Commissioners ensure they commission services that offer people with unprovoked DVT or PE who are not already known to have cancer investigations for cancer.
People who have an unprovoked (with no obvious cause) deep vein thrombosis or pulmonary embolism and who are not already known to have cancer are offered tests for cancer.

Source guidance references

NICE clinical guideline 144 recommendation 1.5.1.

Data source

Structure
Local data collection.
Process
Outcome
Local data collection.

Definitions

Unprovoked DVT or PE is defined as DVT or PE in a person with no antecedent major clinical risk factor for VTE who is not having hormonal therapy (oral contraceptive or hormone replacement therapy). People with active cancer or a family history of VTE should also be considered as having an unprovoked episode because these underlying risks will remain unchanged in the person. However people with active cancer are not included in this statement.
Investigations for cancer In this context, investigations for cancer refer to the investigations in people with unprovoked DVT or PE who are not already known to have cancer to determine whether the VTE could be related to a previously undetected cancer. In the context of this quality statement the specific investigations are:
  • a physical examination (guided by the patient’s full history
  • chest X-ray (according to baseline risk)
  • blood tests (full blood count, serum calcium and liver function tests)
  • urinalysis.
Timely investigations for cancer The 2-week wait standard for cancers guarantees that everyone referred urgently with suspected cancer would be able to be seen by a specialist or in a diagnostic clinic within 2 weeks from the date of decision to refer. Therefore the investigations for cancer should be carried out within 2 weeks of being ordered.

Thrombophilia testing

This quality statement is taken from the diagnosis and management of venous thromboembolic diseases quality standard. The quality standard defines clinical best practice in diagnosing and managing venous thromboembolic diseases in adults and should be read in full.

Quality statement

People with provoked deep vein thrombosis (DVT) or pulmonary embolism (PE) are not offered testing for thrombophilia.

Rationale

Thrombophilia testing does not provide benefit and is unnecessary for people with provoked DVT or PE.

Quality measure

Structure
Evidence of local arrangements to ensure people with provoked DVT or PE do not have testing for thrombophilia.
Process
The proportion of people with provoked DVT or PE who are tested for thrombophilia.
Numerator – the number of people in the denominator who receive testing for thrombophilia.
Denominator – the number of people with provoked DVT or PE.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to ensure that people with provoked DVT or PE are not tested for thrombophilia..
Healthcare professionals ensure people with provoked DVT or PE are not tested for thrombophilia.
Commissioners ensure they commission services that do not carry out testing for thrombophilia in people with provoked DVT or PE.
People who have had a provoked (with an obvious cause) deep vein thrombosis or pulmonary embolism are not offered tests for thrombophilia (a condition that makes the blood more likely to form clots).

Source guidance references

NICE clinical guideline 144 recommendation 1.6.4.

Data source

Structure
Local data collection.
Process
Local data collection. Contained within NICE clinical guideline 144 clinical audit tool (thrombophilia testing), standard 2.

Definitions

Provoked DVT or PE is defined as DVT or PE that occurred in the presence of an antecedent (within 3 months) and transient major clinical risk factor for VTE (for example surgery, trauma or significant immobility). The NICE Guideline Development Group also considered VTE that occurs in association with hormonal therapy (oral contraceptive or hormone replacement therapy) to be provoked because it has been shown that people having these therapies have a lower risk of VTE recurrence.

Treatment of people with active cancer

This quality statement is taken from the diagnosis and management of venous thromboembolic diseases quality standard. The quality standard defines clinical best practice in diagnosing and managing venous thromboembolic diseases in adults and should be read in full.

Quality statement

People with active cancer and confirmed proximal deep vein thrombosis (DVT) or pulmonary embolism (PE) are offered anticoagulation therapy.

Rationale

In people with cancer, anticoagulation can lead to improved prognosis including a reduction in the risk of recurrent DVT or PE.

