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Venous thromboembolism

About

What is covered

This NICE Pathway covers:
  • assessing and reducing the risk of VTE in adults admitted to hospital
  • diagnosing VTE in adults in primary, secondary and tertiary care, including Wells score, D-dimer measurement, ultrasound and radiological imaging
  • treating VTE in adults
  • investigations for cancer and testing for thrombophilia in adults diagnosed with VTE.
The recommendations on assessing and reducing risk do not cover the care and treatment that should be offered to:
  • people under 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 DVT or PE.
The recommendations on diagnosis and treatment do not apply to people under 18, or women who are pregnant. They aim to support rapid diagnosis and effective treatment for people who develop DVT or PE. They cover testing for conditions that can make a DVT or PE more likely, such as thrombophilia (a blood clotting disorder) and cancer.

Updates

Updates to this NICE Pathway

19 August 2021 Venous thromboembolism in adults (NICE quality standard 201) added.
26 March 2020 Updated on publication of the update of venous thromboembolic diseases: diagnosis, management and thrombophilia testing (NICE guideline NG158).
11 June 2019 Percutaneous mechanical thrombectomy for acute deep vein thrombosis of the leg (NICE interventional procedure guidance 651) added.
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.
12 April 2016 Restructured, and summarised recommendations replaced with full recommendations.
25 August 2015 Edoxaban for treating and for preventing deep vein thrombosis and pulmonary embolism (NICE technology appraisal guidance 354) added.
3 June 2015
  • Apixaban for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism (NICE technology appraisal guidance 341) added.
  • 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.
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.
2 July 2013 Rivaroxaban for treating pulmonary embolism and preventing recurrent venous thromboembolism (NICE technology appraisal guidance 287) 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.
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 NICE Pathway covers:
  • assessing and reducing the risk of VTE in adults admitted to hospital
  • diagnosing VTE in adults in primary, secondary and tertiary care, including Wells score, D-dimer measurement, ultrasound and radiological imaging
  • treating VTE in adults
  • investigations for cancer and testing for thrombophilia in adults diagnosed with VTE.
The recommendations on assessing and reducing risk do not cover the care and treatment that should be offered to:
  • people under 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 DVT or PE.
The recommendations on diagnosis and treatment do not apply to people under 18, or women who are pregnant. They aim to support rapid diagnosis and effective treatment for people who develop DVT or PE. They cover testing for conditions that can make a DVT or PE more likely, such as thrombophilia (a blood clotting disorder) and cancer.

Updates

Updates to this NICE Pathway

19 August 2021 Venous thromboembolism in adults (NICE quality standard 201) added.
26 March 2020 Updated on publication of the update of venous thromboembolic diseases: diagnosis, management and thrombophilia testing (NICE guideline NG158).
11 June 2019 Percutaneous mechanical thrombectomy for acute deep vein thrombosis of the leg (NICE interventional procedure guidance 651) added.
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.
12 April 2016 Restructured, and summarised recommendations replaced with full recommendations.
25 August 2015 Edoxaban for treating and for preventing deep vein thrombosis and pulmonary embolism (NICE technology appraisal guidance 354) added.
3 June 2015
  • Apixaban for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism (NICE technology appraisal guidance 341) added.
  • 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.
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.
2 July 2013 Rivaroxaban for treating pulmonary embolism and preventing recurrent venous thromboembolism (NICE technology appraisal guidance 287) 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.
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 (2021) NICE quality standard 201

Quality standards

Quality statements

Timing of pharmacological venous thromboembolism prophylaxis

This quality statement is taken from the venous thromboembolism in adults quality standard. The quality standard defines clinical best practice for venous thromboembolism in adults and should be read in full.

Quality statement

People aged 16 and over who are in hospital and assessed as needing pharmacological venous thromboembolism (VTE) prophylaxis start it as soon as possible and within 14 hours of hospital admission.

