1
This document has been reviewed in line with the Policy Alignment Process for Liverpool Community
Health NHS Trust Services. It is a valid Mersey Care document, however due to organisational
change this FRONT COVER has been added so the reader is aware of any changes to their role or to
terminology which has now been superseded. When reading this document please take account
of the changes highlighted in Part B and C of this form.
Part A – Information about this Document
Policy Name DVT and VTE Management Policy
Policy Type Board Approved (Trust-wide) ☐ Trust-wide ☐ Divisional / Team / Locality ☒
Action No Change
☐ Minor Change
☒ Major Change
☐ New Policy
☐ No Longer Needed
☐
Approval
As Mersey Care’s Executive Director / Lead for this document, I confirm that this document: a) complies with the latest statutory / regulatory requirements, b) complies with the latest national guidance, c) has been updated to reflect the requirements of clinicians and officers, and
d) has been updated to reflect any local contractual requirements
Signature: Date: 14.12.18
Part B – Changes in Terminology (used with ‘Minor Change’, ‘Major Changes’ & ‘New Policy’ only)
Terminology used in this Document New terminology when reading this Document
Liverpool Community Health NHS Trust Mersey Care NHS Foundation Trust- Community Division
Part C – Additional Information Added (to be used with ‘Major Changes’ only)
Section /
Paragraph No
Outline of the information that has been added to this document – especially where it may
change what staff need to do
Part D – Rationale (to be used with ‘New Policy’ & ‘Policy No Longer Required’ only)
Part E – Oversight Arrangements (to be used with ‘New Policy’ only)
Accountable Director
Recommending Committee
Approving Committee
Next Review Date February 2020
LCH Policy Alignment Process – Form 1
Policy Number 131
Please explain why this new document needs to be adopted or why this document is no longer required
2
Policy Number -131
SUPPORTING STATEMENTS
This document should be read in conjunction with the following statements:
SAFEGUARDING IS EVERYBODY’S BUSINESS
All Mersey Care NHS Foundation Trust employees have a statutory duty to safeguard and
promote the welfare of children and adults, including:
being alert to the possibility of child / adult abuse and neglect through their observation of
abuse, or by professional judgement made as a result of information gathered about the
child / adult;
knowing how to deal with a disclosure or allegation of child / adult abuse;
undertaking training as appropriate for their role and keeping themselves updated;
being aware of and following the local policies and procedures they need to follow if they
have a child / adult concern;
ensuring appropriate advice and support is accessed either from managers, Safeguarding
Ambassadors or the trust’s safeguarding team;
participating in multi-agency working to safeguard the child or adult (if appropriate to your
role);
ensuring contemporaneous records are kept at all times and record keeping is in strict
adherence to Mersey Care NHS Foundation Trust policy and procedures and professional
guidelines. Roles, responsibilities and accountabilities, will differ depending on the post you
hold within the organisation;
ensuring that all staff and their managers discuss and record any safeguarding issues that
arise at each supervision session
EQUALITY AND HUMAN RIGHTS
Mersey Care NHS Foundation Trust recognises that some sections of society experience
prejudice and discrimination. The Equality Act 2010 specifically recognises the protected
characteristics of age, disability, gender, race, religion or belief, sexual orientation and
transgender. The Equality Act also requires regard to socio-economic factors including
pregnancy /maternity and marriage/civil partnership.
The trust is committed to equality of opportunity and anti-discriminatory practice both in the
provision of services and in our role as a major employer. The trust believes that all people
have the right to be treated with dignity and respect and is committed to the elimination of
unfair and unlawful discriminatory practices.
Mersey Care NHS Foundation Trust also is aware of its legal duties under the Human Rights
Act 1998. Section 6 of the Human Rights Act requires all public authorities to uphold and
promote Human Rights in everything they do. It is unlawful for a public authority to perform any
act which contravenes the Human Rights Act.