Quality measure

Structure
Evidence of local arrangements to ensure people with active cancer and confirmed proximal DVT or PE are offered anticoagulation therapy.
Process
The proportion of people with active cancer and confirmed proximal DVT or PE who receive anticoagulation therapy.
Numerator – the number of people in the denominator who receive anticoagulation therapy.
Denominator – the number of people with active cancer and confirmed proximal DVT or PE.
Outcome
Incidence of recurrent DVT or PE in patients with cancer and VTE who have completed anticoagulation therapy.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with active cancer and confirmed proximal DVT or PE to be offered anticoagulation therapy.
Healthcare professionals ensure people with active cancer and confirmed proximal DVT or PE are offered anticoagulation therapy.
Commissioners ensure they commission services that offer people with active cancer and confirmed proximal DVT or PE anticoagulation therapy.
People with active cancer who have had a deep vein thrombosis or pulmonary embolism are offered treatment with an anticoagulant (a drug that helps stop blood clots forming or enlarging and makes it less likely that a blood clot will come loose and travel to the lungs).

Source guidance references

NICE clinical guideline 144 recommendation 1.2.2 (key priority for implementation).

Data source

Structure
Local data collection.
Process
Outcome
Local data collection.

Definitions

Active cancer was defined by the Guideline Development Group (after considering the evidence available) as cancer: receiving active antimitotic treatment; or diagnosed within the past 6 months; or recurrent or metastatic; or inoperable. This definition excludes squamous skin cancer and basal cell carcinoma.
Proximal DVT DVT in the popliteal vein or above; proximal DVT in this context refers to 'above-knee DVT'.
Anticoagulation therapy For active cancer anticoagulation therapy can include treatment with LMWH or rivaroxaban given in accordance with the summary of product characteristics.

Follow-up for people without cancer

This quality statement is taken from the diagnosis and management of venous thromboembolic diseases quality standard. The quality standard defines clinical best practice in diagnosing and managing venous thromboembolic diseases in adults and should be read in full.

Quality statement

People without cancer who receive anticoagulation therapy have a review within 3 months of diagnosis of confirmed proximal deep vein thrombosis (DVT) or pulmonary embolism (PE) to discuss the risks and benefits of continuing anticoagulation therapy.

Rationale

As anticoagulation therapy carries potential risks such as bleeding there is a need to ensure the therapy remains beneficial. For people who have had a confirmed proximal DVT or PE and who do not have cancer, a review should take place.

Quality measure

Structure
Evidence of local arrangements to ensure people without cancer who have had a confirmed proximal DVT or PE and receive anticoagulation therapy receive a review within 3 months of diagnosis to discuss the risks and benefits of continuing anticoagulation therapy.
Process
The proportion of people without cancer who have had a confirmed proximal DVT or PE and receive anticoagulation who have a review within 3 months to discuss the risks and benefits of continuing anticoagulation therapy.
Numerator – the number of people in the denominator who receive a review within 3 months to discuss the risks and benefits of continuing anticoagulation therapy.
Denominator – the number of people who have received anticoagulation therapy following a confirmed diagnosis of proximal DVT or PE at least 3 months previously and who do not have cancer.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people without cancer who have had a confirmed proximal DVT or PE and receive anticoagulation therapy to be offered a review within 3 months to discuss the risks and benefits of continuing anticoagulation therapy beyond 3 months.
Healthcare professionals ensure people without cancer who have had a confirmed proximal DVT or PE and receive anticoagulation therapy are offered a review within 3 months of diagnosis to discuss the risks and benefits of continuing anticoagulation therapy.
Commissioners ensure they commission services that offer people without cancer who have had a confirmed proximal DVT or PE and receive anticoagulation therapy a review within 3 months to discuss the risks and benefits of continuing anticoagulation therapy.
People without cancer who have had deep vein thrombosis or pulmonary embolism and who are having treatment with an anticoagulant (a drug that helps stop blood clots forming or enlarging and makes it less likely that a blood clot will come loose and travel to the lungs) are offered a review within 3 months to discuss the risks and benefits of continuing treatment with an anticoagulant.

Source guidance references

NICE clinical guideline 144 recommendation 1.2.3.

Data source

Structure
Local data collection.
Process

Definition

Timing of review Healthcare professionals need to consider the summary of product characteristics to determine the timing of the review and duration of treatment required for the anticoagulant received.
Proximal DVT DVT in the popliteal vein or above; proximal DVT in this context refers to 'above-knee DVT'.