Rationale

VTE risk assessments are carried out for most people admitted to hospital, but the results are not always acted on promptly, meaning that pharmacological prophylaxis can be delayed and the risk of hospital-acquired thrombosis increased. Ensuring that prophylaxis is started as soon as possible and within 14 hours of hospital admission for medical, surgical and trauma patients will reduce the chance of VTE.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured and can be adapted and used flexibly.
Structure
Evidence of arrangements to ensure that people aged 16 and over who are in hospital and assessed as needing pharmacological VTE prophylaxis start it as soon as possible and within 14 hours of hospital admission.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from service protocols and prescribing systems.
Process
Proportion of people aged 16 and over who are in hospital and assessed as needing pharmacological VTE prophylaxis who start it within 14 hours of hospital admission.
Numerator – the number in the denominator who start pharmacological VTE prophylaxis within 14 hours of hospital admission.
Denominator – the number of people aged 16 and over who are in hospital and assessed as needing pharmacological VTE prophylaxis.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.
Outcome
Rates of hospital-acquired thrombosis (HAT).
Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records. The Royal National Orthopaedic Hospital, NHS England and NHS Improvement’s GIRFT Thrombosis Survey includes the number of HAT cases.

What the quality statement means for different audiences

Service providers (secondary care services) ensure that written clinical protocols are in place so that people aged 16 and over who are in hospital and assessed as needing pharmacological VTE prophylaxis start it as soon as possible and within 14 hours of hospital admission. They also have clinical protocols on considering an adjusted dose of low molecular weight heparin (LMWH) for people who are at extremes of body weight or have impaired renal function. They ensure that they have healthcare professionals available to carry out the assessment and prescribing systems designed to start VTE prophylaxis within this timeframe.
Healthcare professionals (such as pharmacists, advanced nurse practitioners and doctors) prescribe pharmacological VTE prophylaxis to people aged 16 and over who are in hospital and assessed as needing pharmacological VTE prophylaxis. They discuss the medicine with the person and involve them in making decisions about it, and give them verbal and written information on the importance of using pharmacological VTE prophylaxis correctly and possible side effects. They make sure that the person starts treatment as soon as possible and within 14 hours of hospital admission. For people at extremes of body weight or with impaired renal function, they consider adjusting the dose of LMWH in line with the summary of product characteristics and locally agreed protocols.
Commissioners (clinical commissioning groups) ensure that services have written clinical protocols in place for people in hospital who are assessed as needing pharmacological VTE prophylaxis to start it as soon as possible and within 14 hours of hospital admission. They also ensure they have clinical protocols on considering an adjusted dose of LMWH for people who are at extremes of body weight or have impaired renal function. They ensure that services have healthcare professionals available to carry out the assessment and prescribing systems designed to start VTE prophylaxis within this timeframe.
People aged 16 and over who are in hospital and who need medicine to prevent blood clots start taking the medicine within 14 hours of being admitted to hospital. People who have a very low or high body weight or whose kidney function is impaired have the dose of medicine they are given adjusted. They discuss the medicine with a healthcare professional and make decisions about taking it. Their healthcare professional explains and gives them written information about how to use the medicine and any possible side effects.

Source guidance

Definition of terms used in this quality statement

People aged 16 and over who are in hospital
This includes medical, surgical and trauma patients. NICE’s guideline on venous thromboembolism in over 16s, sections 1.4 to 1.15, should be referred to for population-specific recommendations on different timings and types of pharmacological VTE prophylaxis. [NICE’s guideline on venous thromboembolism in over 16s, recommendations 1.1.4, 1.1.6 and 1.1.7]
Hospital admission
Admission as an inpatient, where a bed is provided for 1 or more nights, or admission as a day patient, where a bed is provided for a procedure including surgery or chemotherapy but not for an overnight stay. [NICE’s guideline on venous thromboembolism in over 16s, terms used in this guideline]

Equality and diversity considerations

The supporting information for this statement highlights that people should be given verbal and written information on using VTE prophylaxis correctly and the possible side effects. Information should be in a format that suits their needs and preferences. It should be accessible to people who do not speak or read English, and it should be culturally appropriate and age appropriate. For people with additional needs related to a disability, impairment or sensory loss, information should also be provided as set out in NHS England's Accessible Information Standard or the equivalent standards for the devolved nations.
Heparins are a type of pharmacological prophylaxis used to prevent VTE. They are of animal origin and this may be of concern to some people because of religious or ethical beliefs. The suitability, advantages and disadvantages of alternatives to heparin should be discussed with the person.

Venous thromboembolism risk assessment for people with lower limb immobilisation

This quality statement is taken from the venous thromboembolism in adults quality standard. The quality standard defines clinical best practice for venous thromboembolism in adults and should be read in full.

Quality statement

People aged 16 and over who are discharged with lower limb immobilisation are assessed to identify their risk of venous thromboembolism (VTE).