Mersey Care NHS Foundation Trust is committed to carrying out its functions and service
delivery in line the with a Human Rights based approach and the FREDA principles of
3
Policy Number -131
Fairness, Respect, Equality Dignity, and Autonomy
4
Policy Number -131
Policy for the Referral Diagnosis and Treatment of New Venous Thromboembolism (VTE)/Deep
Venous Thrombosis (DVT) within Liverpool Community Health
(LCH) Adult services
5
Policy Number -131
Version Number V2
Reference Number 131
Ratified by Clinical Standards Group
Date of Approval: (Original Version)
27th February 2018
Name of originator/author Clinical Nurse Manager and Nurse Clinician
Approving Body /
Committee Clinical Standards Group
Date issued: (Current Version)
February 2018
Review date: (Current Version)
February 2020
Target audience LCH Patient Services
Name of Lead Director / Managing Director
Deputy Director of Nursing
Changes / Alterations Made To Previous Version (including date of changes)
This is a combination of both the Policy for the Diagnosis and Treatment of New Venous Thromboembolism (VTE) within Liverpool Community Health (LCH) Adult Services and the Clinical Policy for the Management of a DVT in Patients who attend Liverpool Walk-In Centres.
Key individuals involved in developing the document
Name Designation
Liz Norris Clinical Nurse Manager
Margaret Carran Nurse Clinician Ambulatory Care and Diagnostics
Tracey Carver Clinical Lead, South Locality
This document was circulated to the following individuals for consultation
Name Designation
Alan Martin Call handler/Referral Management Advisor
6
Policy Number -131
Contents
Section Page
1 Introduction 4
2 Policy Statement 5
3 Status 5
4 Purpose 5
5 Scope 6
6 Duties 6
7 Definitions 8
8 Policy 9
9 Training 13
10 Implementation 13
11 Monitoring 13
12 Equality Analysis 14
13 Linked areas / Information 15
14 Relevant Legislation / Statutory requirements 15
15 References & Bibliography 16
Appendix 1 GP/Health professional referral pathway
17
Appendix 2 SPC DVT criteria 18
Appendix 3 DVT suspected LCH WIC flow chart 19
Appendix 4 Two level DVT WELLS 20
Appendix 5 SOP undertaking D-Dimer 21
Appendix 6 Ultrasound referral pathway 24
Appendix 7 Ultrasound request form 25
Appendix 8 Ultrasound patient information sheet 26
Appendix 9 DVT referral checklist 27
Appendix 10 NICE/RLBGUH Algorithm for diagnosis and management DVT 28
Appendix 11 LBGUHT AMU outpatient management and algorithm for DVT 29
Policy Number LCH-131
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Introduction
Venous Thrombolytic Embolism (VTE) is a condition in which a blood clot (a
thrombus) forms in a vein. It most commonly occurs in the deep veins of the legs
this is called deep vein thrombosis (DVT). or the pelvis; The thrombus may
dislodge from its site of origin to travel in the blood - a phenomenon called
embolism the most serious of which is a pulmonary embolism (PE) when it lodges in
a blood vessel (artery) in the lung it can cause damage to the lung if the clot is large
enough it could stops blood flow to the lung which can be deadly
DVT has a annual incidence is about 1 in 1000 people only about a third of people
with a clinical suspicion of DVT have the condition.
National institute of health care and excellence have a pathway for diagnosis and
subsequent management in primary secondary and tertiary care
https://pathways.nice.org.uk/pathways/venous-
thromboembolism#path=view%3A/pathways/venous-thromboembolism/diagnosing-
venous-thromboembolism-in-primary-secondary-and-tertiary-care.xml&content=view-
index.
This document sets out Liverpool Community Health`s (LCH) system for diagnosis of
suspected Venous Thromboembolism (VTE) and treatment of patients for whom
VTE is confirmed. This policy provides a robust framework to ensure a consistent
approach across LCH and also supports our statutory duties as set out in the NHS
Constitution (2012).
Liverpool Walk-In Centers (LWIC) is a nurse led service that leads on the DVT
Service provided by Liverpool Community Health NHS Trust (LCH) in collaboration
with the Royal Liverpool and Broadgreen University Hospital Trust (RLBUHT) have
a pathway in place for all patients who are registered with a Liverpool GP .
This service aims to provide same day assessments, investigation and diagnosis or
exclusion of a DVT for patients on a daily basis from, 8am-19:30pm
The service is also available at weekends and on Bank Holidays. However, the
ultrasound service is not available during these periods but treatment will be
provided for patients who are suspected to have a DVT.
Policy Number LCH-131
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2. Policy Statement
This policy is intended to assist with the reduction in fatal pulmonary emboli by a
providing a standardised and evidence based approach into the timely identification
of a suspected VTE and early identification and management of suspected DVT
3. Status
This is a clinical policy document for use within Liverpool Community Health NHS
Trust (LCH).
4. Purpose
The purpose of this Policy is to ensure the risk to patient safety is reduced through
adherence to national VTE prevention strategy, ensuring compliance to NICE
guidance.
