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Venous thromboembolism

About

What is covered

This interactive flowchart covers:
  • assessing and reducing the risk of venous thromboembolism in adults admitted to hospital
  • diagnosing venous thromboembolism in adults in primary, secondary and tertiary care, including Wells score, D-dimer measurement, ultrasound and radiological imaging
  • treating venous thromboembolism in adults
  • investigations for cancer and testing for thrombophilia in adults diagnosed with venous thromboembolism.
The recommendations on assessing and reducing risk do not cover the care and treatment that should be offered to:
  • people under the age of 18
  • people attending hospital as outpatients
  • people attending emergency departments who are not admitted to hospital
  • older people who are cared for at home or in residential care homes
  • people who are immobile and are cared for at home or in residential care homes
  • people who are admitted to hospital because they have a diagnosis or signs and symptoms of deep vein thrombosis or pulmonary embolism.
The recommendations on diagnosis and treatment do not apply to children or young people aged under 18, or women who are pregnant.

Updates

Updates to this interactive flowchart

20 March 2018 Recommendations amended in reducing venous thromboembolism risk in hospital patients in line with the update and replacement of NICE guideline CG92 on venous thromboembolism: reducing the risk for patients in hospital with NICE guideline NG89 on venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism.
26 April 2016 Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension (NICE interventional procedure guidance 554) added to mechanical interventions.
12 April 2016 Restructured, and summarised recommendations replaced with full recommendations. Updated statements for venous thromboembolism in adults: diagnosis and management (NICE quality standard 29) added.
24 November 2015 Recommendations in thrombolytic therapy and mechanical interventions amended in line with the update of NICE guideline CG144 on venous thromboembolic diseases in adults: diagnosis, management and thrombophilia testing.
25 August 2015 Edoxaban for treating and for preventing deep vein thrombosis and pulmonary embolism (NICE technology appraisal guidance 354) added to pharmacological interventions.
3 June 2015
  • Apixaban for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism (NICE technology appraisal guidance 341) added to pharmacological interventions.
  • Ultrasound-enhanced, catheter-directed thrombolysis for deep vein thrombosis (NICE interventional procedure guidance 523) and Ultrasound-enhanced, catheter-directed thrombolysis for pulmonary embolism (NICE interventional procedure guidance 524) added to thrombolytic therapy.
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.
2 July 2013 Rivaroxaban for treating pulmonary embolism and preventing recurrent venous thromboembolism (NICE technology appraisal guidance 287) added to pharmacological interventions.
28 March 2013 Venous thromboembolism in adults: diagnosis and management (NICE quality standard 29) added.
31 July 2012 Rivaroxaban for the treatment of deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary embolism (NICE technology appraisal guidance 261) added to pharmacological interventions.
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 Apixaban for the prevention of venous thromboembolism after total hip or knee replacement in adults (NICE technology appraisal guidance 245) added to elective hip or knee replacement.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on assessing, diagnosing, treating and reducing the risk of venous thromboembolism in adults in an interactive flowchart

What is covered

This interactive flowchart covers:
  • assessing and reducing the risk of venous thromboembolism in adults admitted to hospital
  • diagnosing venous thromboembolism in adults in primary, secondary and tertiary care, including Wells score, D-dimer measurement, ultrasound and radiological imaging
  • treating venous thromboembolism in adults
  • investigations for cancer and testing for thrombophilia in adults diagnosed with venous thromboembolism.
The recommendations on assessing and reducing risk do not cover the care and treatment that should be offered to:
  • people under the age of 18
  • people attending hospital as outpatients
  • people attending emergency departments who are not admitted to hospital
  • older people who are cared for at home or in residential care homes
  • people who are immobile and are cared for at home or in residential care homes
  • people who are admitted to hospital because they have a diagnosis or signs and symptoms of deep vein thrombosis or pulmonary embolism.
The recommendations on diagnosis and treatment do not apply to children or young people aged under 18, or women who are pregnant.