Follow-up for people with cancer

This quality statement is taken from the diagnosis and management of venous thromboembolic diseases quality standard. The quality standard defines clinical best practice in diagnosing and managing venous thromboembolic diseases in adults and should be read in full.

Quality statement

People with active cancer who receive anticoagulation therapy have a review within 6 months of confirmed diagnosis of proximal deep vein thrombosis (DVT) or pulmonary embolism (PE) to discuss the risks and benefits of continuing anticoagulation therapyAt the time this part of the pathway was created (June 2012) some types of LMWH did not have a UK marketing authorisation for 6 months of treatment of DVT or PE in patients with cancer. Prescribers should consult the summary of product characteristics for the individual LMWH and make appropriate adjustments for severe renal impairment or established renal failure. Informed consent for off-label use should be obtained and documented., Although this use is common in UK clinical practice, at the time this part of the pathway was created (June 2012) none of the anticoagulants had a UK marketing authorisation for the treatment of DVT or PE beyond 6 months in patients with cancer. Informed consent for off-label use should be obtained and documented..

Rationale

As anticoagulation therapy carries potential risks such as bleeding there is a need to ensure the therapy remains beneficial. For people who have had a confirmed diagnosis of proximal DVT or PE and who have cancer, a review should take place.

Quality measure

Structure
Evidence of local arrangements to ensure people with cancer who have had a confirmed proximal DVT or PE and who receive anticoagulation are reviewed within 6 months of diagnosis to discuss the risks and benefits of continuing anticoagulation therapy.
Process
The proportion of people with cancer who have had a confirmed proximal DVT or PE and receive anticoagulation who have a review within 6 months of diagnosis to discuss the risks and benefits of continuing anticoagulation therapy.
Numerator – the number of people in the denominator who receive a review within 6 months to discuss the risks and benefits of continuing anticoagulation therapy.
Denominator – the number of people who have received anticoagulation therapy following a confirmed diagnosis of proximal DVT or PE at least 6 months previously and who have a diagnosis of cancer.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with cancer who have had a confirmed proximal DVT or PE to be offered a review to discuss the risks and benefits of continuing anticoagulation therapy.
Healthcare professionals ensure people with cancer who have had a confirmed proximal DVT or PE are offered a review to discuss the risks and benefits of continuing anticoagulation therapy.
Commissioners ensure they commission services that offer people with cancer who have had a confirmed proximal DVT or PE a review to discuss the risks and benefits of continuing anticoagulation therapy.
People with cancer who have had deep vein thrombosis or pulmonary embolism and who are having treatment with an anticoagulant (a drug that helps stop blood clots forming or enlarging and makes it less likely that a blood clot will come loose and travel to the lungs) are offered a review to discuss the risks and benefits of continuing treatment with an anticoagulant.

Source guidance references

NICE clinical guideline 144 recommendation 1.2.2 (key priority for implementation).

Data source

Structure
Local data collection.
Process

Definition

Timing of review Healthcare professionals need to consider the summary of product characteristics to determine the timing of the review and duration of treatment required for the anticoagulant received.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Service improvement and audit

These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Supporting information

Glossary

Activated partial thromboplastin time
Body mass index
Computed tomography
Computed tomography pulmonary angiogram
Dabigatran etexilate
Deep vein thrombosis
Fondaparinux sodium
Hormone replacement therapy
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)
Inferior vena caval
Low molecular weight heparin
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
Pulmonary embolism
In the popliteal vein or above. Sometimes referred to as 'above-knee'
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)
Reduced renal function that may be acute or chronic. An estimated glomerular filtration rate (eGFR) < 90 ml/min/1.73 m2 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.
Estimated glomerular filtration rate (eGFR) < 30 ml/min/1.73 m2. 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.
Bedbound, unable to walk unaided or likely to spend a substantial proportion of the day in bed or in a chair
Unfractionated heparin
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
Vitamin K antagonist
Ventilaton/perfusion single photon emission computed tomography
Venous thromboembolism
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 guideline recommends the two-level DVT Wells score and the two-level PE Wells score.

Paths in this pathway

Pathway created: May 2011 Last updated: December 2014

© NICE 2014

Recently viewed