Implementation of this policy will ensure that:
All patients under the care of LCH services, presenting with signs and
symptoms of a possible VTE will be investigated in a timely manner.
All patients who have a suspected DVT will be managed according to current
NICE guidance and clinical evidence base.
Assists with the reduction in fatal VTE
Provide comprehensive guidance to all Nurse Practitioners working within this
policy
That appropriate referral pathways and process are in place in order to
facilitate early recognition and identification of a potential lower limb DVT
The is collaborative working with the Royal Liverpool and Broadgreen
University Hospital Trust Acute Medical Unit (AMU) to investigate patients
with suspected DVT of the leg
Supports the reduction of access to secondary care emergency services and
provide a comprehensive service for patients in the Liverpool community
Healthcare professionals, both temporary and permanent, are expected to take the
policy fully into account when exercising their clinical judgment. However, this policy
does not override the individual responsibility of healthcare professionals to make
decisions appropriate to the circumstances of the individual patient, in consultation
Policy Number LCH-131
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with the patient and/or guardian /carer.
5. Scope
This policy applies to all the staffing groups involved in patients care across
LCH.
Community Matrons
General Practitioners, Nurse Practitioners, Advanced Nurse Practitioner
Intensive Community Care Team (ICCT)
Walk in Centres
6. Duties
6.1 Duties within LCH
The following general (statutory) duties apply:
All LCH staff are responsible for co-operating with the development and
implementation of Trust policies as part of their normal duties and responsibilities.
All other personnel will be expected to comply with the requirements of all relevant
Trust policies applicable to their area of operation.
6.2 Role of Chief Executive
The Chief Executive is ultimately responsible for the content of all organisation wide
procedural documents and their implementation
6.3 Role of General Practitioner/Advanced Nurse Practitioner/Community
Matron within community settings
The general practitioners, advanced nurse practitioners and community matron
within community settings are responsible for;
Performing a clinical assessment of all patients presenting or being referred,
with symptoms of VTE/DVT.
Referring the patient through Single Point of Contact to the appropriate health
care service for investigation. The appropriate service may be secondary care
Policy Number LCH-131
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or the walk in centre, and will be sign-posted by the Single Point of Contact
(SPC).
Reviewing the patient if a diagnosis of DVT is excluded, for possible
alternative conditions/diagnosis.
6.4 Role of Nursing Lead for community settings
The Nursing Lead is responsible for:
Dissemination of this policy
Ensuring staff are kept up to date in any training needs associated with this
policy
Ensuring that nursing staff comply with this policy
6.5 Role of the Single Point of Contact
The Single Point of Contact is responsible for :-
Facilitating the clinical triage of patient referrals into the appropriate primary or
secondary healthcare facility.
Applying criteria on the suitability for the patient to be managed within the
WIC’s (Appendix 2)
6.6 Role of Harm Free Lead for VTE
The Nursing Lead is responsible for:
Dissemination of this policy
Ensuring staff are kept up to date in any training needs associated with this
policy
Ensuring that nursing staff comply with this policy
6.7 Service Manager and Clinical Nurse Managers for Liverpool Walk-In Centres.
Are responsible for the implementation of the policy and service delivery of the initial diagnostic testing and further management pathway
That all staff involved in the delivery of the DVT pathway will be made aware of this policy on commencement to post and as part of their LWIC’s local induction process
Policy Number LCH-131
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6.8 Nurse Practitioners Liverpool WIC
Those practitioners within WIC that offer DVT
Are responsible in ensuring they have undertaken and update the relevant
training
Follow the relvent processess/pathways and procedures in place appopriate to
patients presenting with suspected VTE/DVT
Perform clinical assessment as outlined within this policy
7. Definitions
Deep Vein Thrombosis – (DVT) is a formation of a thrombus (blood clot)
in a deep vein, usually of the lower limbs. Blood flow in the vein is partially
or completely obstructed.
Patient Group Direction – (PGD) for supply / administration of medication
within a clinical pathway for management of a suspected DVT.
Wells Score – is a risk predicter score for the possibility of DVT.
D-Dimer – is a type of blood test that may determine the presence of a
DVT but can be raised in other conditions that cause abnormal clot
formation and breakdown.
Ultrasound Scan: Doppler ultrasound scan is a test that uses reflected
sound waves to evaluate blood as it flows through a blood vessel.
DVT Pathway – is a guide on the patient’s journey from the GP to Old
Swan Walk-In Centre from diagnosis to possible treatment.