Updates

Updates to this interactive flowchart

20 March 2018 Recommendations amended in reducing venous thromboembolism risk in hospital patients in line with the update and replacement of NICE guideline CG92 on venous thromboembolism: reducing the risk for patients in hospital with NICE guideline NG89 on venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism.
26 April 2016 Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension (NICE interventional procedure guidance 554) added to mechanical interventions.
12 April 2016 Restructured, and summarised recommendations replaced with full recommendations. Updated statements for venous thromboembolism in adults: diagnosis and management (NICE quality standard 29) added.
24 November 2015 Recommendations in thrombolytic therapy and mechanical interventions amended in line with the update of NICE guideline CG144 on venous thromboembolic diseases in adults: diagnosis, management and thrombophilia testing.
25 August 2015 Edoxaban for treating and for preventing deep vein thrombosis and pulmonary embolism (NICE technology appraisal guidance 354) added to pharmacological interventions.
3 June 2015
  • Apixaban for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism (NICE technology appraisal guidance 341) added to pharmacological interventions.
  • Ultrasound-enhanced, catheter-directed thrombolysis for deep vein thrombosis (NICE interventional procedure guidance 523) and Ultrasound-enhanced, catheter-directed thrombolysis for pulmonary embolism (NICE interventional procedure guidance 524) added to thrombolytic therapy.
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.
2 July 2013 Rivaroxaban for treating pulmonary embolism and preventing recurrent venous thromboembolism (NICE technology appraisal guidance 287) added to pharmacological interventions.
28 March 2013 Venous thromboembolism in adults: diagnosis and management (NICE quality standard 29) added.
31 July 2012 Rivaroxaban for the treatment of deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary embolism (NICE technology appraisal guidance 261) added to pharmacological interventions.
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 Apixaban for the prevention of venous thromboembolism after total hip or knee replacement in adults (NICE technology appraisal guidance 245) added to elective hip or knee replacement.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Ultrasound-enhanced, catheter-directed thrombolysis for pulmonary embolism (2015) NICE interventional procedures guidance 524
Ultrasound-enhanced, catheter-directed thrombolysis for deep vein thrombosis (2015) NICE interventional procedures guidance 523
The geko device for reducing the risk of venous thromboembolism (2014) NICE medical technologies guidance 19
Venous thromboembolism in adults: diagnosis and management (2013 updated 2016) NICE quality standard 29
Venous thromboembolism in adults: reducing the risk in hospital (2010 updated 2018) NICE quality standard 3

Quality standards

Venous thromboembolism in adults: reducing the risk in hospital

These quality statements are taken from the venous thromboembolism in adults: reducing the risk in hospital quality standard. The quality standard defines clinical best practice in venous thromboembolism in adults: reducing the risk in hospital and should be read in full.

Quality statements

VTE and bleeding risk assessment

This quality statement is taken from the venous thromboembolism in adults: reducing the risk in hospital quality standard. The quality standard defines clinical best practice in preventing VTE and should be read in full.

Quality statement

Medical, surgical or trauma patients have their risk of VTE and bleeding assessed using a national tool as soon as possible after admission to hospital.

Quality measure

Structure: Evidence that medical, surgical and trauma patients have their risk of VTE and bleeding assessed using a national tool as soon as possible after admission to hospital.
Process: Proportion of medical, surgical and trauma patients who have their risk of VTE and bleeding assessed using a national tool as soon as possible after admission to hospital.
Numerator – the number in the denominator who have their risk of VTE and bleeding assessed using a national tool as soon as possible after admission to hospital.
Denominator – the number of medical, surgical or trauma patients admitted to hospital.

What the quality statement means for each audience

Service providers ensure that systems are in place for medical, surgical and trauma patients to be assessed for risk of VTE and bleeding using a national tool as soon as possible after admission.
Healthcare professionals assess medical, surgical and trauma patients for risk of VTE and bleeding using a national tool as soon as possible after admission.
Commissioners ensure services assess medical, surgical and trauma patients for risk of VTE and bleeding using a national tool as soon as possible after admission.
Medical, surgical and trauma patients have their risk of VTE and bleeding assessed using a national tool as soon as possible after they are admitted to hospital.

Definitions

This statement applies to medical, surgical and trauma 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 a national tool.
A national tool should be published by a national UK body, professional network or peer-reviewed journal. The most commonly used risk-assessment tool is the Department of Health and Social Care VTE risk assessment tool.

Data source

Structure: Local data collection.
Process: NHS England’s VTE risk assessment statistics.

Information about VTE prevention

This quality statement is taken from the venous thromboembolism in adults: reducing the risk in hospital quality standard. The quality standard defines clinical best practice in preventing VTE and should be read in full.

Quality statement

Patients who are at increased risk of VTE, are given information about VTE prevention on admission to hospital.

Quality measure

Structure: Evidence of patient information on VTE prevention being available to patients on admission to hospital.
Process: Proportion of patients who are at increased risk of VTE who are given information about VTE prevention on admission to hospital.
Numerator – the number in the denominator who are given information about VTE prevention on admission to hospital.
Denominator – the number of patients who are at increased risk of VTE.

