A member of the NICE guideline development group highlights the important issues from the latest evidence based guideline for readers of Nursing Times
Deep vein thrombosis (DVT) and pulmonary embolism (PE) are common but often underestimated consequences of hospital admission. The guideline, published last month, covers all patients admitted to hospital and all specialties. It includes an update of previous NICE guidance on surgical inpatients.
It is estimated there are more than 25,000 preventable deaths each year in the UK from hospital acquired VTE, which is more than the number of deaths from breast cancer, Aids and road traffic accidents combined, and 25 times the number of deaths from MRSA (Department of Health, 2007; 2005).
VTE includes deep vein thrombosis (DVT) and pulmonary embolism (PE). It is often called the silent killer because, while some patients have symptoms such as leg swelling and pain in DVT and shortness of breath and chest pain in PE, up to 80% of VTE events are silent (DH, 2005).
Non fatal VTE events are associated with long term morbidity in the form of pulmonary hypertension and post thrombotic syndrome.
Uptake of VTE guidelines has been inconsistent. Implementation of this guideline, together with the NICE quality standard for VTE, due to be published in April, will ensure consistent best practice.
All patients must be assessed for risk of VTE and of bleeding on admission. Risk should be reassessed after 24 hours and whenever the clinical situation changes.
The assessment should take into account the VTE risk associated with the admission, such as immobility, illness or procedure, together with individual risk factors such as cancer, heart disease, thrombophilia, use of HRT or oestrogen-containing contraception, or history of VTE. A full list is given in the guidance.
There is a separate risk assessment for use in pregnancy and the postpartum period that is consistent with Royal College of Obstetricians and Gynaecologists guidance (RCOG, 2009).
Risk assessment should identify patients at risk of VTE and appropriate thromboprophylaxis for each individual.
There are sections for each surgical specialty, medicine and obstetrics, and a quick reference guide.
Mechanical methods recommended include anti-embolism stockings, foot impulse devices and intermittent pneumatic compression devices.
Pharmacological prophylaxis includes low molecular weight heparins, unfractionated heparin, fondaparinux, dabigatran and rivaroxaban, and advice is given on their use in different patient groups.
Indications for each method are set out, together with duration of therapy and contraindications.
The guideline does not recommend aspirin for VTE prophylaxis in any instance.
Thromboprophylaxis that continues after discharge is recommended for certain patients, including those with a hip fracture or having hip or knee replacement surgery, and pelvic or abdominal surgery for cancer.
Some patients having day surgery or with a lower limb plaster cast may require thromboprophylaxis after discharge.
Combined mechanical and pharmacological prophylaxis is indicated for most surgery. Pharmacological methods alone are preferred for medical patients unless there are contraindications/bleeding risks. Anti-embolism stockings are not recommended in acute stroke (CLOTS Trials Collaboration, 2009).
Providing patient information on admission and at discharge is important.
Before thromboprophylaxis is started, patients and carers should be offered both written and verbal information on: the risks and consequences of VTE; the importance of thromboprophylaxis, its use and side effects; and of reducing risk by keeping mobile and hydrated.
Most inpatient stays are of a few days but VTE risk may continue for several weeks. Therefore, patient information is a vital element of the discharge plan.
On discharge, patients and carers should be offered written and verbal information on: the signs and symptoms of DVT and PE; the importance of seeking prompt medical help if they have symptoms; and using their treatment and its duration.
Patients’ GPs should be notified of any extended prophylaxis.
This guideline gives an overview of VTE risk in patients admitted to hospital and of evidence based methods of reducing that risk. It will enable nurses to assess the risk of VTE, and provide prophylaxis and information on admission and discharge.
Click here for the NICE guideline.
AUTHOR Kim Carter, BSc,DipHE, RN, is VTE nurse specialist, Portsmouth Hospitals Trust.
CLOTS Trials Collaboration (2009) Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial. The Lancet; 373: 9679, 1958-1965.
Department of Health (2005) House of Commons Health Committee: The Prevention of Venous Thromboembolism in Hospitalised Patients: Second Report of the Session 2004-5. London: The Stationery Office.
Department of Health (2007) Report of the Independent Expert Working Group on the Prevention of Venous Thromboembolism in Hospitalised Patients. London: The Stationery Office.
Royal Collegeof Obstetricians and Gynaecologists (2009) Reducing the Risk of Thrombosis and Embolism During Pregnancy and the Puerperium. Green Top Guideline No 37: 2009. London: RCOG.