Provoked VTE: A provoked VTE is a clot that develops in a patient with an
antecedent (within 3 months) and transient major clinical risk factor for VTE
– 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).
Unprovoked VTE: An unprovoked VTE is a clot that develops in a patient
with:-No antecedent major clinical risk factor for VTE (see 'Provoked deep
vein thrombosis or pulmonary embolism' above) who is not having
Policy Number LCH-131
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hormonal therapy (oral contraceptive or hormone replacement therapy) or
Active cancer, thrombophilia or a family history of VTE, because these are
underlying risks that remain constant in the patient
Policy
8. Recognizing VTE
VTE occurs with a broad range of clinical symptoms from asymptomatic calf vein
thrombosis to life-threatening, acute, massive PE. Classically DVT produces pain
and oedema in the affected limb. However, patients can show no symptoms,
conversely they maybe unilateral or bilateral. Patients with PE also rarely present
with the classical symptoms of abrupt onset pleuritic chest pain, shortness of
breath and hypoxia. In fact studies of patients having died from PE, often show
complaints of nagging symptoms for weeks prior to death.
Consider the possibility of VTE in a person with any of the clinical features,
particularly if they also have a risk factor and an alternative diagnosis is unlikely.
Clinical features of deep vein thrombosis may
include; Pain and swelling
Tenderness
Changes to skin colour and temperature
Vein distension
Clinical features of pulmonary embolism may include:
New or worsening breathlessness, particularly if it was sudden in onset.
Tachypnoea (respiratory rate of 20 breaths or more per minute).
Chest pain, which may be pleuritic, or retrosternal and angina-like.
Tachycardia (heart rate greater than 100 beats per minute). Haemoptysis.
Syncope.
Hypotension (systolic blood pressure less than 90 mmHg).
Crepitation’s.
Cough or fever may also be present but are too non-specific to be helpful.
Policy Number LCH-131
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Risk factors for the development of VTE include (list not fully inclusive);
Venous stasis
Hypercoagulable states
Immobilisation, due to hospitalisation, stroke, paresis or paralysis
Surgery and trauma, particularly to lower extremities and pelvis, in the last
three months
Pregnancy
Oral contraceptives and oestrogen replacement Malignancy, especially lung
cancer
Hereditary factors resulting in a hypercoagulable state
Acute medical illness
Drug abuse (intravenous drugs) Haemolytic anaemias
Heparin associated thrombocytopenia
Varicose veins
Travel of 4 hours or more in the past month Current or past history of
thrombophlebitis Smoking
Previous history of VTE
8.1 Procedure to be followed if VTE suspected within
Community Services
All patients presenting with signs and symptoms of venous thromboembolism
(Clinical or worsening signs of suspected PE as above 999) should be
referred to an Advanced Nurse Practitioner/Community Matron /General
Practitioner in order to:
Take a full clinical history and clinical examination with the aim of
detecting underlying conditions contributing to the development of
thrombosis and assessing suitability for antithrombotic therapy.
Assess if provoked or unprovoked in order to identify if further investigations
needed
Clinical assessment should also consider likely alternative
diagnosis.
Policy Number LCH-131
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Patients with suspected VTE should be referred through the Single Point
of Contact to either Liverpool Walk in or Secondary Care (Appendix 1).
LCH only have pathway in place for the diagnosis and management of VTE in lower
limbs (DVT) in place and if VTE is suspected elsewhere they should be admitted
into secondary care for further assessment
8.2 Procedure to be followed if patient is referred into or presents with
suspected DVT into Liverpool WIC
A DVT Pathway has been put in place in collaboration with the RLBUHT and SPC
for all patients who have a GP registered in the Liverpool area.
The pathway provides same day assessments, investigation and diagnosis or
exclusion of a DVT for patients with a Liverpool GP attending LWIC on a daily basis
from. 8am-19:30pm
The service is also available at weekends and on Bank Holidays. However, the
ultrasound service is not available during these periods but treatment will be
provided for patients who are suspected to have a DVT
Process
The nursing staff will assess the patient and plan care according to the DVT
pathway /Flowchart Appendix 3 .
The staff will take a blood sample for a D-dimer according to the DVT pathway
following the WIC DVT standard operating procedure (Appendix 5 ).
Negative D-Dimer
D Dimer is negative there is no indication of DVT if GP or practitioner assessing
patient has a differential diagnosis , the patient will be managed as the differential
diagnosis. If there is no differential dignosis the patient is referred back to the GP
for further assessment.