What the quality statement means for each audience

Service providers ensure that systems are in place for patient information on VTE prevention to be given on admission to hospital.
Healthcare professionals give information about VTE prevention to patients at increased risk of VTE on admission to hospital.
Commissioners ensure services provide information about VTE prevention to patients at increased risk of VTE on admission to hospital.
Patients are given information about VTE prevention on admission to hospital if they are at risk of VTE.

Definitions

Verbal and written 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).

Data source

Structure: Local data collection.
Process: Local data collection and Admitted patient care commissioning data set.

Anti-embolism stockings

This quality statement is taken from the venous thromboembolism in adults: reducing the risk in hospital 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.

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.

Reassessment

This quality statement is taken from the venous thromboembolism in adults: reducing the risk in hospital quality standard. The quality standard defines clinical best practice in preventing VTE and should be read in full.

Quality statement

Medical, surgical and trauma patients have their risk of VTE reassessed at consultant review or if their clinical condition changes.

Quality measure

Structure: Evidence of local arrangements to ensure medical, surgical or trauma patients have their risk of VTE reassessed at consultant review or if their clinical condition changes.
Process: Proportion of medical, surgical and trauma patients who have their risk of VTE reassessed at consultant review or if their clinical condition changes.
Numerator – the number in the denominator who have their risk of VTE reassessed at consultant review or if their clinical condition changes.
Denominator – the number of medical, surgical and trauma patients.

What the quality statement means for each audience

Service providers ensure systems are in place for medical, surgical and trauma patients to have their risk of VTE reassessed at consultant review or if their clinical condition changes.
Healthcare professionals reassess the VTE risk of medical, surgical and trauma patients at consultant review or if clinical condition changes.
Commissioners ensure services reassess the VTE risk of medical, surgical and trauma patients at consultant review or if their clinical condition changes.
Medical, surgical and trauma patients have their risk of VTE and bleeding reassessed when they have a review with their specialist or if their condition changes.

Data source

Structure: Local data collection.
Process: Local data collection and Admitted patient care commissioning data set.

VTE prophylaxis

This quality statement is taken from the venous thromboembolism in adults: reducing the risk in hospital 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.

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 thromboprophlyaxis.
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 thromboprophlyaxis.

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 venous thromboembolism in adults: reducing the risk in hospital 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.

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.

Data source

Structure: Local data collection.
Process: Local data collection and Admitted patient care commissioning data set.

Extended VTE prophylaxis

This quality statement is taken from the venous thromboembolism in adults: reducing the risk in hospital 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.

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.

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

NICE guideline CG144 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 guideline CG144 clinical audit tool (diagnosis of deep vein thrombosis), standards 6 and 15.
Outcome
Local data collection.

Definitions

Suspected DVT NICE guideline CG144 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 guideline CG144 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.

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

NICE guideline CG144 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 guideline CG144 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 guideline CG144 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.

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

NICE guideline CG144 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
Local data collection. Contained within NICE guideline CG144 clinical audit tool (diagnosis of pulmonary embolism), standard 5.
Outcome
Local data collection.

Definitions

Suspected PE NICE guideline CG144 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 guideline CG144 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 has been removed. This change has been made because the source guidance for this statement (NICE's guideline on venous thromboembolic diseases: diagnosis, management and thrombophilia testing) was updated in November 2015 and the advice on using compression stockings has changed.

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.

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

NICE guideline CG144 recommendation 1.5.1.

Data source

Structure
Local data collection.
Process
Local data collection. Contained within NICE guideline CG144 clinical audit tool (treatment of venous thromboembolism and investigations for cancer), standard 5.
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.

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

NICE guideline CG144 recommendation 1.6.4.

Data source

Structure
Local data collection.
Process
Local data collection. Contained within NICE guideline CG144 clinical audit tool (thrombophilia testing), standard 2.

Definition

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.

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

NICE guideline CG144 recommendation 1.2.2 (key priority for implementation).

Data source

Structure
Local data collection.
Process
Local data collection. Contained within NICE guideline CG144 clinical audit tool (treatment of venous thromboembolism and investigations for cancer), standards 2a and 2b.
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.

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

NICE guideline CG144 recommendation 1.2.3.

Data source

Structure
Local data collection.
Process
Local data collection. Contained within NICE guideline CG144 clinical audit tool (treatment of venous thromboembolism and investigations for cancer), standard 3d.

Definitions

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.

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

NICE guideline CG144 recommendation 1.2.2 (key priority for implementation).

Data source

Structure
Local data collection.
Process
Local data collection. Contained within NICE guideline CG144 clinical audit tool (treatment of venous thromboembolism and investigations for cancer), standard 2c.