Rationale

A significant number of people are discharged after hospital treatment for trauma or orthopaedic surgery with temporary lower limb immobilisation. These people may have an increased risk of VTE, but may not have their VTE risk assessed if they are treated in the emergency department or as outpatients. Ensuring that they have a risk assessment will enable them to have VTE prophylaxis if needed and reduce their risk of VTE and mortality. It is also an opportunity to explain the risks of VTE from immobilisation to them.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured and can be adapted and used flexibly.
Structure
Evidence of written clinical protocols to ensure that people aged 16 and over who are discharged with lower limb immobilisation are assessed to identify their risk of VTE.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from service protocols.
Process
Proportion of people aged 16 and over who are discharged with lower limb immobilisation who are assessed to identify their risk of VTE.
Numerator – the number in the denominator who are assessed to identify their risk of VTE.
Denominator – the number of people aged 16 and over who are discharged with lower limb immobilisation.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.
Outcome
Rates of thrombosis.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.

What the quality statement means for different audiences

Service providers (secondary care services, such as orthopaedic departments, fracture clinics and emergency departments) ensure that written clinical protocols are in place so that people aged 16 and over who are discharged with lower limb immobilisation are assessed to identify their risk of VTE and to decide whether they need pharmacological VTE prophylaxis. They also have protocols on giving verbal and written information to people and their family members or carers about the signs and symptoms of VTE, how to reduce their risk of VTE and how to seek help if VTE is suspected, as well as the benefits and possible side effects of pharmacological VTE prophylaxis.
Healthcare professionals (such as doctors, allied health professionals, trauma teams and orthopaedic specialists) carry out a risk assessment for people aged 16 and over who are discharged with lower limb immobilisation to identify their risk of VTE and decide whether they need pharmacological VTE prophylaxis. They discuss the outcome of the assessment with the person and involve them in making decisions about pharmacological VTE prophylaxis if it is needed. They also give verbal and written information to people and their family members or carers about the signs and symptoms of VTE, how to reduce their risk of VTE and how to seek help if VTE is suspected, as well as the benefits and possible side effects of pharmacological VTE prophylaxis.
Commissioners (clinical commissioning groups) ensure that services have written clinical protocols in place so that people aged 16 and over who are discharged with lower limb immobilisation are assessed to identify their risk of VTE and to decide whether they need pharmacological VTE prophylaxis. They also ensure they have protocols on giving verbal and written information to people and their family members or carers about the signs and symptoms of VTE, how to reduce their risk of VTE and how to seek help if VTE is suspected, as well as the benefits and possible side effects of pharmacological VTE prophylaxis.
People aged 16 and over who have a limb that is affected in a way that means they are unable to bear weight on it when they are sent home from hospital (for example, with a leg in a plaster cast or splint) have an assessment to check whether they need to take medicine temporarily (until they can move their leg normally again) to prevent a blood clot developing. They discuss the result of the assessment with a healthcare professional and make decisions about taking the medicine if it is needed. Their healthcare professional explains and gives them written information about the signs and symptoms of blood clots, how to reduce their risk of getting a blood clot and what to do if they think they have one, as well as the benefits and possible side effects of medicine to prevent blood clots.

Source guidance

Definitions of terms used in this quality statement

Discharged with lower limb immobilisation
Discharged from the emergency department or from outpatient treatment with any clinical decision taken to temporarily manage the affected limb in a way that would prevent normal weight-bearing status or use of that limb, or both. [Adapted from NICE’s guideline on venous thromboembolism in over 16s, terms used in this guideline and expert opinion]

Equality and diversity considerations

Statement 2 highlights that people are given verbal and written information on the signs and symptoms of venous thromboembolism (VTE), how to reduce their risk of VTE and how to seek help if VTE is suspected. Information should be in a format that suits their needs and preferences. It should be accessible to people who do not speak or read English, and it should be culturally appropriate and age appropriate. For people with additional needs related to a disability, impairment or sensory loss, information should also be provided as set out in NHS England's Accessible Information Standard or the equivalent standards for the devolved nations.

Proximal leg vein ultrasound scan for a ‘likely’ deep vein thrombosis Wells score

This quality statement is taken from the venous thromboembolism in adults quality standard. The quality standard defines clinical best practice for venous thromboembolism in adults and should be read in full.