Postive D-Dimer
If the D-dimer is positive staff should follow the DVT pathway (Appendix 3) on
referrals to the RLBUHT Ultrasound Department.
Policy Number LCH-131
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All patients must be given a copy of the information sheet (Appendix 8 and a
letter which provides them with the contact details of the Ultrasound Department
appendix .
D-dimer machine is changed every Tuesday on weekly basis by point of care
RLBGUHT under a service level agreement
If the D-Dimer is found not to be operational the practitioner will contact the point
of care and a replacement will be sent .
D-D imer unavalible
The following procedure applies:
Inform AMU that the machine is unavailable; however, LWIC’s will continue to
provide a service.
Review the Wells Score of the patient; if ≤1, the patient is referred to AMU. A
blood sample is to be transferred to RLBUHT with the patient whenever
feasible. The patient’s blood sample is analysed by the laboratory and AMU
will take over the care of the patient.
If the Wells score is 2 or above, treat the patient and refer for next available
ultrasound appointment.
This is to prevent the ultrasound being blocked with potentially negative DVT
patients.
Ultrasound
Ultrasound uses reflective sound waves to identify blood clots within the veins
and all patients with postive D-Dimer will be sent for this assessment using the
ultrasound referal pathway (Appendix 6 )
If the ultrasound is not available within 4 hours patients should be prescribed and
administered with Dalteparin s/c via the Dalteparin PGD. If the patient attends a
LWIC on a Friday and the ultra sound appointment is not available until the
following Monday the patient will return daily with a 24 hour gap for Dalteparin via
the PGD guidelines. The patient will be provided with all the relevant
documentation to take to the Ultrasound Department.
If the ultrasound is positive, the patient will be managed by the Acute
Medical Unit (AMU) using LBGUHT AMU outpatient management and
algorithm for DVT (appendix 11 ) this is based on the NICE pathway .
Policy Number LCH-131
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If the ultrasound is negative, the patient will be referred back to the GP with
the result for follow up.
Policy compliance will be measured against the local service plan using the
DVT clinical audit tool (Appendix). The service will be continually audited,
evaluated and developed accordingly on a monthly basis.
9. Training Requirements
All Walk in Centre ANP staff and ANP staff working with adults will be made
aware of this policy on commencement to post and as part of their LWIC’s
local induction process.
Training Requirements for diagnosis/exclusion DVT within LCH WIC
LWIC’s training will consist of:
Theory and Practice in relation to patients presenting with a suspected
DVT within LWIC’s
Shadowing other health care professionals within Liverpool Walk-In
Centres
Self directed learning on presentation and management of patients
within LWIC’s with a suspected DVT
D Dimmer traing provided by the RLBGUH
Updated training will be provided by qualified nurses who have undertaken a
period of extended training via a recognised institution and are deemed
competent to teach others.
10. Implementation, Monitoring and Review
10.1. The Clinical Lead of the VTE Harm free group is responsible for implementing
this policy. This process has been delegated to the Services Managers within
the community for the identified teams and service manager for LCH Walk-In
Centres.
Policy Number LCH-131
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10.2. The Clinical lead of the VTE harm free group is responsible for ensuring that
this policy is reviewed and if necessary, revised in the light of legislative
guidance, changes to current evidence or organisational change. This process
has been delegated to the Service Managers within the community and the
Walk-In Centres.
Aspect of compliance or effectiveness being monitored
Method of monitoring
Person/s responsible
Monitoring Frequency
Results reviewed by
Person/s responsible for completing actions
Patients with symptoms of VTE are
recognised
immediately,
undergo
timely clinical
assessment and appropriate
investigation as
Audit VTE Steering Group
Annually Harm Care Steering Group
Free Divisional Managers
Staff completed
training associated with
this policy as per LCH TNA
Monthly
Reports Manager
LDB Monthly Divisional
Governance Groups
Divisional
Managers
Staff within LCH WIC providing D- Dimer results have yearly update training
QA lead RLBGUH Will not renew bar code to
QA lead D- dimer RLBGUH
Rolling programme due to staff turnover and service need
DVT lead LCH WIC
CNM LCH WIC
10.3. The implementation of the policy will be undertaken by the Service Manager
and Clinical Nurse Managers for Liverpool Walk-In Centres. Policy compliance
will be measured by auditing the service delivery by the Clinical Nurse
Managers for respective Liverpool Walk-In Centres using the LCH DVT clinical
guidance audit tool (Appendix). This will take place on a monthly basis with a
six monthly review. Action Plans will be monitored at the Walk-In Centres
Clinical Network Meeting and the Adult Division Governance meetings.
