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NICE calls on nurses to advocate better VTE care

Nurses have been called on to act as advocates for “challenging” new guidance on services for patients presenting with a suspected venous thromboembolism.

Trusts should provide patients with suspected VTE a “seven-days-a-week” service, according to the National Institute for Health and Clinical Excellence.

NICE today published its first ever guidance on the diagnosis and treatment of VTE, including DVT and pulmonary embolism.

It said clinicians should use the two-level Wells score to assess the initial level of risk of both DVT and PE in patients presenting with signs and symptoms of DVT.

Patients with scores indicating DVT should be given a proximal leg vein ultrasound within four hours of being requested. If the result proves negative a D-dimer blood test should take place.

At the very least, patients with suspected DVT should not have to wait more than 24 hours for an ultrasound, NICE said. If one is not available within four hours, patients should be given a D-dimer test and an interim 24-hour dose of parenteral anticoagulant.  

Patients with suspected PE should be offered an immediate CT pulmonary angiogram or, if not available straight away, immediate interim parenteral anticoagulant therapy followed by the CT scan.

Patients with confirmed VTE should then receive either a low molecular weight heparin, fondaparinux (Arixtra), unfractionated heparin, or warfarin. 

A week following diagnosis, VTE patients should be offered compression stockings and advised to continue wearing them for at least two years.

In addition, NICE recommended patients over 40 who presented with a DVT or a PE without an obvious cause, such as having undergone surgery, should also undergo investigations for cancer due to evidence of a link between the two conditions.

These patients should be treated with low molecular weight heparin, rather than warfarin.

Gerrard Stansby, professor of vascular surgery and guideline development group chair, warned there was currently “variable practice” in how patients were investigated for VTE.

“It should not be the case that if you come in Friday you have to wait till Monday for diagnostic tests, not for such potentially fatal conditions,” he said. He added that the NHS should provide a “seven-days-a-week” for VTE.

Hayley Flavell, anticoagulant and thrombosis consultant nurse and member of the NICE guideline development group, said the guidance enabled nurses to “challenge omissions in practice”.

“This guideline provides the evidence to ensure that all nurses know what investigations and what care patients should receive, as well as having the evidence to justify these decisions,” she said.

“It will provide nurses with the evidence to demand service improvement in areas where there may be a lack of timely service provision.”

Ms Flavell, who works at Royal Bournemouth and Christchurch Hospitals Foundation Trust, added: “At the end of the day, we are the patient’s advocate.

“If you believe that this patient should be on the VTE pathway then you should be reminding doctors about the [test] timeline, what time the patient was admitted, how long we’ve got before the scan is performed, when we need to administer treatment.”  

The guidance follows a warning in July last year from NHS medical director Sir Bruce Keogh. He said it was “absolutely disgraceful” that some 25,000 patients died every year after developing DVT.

Readers' comments (4)

  • MeThinks

    “It will provide nurses with the evidence to demand service improvement in areas where there may be a lack of timely service provision.”

    Even if you have got the evidence, 'demanding' things within the NHS is not easy !

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  • why is NICE telling nurses to improve their care when they fail to deny patients some treatments?

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  • Depends who decides the provision and how they feel about NICE as a resource for guidelines of clinical care really doesn't it?

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  • 4 hour time frame for an ultrasound is unrealistic to say the least. I work in a community hospital in a rural location, patients have to drive or have transport provided to enable them to attend for a scan - most of the 4 hours would be taken up travelling to a larger hospital. Unless NICE is recommending that ultrasounds are available in community hospitals as well as the larger ones.
    Unfortuntaely this would be expensive and in the these times when the NHS is cash strapped, I'm not sure it'll happen just yet.

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