Quality statement

People aged 18 and over with a deep vein thrombosis (DVT) Wells score of 2 points or more have a proximal leg vein ultrasound scan within 4 hours of it being requested.

Rationale

People aged 18 and over with a suspected DVT need to have a proximal leg vein ultrasound scan quickly to diagnose or rule out a DVT so that treatment can be started promptly if needed. The scan should be done within 4 hours of the request to avoid unnecessary interim anticoagulation treatment and, if DVT is ruled out, alternative diagnoses can be investigated promptly.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured and can be adapted and used flexibly.
Structure
Evidence of the availability of staff to perform proximal leg vein ultrasound scans for people aged 18 and over with a DVT Wells score of 2 points or more within 4 hours of it being requested.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from staff rotas.
Process
Proportion of people aged 18 and over with a DVT Wells score of 2 points or more who have a proximal leg vein ultrasound scan within 4 hours of it being requested.
Numerator – the number in the denominator who have a proximal leg vein ultrasound scan within 4 hours of it being requested.
Denominator – the number of people aged 18 and over with a DVT Wells score of 2 points or more.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.
Outcome
Prescribing rates of interim therapeutic anticoagulation to prevent DVT.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from prescribing systems.

What the quality statement means for different audiences

Service providers (such as secondary care services) ensure that ultrasound scanning equipment and staff are available to perform proximal leg vein ultrasound scans for people aged 18 and over with a DVT Wells score of 2 points or more within 4 hours of the scan being requested. They ensure that written clinical protocols are in place so that, if it is not possible to have the scan result within 4 hours, people are offered a D dimer test, then interim therapeutic anticoagulation until the scan results are obtained (within 24 hours) and treatment is reviewed.
Healthcare professionals (such as GPs, specialists and nurses) are aware of referral pathways for proximal leg vein ultrasound scans, and refer people aged 18 and over with a DVT Wells score of 2 points or more to have this imaging. If it is not possible to obtain the scan result within 4 hours, they offer a D dimer test, then interim therapeutic anticoagulation and an ultrasound scan within 24 hours.
Commissioners (such as clinical commissioning groups) ensure that services have referral pathways and written clinical protocols in place so that people aged 18 and over with a DVT Wells score of 2 points or more can have a proximal leg vein ultrasound scan within 4 hours of it being requested, or within 24 hours if this is not possible. They also ensure that services have the equipment and capacity to perform this imaging within this timeframe.
People aged 18 and over who have signs and symptoms of a deep vein thrombosis (blood clot) and are referred for an ultrasound scan have the scan within 4 hours of the referral being made. If this is not possible, they are given the scan within 24 hours, and offered a blood test to measure a protein called D dimer, which can indicate whether there is a blood clot, and an anticoagulant (medicine to treat blood clots) to take while waiting for the scan.

Source guidance

Definition of terms used in this quality statement

DVT Wells score of 2 points or more
A ‘likely’ DVT Wells score, which is a score that predicts the probability of DVT for people with suspected DVT, estimated using the Wells clinical prediction rule:
Two-level DVT Wells score
Clinical feature
Points
Active cancer (treatment ongoing, within 6 months, or palliative)
1
Paralysis, paresis or recent plaster immobilisation of the lower extremities
1
Recently bedridden for 3 days or more, or major surgery within 12 weeks requiring general or regional anaesthesia
1
Localised tenderness along the distribution of the deep venous system
1
Entire leg swollen
1
Calf swelling at least 3 cm larger than asymptomatic side
1
Pitting oedema confined to the symptomatic leg
1
Collateral superficial veins (non-varicose)
1
Previously documented DVT
1
An alternative diagnosis is at least as likely as DVT
-2
Clinical probability simplified score
Points
Collateral superficial veins (non-varicose)
1
DVT likely
2 points or more
DVT unlikely
1 point or less

Equality and diversity considerations

NICE’s guideline on venous thromboembolic diseases covers people aged 18 and over because the evidence for the recommendations focused on this age group. This statement applies to people aged 18 and over, but clinical judgement should be used when treating people aged between 16 and 18 for suspected DVT.
Heparins are a type of anticoagulant used to prevent VTE. They are of animal origin and this may be of concern to some people because of religious or ethical beliefs. The suitability, advantages and disadvantages of alternatives to heparin should be discussed with the person.

Venous thromboembolism anticoagulation review

This quality statement is taken from the venous thromboembolism in adults quality standard. The quality standard defines clinical best practice for venous thromboembolism in adults and should be read in full.