10.4. This policy will be reviewed within 3 years unless practice changes in the
interim.
Policy Number LCH-131
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This review of the policy was undertaken in collaboration with RLBUHT and
approved through the policy approval process in place at RLBUHT.
All relevant personnel will be informed of the changes to the policy via the
Walk-In Centre and Adult Division Governance networks. The following people
are on the distribution list for notification of policy changes:
General Practitioners (GP’s)
Single point contact (UCD)
Nurse Practitioners at Liverpool Walk-In Centres
Medical/Nursing staff at AMU, RLBUHT
Service lead for Liverpool Walk-In Centre
All nurses are required to maintain contemporaneous records of patients care,
which are unambiguous and legible in accordance with statutory NMC Code
2015: Professional standards and behaviour for nurses and midwives.
Documentation will be provided by the Trust to assist the process.
11. Equality Analysis
An Equality Analysis has been undertaken and retained by the author of this
policy and the Equality and Diversity Lead of LCH.
12. Linked Areas/Information
This policy should be read in conjunction with the following guidance
documents of the Trust:
Health and Safety Policies.
Accident and Incident Reporting and Management Policy (Including Serious
Untoward Incidents).
CPR/Cardiopulmonary Resuscitation Policy.
http://publications.nice.org.uk/venous-thromboembolic-diseases-the-
management-of-venous-thromboembolic-diseases-and-the-role-of-cg144
13. Relevant Legislation/Statutory Requirements
This policy should be read in conjunction with:
Guidance documents from the NMC (Nursing and Midwifery Council)
Policy Number LCH-131
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www.nmc-nhs.org
All nursing staff should follow the Nursing and Midwifery Council Guidelines
for thestandards of Medicines 2007.
14. References
NICE:- CG144 Venous thromboembolic diseases: two-level Wells score - templates
for deep vein thrombosis and pulmonary embolism.
Nice algorithm for DVT Management (Appendix 9).
Guidelines for arranging ultrasound venous leg dopplers; RLBUHT Ultrasound
Department. (Appendix 6 )
https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-standards-for-
medicines-management.pdf
NMC Code 2015
https://www.nmc.org.uk/news/news-and-updates/revised-code-for-nurses-and-
midwives-
Policy Number LCH-131
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Appendix 1 General Practitioner /Health professional referral pathway
General Practitioner contacts UCD via LCH Single Point of Contact on
0300 323 0240
to make a referral to Old Swan Walk-In Centre for a D-dimer blood test.
UCD referral advisor will ask a series of questions to include
differential diagnosis, and arrange for the patient to attend
Old Swan Walk-In Centre.
Pregnant
Suspected Pulmonary
Embolism
Intravenous drug user
Not ambulant
On anticoagulant
Patients whose symptoms are in the lower limb:
Thigh
Calf
Referral advisor will arrange a direct admission into the AMU.
Referral advisor will arrange for the patient to attend Old Swan Walk-In Centre.
Policy Number LCH-131
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Appendix 2 Single Point of Contact (UCD) D.V.T. Criteria
The following questions must be asked by the Referral Advisor:
Is the patient an intravenous drug user?
Is PE suspected?
Is the patient pregnant?
Is the patient on any anticoagulation?
Is the patient ambulant (if a wheelchair user, can the patient stand
unsupported)
If the GP answers yes to any of the first 4 questions the patient needs to be referred
to RLBUHT as a medical admission.
If the GP answers yes to the last question but the patient cannot access the WIC
they will also need to be referred to RLBUHT as a medical admission.
If the patient meets the criteria, the GP will advise the patient to attend Old Swan
Walk-In Centre.
If the GP refuses, or the patient is not suitable, the response should be documented
in the notes for follow up.
The GP will be required to provide the following information to the Walk-In Centre
either by fax or with the patient:
GP letter
List of current medication
Past medical history if possible
Differential diagnosis
The Referral advisor will be required to print off a copy of the call and fax it to Old
Swan Walk-In Centre on 0151 285 3566.
The Referral advisor will be required to contact the Walk-In Centre on 0151 285
3565 to confirm receipt of the fax.
If any further information is required or there are any queries please contact a nurse
advisor
Policy Number LCH-131
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Nurse obtains a D-dimer blood test
WELL’s score completed Other causes excluded through general medical assessment, history and
physical examination.