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

NICE has produced resources to help implement its guidance on:

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Intermittent pneumatic compression

A method of prophylaxis that includes an air pump and inflatable garments in a system designed to improve venous circulation in the lower limbs of people at risk of deep vein thrombosis or pulmonary embolism. The inflation-deflation cycle of intermittent pneumatic compression therapy simulates the thigh, calf and foot's normal ambulatory pump action increasing both the volume and rate of blood flow, eliminating venous stasis and replicating the effects of the natural muscle pump. Intermittent pneumatic compression devices can be thigh or knee length sleeves that are wrapped around the leg, or a garment that can be wrapped around or worn on the foot that is designed to mimic the actions of walking.
Consider regional anaesthesia for individual patients, in addition to other methods of VTE prophylaxis, as it carries a lower risk of VTE than general anaesthesia. Take into account the person's preferences, their suitability for regional anaesthesia and any other planned method of VTE prophylaxis.
If regional anaesthesia is used, plan the timing of pharmacological VTE prophylaxis to minimise the risk of epidural haematoma. If antiplatelet or anticoagulant agents are being used, or their use is planned, refer to the summary of product characteristics for guidance about the safety and timing of these in relation to the use of regional anaesthesia.
Do not routinely offer pharmacological or mechanical VTE prophylaxis to people undergoing a surgical procedure with local anaesthesia by local infiltration with no limitation of mobility.
For pharmacological VTE prophylaxis in people under 18, follow the recommendations on apixaban, aspirin, dabigatran etexilate, fondaparinux sodium, low-molecular-weight heparin (LMWH) and rivaroxaban in this flowchart.At the time of publication (March 2018), these drugs did not have a UK marketing authorisation for use in young people under 18 for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.
If using pharmacological VTE prophylaxis for surgical and trauma patients, start it as soon as possible and within 14 hours of admission, unless otherwise stated in the population-specific recommendations.
Diagnose DVT and treat patients with a positive proximal leg vein ultrasound scan (see treating venous thromboembolism).
For patients who have an allergy to contrast media, or who have renal impairment, or whose risk from irradiation is high:
  • Assess the suitability of a V/Q SPECT scan or, if a V/Q SPECT scan is not available, a V/Q planar scan, as an alternative to CTPA.
  • If offering a V/Q SPECT or planar scan that will not be available immediately, offer immediate interim parenteral anticoagulant therapy.
Diagnose PE and treat patients with a positive CTPA or in whom PE is identified with a V/Q SPECT or planar scan (see the recommendations on treatment).
Two-level DVT Wells scoreAdapted with permission from Wells PS et al. (2003) Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis.
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 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
Points
DVT likely
2 points or more
DVT unlikely
1 point or less
Clinical feature
Points
Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins)
3
An alternative diagnosis is less likely than PE
3
Heart rate > 100 beats per minute
1.5
Immobilisation for more than 3 days or surgery in the previous 4 weeks
1.5
Previous DVT/PE
1.5
Haemoptysis
1
Malignancy (on treatment, treated in the last 6 months, or palliative)
1
Clinical probability simplified score
Points
PE likely
More than 4 points
PE unlikely
4 points or less

Risk factors for bleeding

  • Active bleeding
  • Acquired bleeding disorders (such as acute liver failure)
  • Concurrent use of anticoagulants known to increase the risk of bleeding (such as warfarin with INR higher than 2)
  • Lumbar puncture/epidural/spinal anaesthesia expected within the next 12 hours
  • Lumbar puncture/epidural/spinal anaesthesia within the previous 4 hours
  • Acute stroke
  • Thrombocytopenia (platelets less than 75 x 109/l)
  • Uncontrolled systolic hypertension (230/120 mmHg or higher)
  • Untreated inherited bleeding disorders (such as haemophilia and von Willebrand's disease)
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.

Glossary

activated partial thromboplastin time
computed tomography pulmonary angiogram
(in these recommendations, 'discharge' refers to discharge from hospital as an inpatient or after a day procedure)
(in these recommendations, 'discharge' refers to discharge from hospital as an inpatient or after a day procedure)
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)
low molecular weight heparin
low molecular weight heparins
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)
an estimated glomerular filtration rate (eGFR) of less than 30 ml/min/1.73 m2. (For more detailed information on renal impairment, see what NICE says on chronic kidney disease in adults.)
estimated glomerular filtration rate of less than 30 ml/min/1.73m2
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
ventilation/perfusion single photon emission computed tomography
venous thromboembolism
a clinical prediction rule for estimating the probability of DVT or PE– there are a number of versions of Wells scores available; this guidance recommends the two-level DVT Wells score and the two-level PE Wells score

Paths in this pathway

Pathway created: May 2011 Last updated: March 2018

© NICE 2018. All rights reserved. Subject to Notice of rights.

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