Quality statement

People aged 18 and over taking anticoagulation treatment after a venous thromboembolism (VTE) have a review at 3 months and then at least once a year if they continue to take it long term.

Rationale

The benefits of anticoagulation treatment for VTE prevention become less certain over time, and after 3 months treatment needs to be reviewed and a decision made about whether to continue or stop treatment. Reviewing long-term anticoagulation treatment for people who decide to continue it beyond 3 months ensures that treatment is guided by the person's changing balance of benefits and risks, and changes in their preferences over time. At a review, the information, advice and support provided to people when they started having anticoagulation treatment should be reviewed and updated.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured and can be adapted and used flexibly.
Structure
a) Evidence of local systems to identify and invite people aged 18 and over, taking anticoagulation treatment after a VTE for a review at 3 months.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from service specifications.
b) Evidence of local systems to identify and invite people aged 18 and over taking long-term anticoagulation treatment after a VTE for a review at least once a year.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from service specifications.
Process
a) Proportion of people aged 18 and over taking anticoagulation treatment for 3 months after a VTE who have a review.
Numerator – the number in the denominator who have a review at 3 months.
Denominator – the number of people aged 18 and over taking anticoagulation treatment after a VTE.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.
b) Proportion of people aged 18 and over taking long-term anticoagulation treatment for secondary prevention of VTE who have a review at least once a year.
Numerator – the number in the denominator who had a review in the previous year.
Denominator – the number of people aged 18 and over taking long-term anticoagulation treatment for secondary prevention of VTE.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.

What the quality statement means for different audiences

Service providers (such as GP practices and secondary care services) ensure that local systems are in place to identify and invite people aged 18 and over taking anticoagulation treatment after a VTE for a review at 3 months and then at least once a year. They also ensure that staff have the time to carry out the reviews and that they review and update the information, advice and support given to people when they started having anticoagulation treatment.
Healthcare professionals (such as GPs, specialists and nurses) carry out a review for people aged 18 and over taking anticoagulation treatment after a VTE after 3 months of treatment to discuss the benefits and risks of continuing, stopping or changing the anticoagulant. They give people information about when their anticoagulation will next be reviewed. They also carry out a review for people taking long-term anticoagulation treatment for secondary prevention of VTE at least once a year to review general health, risk of VTE recurrence, bleeding risk, adherence, side effects and treatment preferences. They make sure that they review and update the information, advice and support given to people when they started having anticoagulation treatment.
Commissioners (such as clinical commissioning groups and NHS England) ensure that services have local systems in place to identify and invite for review people aged 18 and over taking anticoagulation treatment after a VTE at 3 months after starting treatment and adults taking long-term anticoagulation treatment for secondary prevention of VTE at least once a year. They also ensure that services have the capacity to carry out the reviews and to review and update the information, advice and support given to people when they started having anticoagulation treatment.
People aged 18 and over who have had a blood clot and are taking an anticoagulant (medicine to prevent another blood clot) have a review at 3 months to discuss whether to continue or stop taking the anticoagulant, or change to a different anticoagulant. If they continue the anticoagulant, they have a review at least once a year. The information, advice and support they were given when they started having anticoagulation treatment is reviewed and updated, and they are also given information about when their treatment reviews will be scheduled.

Source guidance

Definitions of terms used in this quality statement

Review at 3 months
A review after 3 months of anticoagulation treatment to assess and discuss the benefits and risks of continuing, stopping or changing the anticoagulant with the person having treatment, and to review and update the information, advice and support given when they started having anticoagulation treatment. [Adapted from NICE’s guideline on venous thromboembolic diseases, recommendation 1.4.1 and expert opinion].
Review at least once a year
A review of general health, risk of VTE recurrence, bleeding risk and treatment preferences and to review and update the information, advice and support given when they started treatment for people taking long-term anticoagulation treatment. [Adapted from NICE’s guideline on venous thromboembolic diseases, recommendation 1.4.12]

Equality and diversity considerations

NICE’s guideline on venous thromboembolic diseases covers people aged 18 and over because the evidence for the recommendations focused on this age group. This statement applies to people aged 18 and over, but clinical judgement should be used when treating people aged under 18 taking anticoagulation treatment after a VTE.
Information given to people should be in a format that suits their needs and preferences. The reviews should be accessible to people who do not speak or read English, and it should be culturally appropriate and age appropriate. For people with additional needs related to a disability, impairment or sensory loss, information should also be provided as set out in NHS England's Accessible Information Standard or the equivalent standards for the devolved nations.
Heparins are a type of anticoagulant used to treat VTE. They are of animal origin and this may be of concern to some people because of religious or ethical beliefs. The suitability, advantages and disadvantages of alternatives to heparin should be discussed with the person.