Available within four hours
Not available within four hours or on same day
follow anticoagulant
PGD
Refer patient for ultrasound next available appointment
Appendix 3
DVT Suspected
Patient discharged to ultrasound
Discharged home reassure patient
Make appointment with referring health
professional
Is there a differential diagnosis
Not available within four
hours but Appt on same day
follow anticoagulant
PGD
Yes No
Discharged home with advice on
management and treatment of
differential diagnosis if possible /and
or refer back to GP letter sent
Patient given written information on
Ultrasound attendance Ultrasound referral letter WIC Re-attendance DVT information leaflet
Patient is triaged
Patient presents at Old Swan Walk-In
Self-referral Referred from Community GP
/ Matron/ other WIC
Wells score ≤1 point
Positive D-dimer >500 nanograms
per millilitre Wells > 2
Negative D-dimer <500 nanograms
per millilitre
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Appendix 4 Two-Level WELLS DVT score
Patient’s Details
Surname Date of Birth First names
Address
Telephone number ID Number
GP Contact number GP Address
NB.** If patient has only one leg, practioners need to score as +1 in these areas
Clinical Risk Stratification
Clinical Feature Points Patient Score
Active cancer (treatment on-going, 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 anesthesia.
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
DVT likely 2 points or more DVT unlikely 1 point or less
Please Note:
Alternate diagnosis is at least as likely: e.g. Ruptured Baker’s cyst, superficial
thrombophlebitis, cellulitis, chronic venous insufficiency or calf injury.
Wells Score (2003) (two level)
In 2003 a further component, previously documented DVT, was added to the original Wells
Score. Additionally, the duration of risk after surgery was increased from 4 weeks to 12
weeks2. This gives a possible score range of −2 to 9. This version reduced the number of
risk categories from three to two: likely (2 points or more) and unlikely (less than 2 points).
Policy Number LCH-131
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Appendix 5 Standard operating procedure undertaking D-Dimer
Standard operating procedure for undertaking a D-Dimer within LCH Walk in centre
SOP number: Version Number: 1
Effective Date: 11/06/2017 Review Date: June 2018
Author: Liz Norris, Clinical Nurse Manager and Margaret Carran, Nurse Clinician
Authorisation:
Name/Position:
Signature:
Date:
Purpose and Objective:
1. To support clinical staff working within Liverpool Community Health (LCH) Walk in Centres in undertaking a d-dimer blood test when a patient presents with suspected DVT using the Roche Cobas H232 machine.
2. To ensure that the staffs undertaking a D-Dimer follow the correct procedure and are trained appropriately.
Introduction
A D Dimer is undertaken as part of the assessment and Management of patients presenting within Liverpool community Health (LCH) Walk in centres with suspected deep venous thrombosis (DVT)
The following documentation include the training, assessment and processes used for the diagnosis treatment and management of patients presenting with suspected DVT and should be read in conjunction with the process outlined below.
http://nww.liverpoolch.nhs.uk/Downloads/Policies-and-Procedures/Clinical- Policies/WICs/Deep_Vein_Thrombosis.pdf
http://nww.liverpoolch.nhs.uk/Downloads/Policies-and- Procedures/PGDs/WIC/035%20Dalteparin%20for%20Management%20of%2 0DVT%20PGD%20V4%20extended%20until%2030th%20June%202014.pdf
Policy Number LCH-131
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Procedure:- patient presenting following booking in at reception Responsibility Activity
1.
Triage 2 Nurse Practitioner
Identifies the patient suspected of having a DVT from computer system. The patient is called into Triage room 2.
2.
Triage 2 nurse Patient details checked Blood is obtained from patient Collected in orange heparinised tube This is the only sample that is used in the Roche Cobas H232 machine The wording on the bottle is Li-Heparin LH/2.6 ml
Write patient details onto the bottle
Triage 2 nurse
A Roche pipette is used to draw sample from the The Li-Heparin orange tube up to the blue line
Individual Nurse practitioner in triage 2 to use Personal identification swipe card
POCT bar code identification card is swiped onto the Roche Cobas machine
Triage 2nurse Machine is activated The Patients NHS or computer system number is entered, when indicated by the machine the D-Dimer strip is inserted. Add patient details onto paper record.
Triage 2 nurse When the machine indicates, the Blood from the pipette is applied onto the test strip. Test takes 8-12 minutes
Triage 2 nurse Continue with patient triage. Undertakes B/P pulse .respiratory rate and document the results in the patient’s notes Brief history entered in to triage Applet.