Follow-up for outpatients with low-risk pulmonary embolism

This quality statement is taken from the venous thromboembolism in adults quality standard. The quality standard defines clinical best practice for venous thromboembolism in adults and should be read in full.

Quality statement

People aged 18 and over having outpatient treatment for suspected or confirmed low-risk pulmonary embolism (PE) have an agreed plan for monitoring and follow-up.

Rationale

Having clear arrangements for monitoring and follow up for outpatients ensures that they receive the same quality of care from secondary care services as inpatients. Patients should have a written plan that makes them aware of signs to look out for and how and when to get help when needed. This will help to ensure that people having outpatient treatment for suspected or confirmed PE act in a timely manner before things worsen. Specialist services with expertise in thrombosis may not be available at all times, so it is important that the plan also includes information about who they can contact if they need advice outside normal service hours.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured and can be adapted and used flexibly.
Structure
a) Evidence of local arrangements to ensure that people aged 18 and over having outpatient treatment for suspected or confirmed low-risk PE have an agreed plan for monitoring and follow-up.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from service specifications or local protocols.
b) Evidence that information is available for people aged 18 and over having outpatient treatment for suspected or confirmed low-risk PE on symptoms and signs to look out for, and contact information for healthcare professionals they can discuss concerns with.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from information leaflets.
Process
Proportion of people aged 18 and over having outpatient treatment for suspected or confirmed low-risk PE who have an agreed plan for monitoring and follow-up.
Numerator – the number in the denominator who have an agreed plan for monitoring and follow-up.
Denominator – the number of people aged 18 and over having outpatient treatment for suspected or confirmed low-risk PE.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.
Outcome
Rates of emergency admissions to hospital for people aged 18 and over having outpatient treatment for low-risk PE.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from case records.

What the quality statement means for different audiences

Service providers (such as secondary care services) ensure that healthcare professionals have the time and resources to discuss and agree a plan for monitoring and follow up with people having outpatient treatment for suspected or confirmed low-risk PE.
Healthcare professionals (such as specialists, specialist nurses and allied health professionals) discuss and agree a plan for monitoring and follow up with people having outpatient treatment for suspected or confirmed low-risk PE. They provide them with written information on symptoms and signs to look out for, direct contact details of a healthcare professional or team with expertise in thrombosis to discuss concerns with, and information about out-of-hours services they can contact when their secondary care healthcare team is not available. They should provide adequate information to enable people to make an informed decision about outpatient management.
Commissioners (such as clinical commissioning groups) ensure that services have the capacity and resources to discuss and agree a plan for monitoring and follow up with people having outpatient treatment for suspected or confirmed low-risk PE.
People who are having outpatient treatment for a pulmonary embolism are given written information on signs and symptoms they should look out for and who to contact if they need help or advice, including out-of-hours services.

Source guidance

Definition of terms used in this quality statement

Agreed plan for follow-up
A plan for follow up that is agreed with the person having outpatient treatment for suspected or confirmed low-risk PE. They should be given:
  • written information on symptoms and signs to look out for, including the potential complications of thrombosis and of treatment
  • direct contact details of a healthcare professional or team with expertise in thrombosis who can discuss any new symptoms or signs, or other concerns
  • information about out-of-hours services they can contact when their healthcare team is not available.

Equality and diversity considerations

NICE’s guideline on venous thromboembolic diseases covers people aged 18 and over as the evidence for the recommendations focused on this age group. This statement applies to people aged 18 and over, but clinical judgement should be used when treating people aged under 18 having outpatient treatment for suspected or confirmed low-risk PE.
Statement 5 highlights that people are given written information on symptoms and signs to look out for, including the potential complications of thrombosis and of treatment. Information should be in a format that suits their needs and preferences. It should be accessible to people who do not speak or read English, and it should be culturally appropriate and age appropriate. For people with additional needs related to a disability, impairment or sensory loss, information should also be provided as set out in NHS England's Accessible Information Standard or the equivalent standards for the devolved nations.

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Implementation

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

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.

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)

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.
For pharmacological VTE prophylaxis in people under 18, follow the recommendations on apixaban, aspirin, dabigatran etexilate, fondaparinux sodium, LMWH and rivaroxaban in this guidance. In March 2018, the use of these drugs in young people under 18 was off label. See prescribing medicines at NICE website.
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 people with a positive proximal leg vein ultrasound scan:
For people with symptomatic iliofemoral DVT see thrombolytic therapy for symptomatic iliofemoral DVT.
When offering D-dimer testing for suspected DVT or PE, consider a point-of-care test if laboratory facilities are not immediately available.
If using a point-of-care D-dimer test, choose a fully quantitative test.
When using a point-of-care or laboratory D-dimer test, consider an age-adjusted D-dimer test threshold for people aged over 50.
If PE is identified by CTPA, V/Q SPECT or V/Q planar scan:
For people with PE and haemodynamic instability see thrombolytic therapy for PE with haemodynamic instability.
2-level DVT Wells score
Clinical feature
Points
Active cancer (treatment ongoing, within 6 months, or palliative)
1
Paralysis, paresis or recent plaster immobilisation of the lower extremities
1
Recently bedridden for 3 days or more, or major surgery within 12 weeks requiring general or regional anaesthesia
1
Localised tenderness along the distribution of the deep venous system
1
Entire leg swollen
1
Calf swelling at least 3 cm larger than asymptomatic side
1
Pitting oedema confined to the symptomatic leg
1
Collateral superficial veins (non-varicose)
1
Previously documented DVT
1
An alternative diagnosis is at least as likely as DVT
−2
Clinical probability simplified score
Points
DVT likely
2 points or more
DVT unlikely
1 point or less
Adapted with permission from Wells et al. (2003) Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis.
2-level PE Wells score
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 more than 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

Provoked deep vein thrombosis or pulmonary embolism

DVT or PE in a person with a recent (within 3 months) and transient major clinical risk factor for VTE, such as 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 person who is having hormonal therapy (combined oral contraceptive pill or HRT).

Unprovoked deep vein thrombosis or pulmonary embolism

DVT or PE in a person with no recent major clinical risk factor for VTE who is not having hormonal therapy (combined oral contraceptive pill or HRT).
If possible, choose an interim anticoagulant that can be continued if DVT or PE is confirmed. In March 2020, DOACs and some LMWHs were off label for the treatment of suspected DVT or PE. See prescribing medicines at NICE website.
When using interim therapeutic anticoagulation for suspected proximal DVT or PE:
  • carry out baseline blood tests including full blood count, renal and hepatic function, PT and APTT
  • do not wait for the results of baseline blood tests before starting anticoagulation treatment
  • review, and if necessary act on, the results of baseline blood tests within 24 hours of starting interim therapeutic anticoagulation.
Consider outpatient treatment for suspected or confirmed low-risk PE, using a validated risk stratification tool to determine the suitability of outpatient treatment.
Agree a plan for monitoring and follow-up with people having outpatient treatment for suspected or confirmed low-risk PE. Give them:
  • written information on symptoms and signs to look out for, including the potential complications of thrombosis and of treatment
  • direct contact details of a healthcare professional or team with expertise in thrombosis who can discuss any new symptoms or signs, or other concerns
  • information about out-of-hours services they can contact when their healthcare team is not available.

Glossary

(receiving active antimitotic treatment, or diagnosed within the past 6 months, or recurrent or metastatic, or inoperable: excludes squamous skin cancer and basal cell carcinoma)
activated partial thromboplastin time
computed tomography pulmonary angiogram
direct-acting oral anticoagulants
direct-acting oral anticoagulant
(in this guidance, 'discharge' refers to discharge from hospital as an inpatient or after a day procedure)
(in this guidance, '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))
inferior vena caval
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')
(deep vein thrombosis at or above the level of the popliteal trifurcation area)
prothrombin time
(an estimated glomerular filtration rate (eGFR) of less than 30 ml/min/1.73 m2 – for more detailed information on renal impairment, see the NICE Pathway 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
vitamin K antagonist
ventilation/perfusion single photon emission computed tomography
venous thromboembolism
(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 2-level DVT Wells score and the 2-level PE Wells score)

Paths in this pathway

Pathway created: May 2011 Last updated: August 2021

© NICE 2021. All rights reserved. Subject to Notice of rights.

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