Nurse practitioner If department quite patient can stay with nurse for the assessment to be fully completed. If department busy the Patient is sent back to the
waiting area.
Triage 2 When the D Dimer result is ready enter result into the patients computer notes and onto the paper records if the same nurse is undertaking all the sampling they do not need to sign out of the Cobas machine If different nurse is undertaking next patient sampling, they must ensure that the previous
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nurse has signed out. This is to avoid the possibility of using their swipe when the machine is already activated. Thus registering their own details where the patients, details are entered
Nurse practitioner If the patient was returned to the waiting area following a D Dimer and triage assessment Follow process of calling the patient into the consultation room. Undertake a full assessment and documentation Act on the results see supporting documentation above
Training
All nurses undertaking this procedure will have completed the in house training on
DVT’s .
Reviewed the VTE/DVT policy on the trust intranet
Undertaken training in both quality control and patient testing using the Cobas H 232
within the area of diagnostic in which they practice
Be competent in undertaking assessment of patient including calculating the WELL
Score
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Appendix 6.
Ultrasound Referral Pathway
Confirm date and time of ultrasound with department on
0151 706 2750
Discuss any anomalies with GP as required
Appointment available on the next day or over a weekend/
Bank Holiday Appointment available to patient on the same day
Patient referred for ultrasound at RLBUHT by Walk-In Centre staff member
Patient given advice and
information leaflet with all
contact numbers.
If able, the patient will be provided with the date and
time of their ultrasound appointment
If ultrasound is not available until
next day, at the weekend or Bank Holiday:
Patient advised to attend next available appointment and commenced on treatment as per PGD number 35
Patient provided with an appointment time and all relevant documentation
Negative ultrasound
Positive ultrasound
Patient to return to LWIC daily for administration of dalteparin
via PGD number 35
Patient will be managed according
to the NICE guidelines/
RLBUHT DVT protocol and instructed to contact GP
Patient will
attend AMU for follow
up
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Appendix 7
Liverpool Walk-In Centres
DVT Ultrasound Request Form
Liverpool Walk-In Centre State Site:
Surname: Forename:
Address:
Postcode:
DOB: Marital Status:
Telephone:
GP: Address:
Postcode:
Telephone:
Referral Details:
Procedure:
Ultrasound Lower Leg
Left Right
Diagnosis, History, Relevant Medication and Previous Surgery:
Referrers Details:
Name: Contact Number:
Wells score D dimer result
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Appendix .8
Ultrasound Patient Information
Referral to Ultrasound Department
Thank you for attending ………………. Walk-In Centre today at the request of your GP.
Following investigations it is necessary to refer you to the Ultrasound Department at the:
Royal Liverpool and Broadgreen University Hospital,
Prescott Street, Liverpool L7 8XP
Telephone number: 0151 706 2750
The Ultrasound Department is situated off the main corridor.
Please ensure that you have a copy of your documents, which will be contained in a yellow file and given to you by a Nurse Practitioner. These are to be taken to the Ultrasound Department and handed in to the Radiographer.
If you have any further queries then please do not hesitate to contact this Walk-In Centre on 0151 ……………. and ask to speak to a Nurse Practitioner.
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Appendix 9 DVT referral checklist
Please tick completed - and fax the following 1. Referral form and 2. Wells score sheet = fax to 0151-706-5633
Action Completed
1. DVT ultrasound request form
Patient details All details fully filled in
Referral details State history of presenting complaint
Diagnosis history With relevant medication
Leg L/R Which leg? Only one leg to be scanned
D-Dimer result In referral details
Signature on bottom of form
Legible
2. Wells sheet
Completed two level wells score
Name of patient and date on top of form
Wells scoring list DO NOT take from GP notes Redo the wells Taking into account -2 for alternative diagnosis
State wells score at the bottom of the form
Please include the following in the envelope and give to the patient
Action Completed
Patient notes Patient assessment noted Printed From EMIS
DVT Ultrasound request form and wells score
GP notes
Referral to ultrasound department instructions
Write telephone number on the envelope and department to visit i.e. ultrasound
Failure to complete all forms as requested will result in patient not receiving an ultrasound
Completed audit form For all patients who present and have a DVT assessment outcome and presentation irrelevant Complete and leave for Reception supervisor
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Appendix 10 NICE Algorithm for DVT
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Appendix 11 LBGUHT AMU outpatient management and algorithm for DVT