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terminology which has now been superseded.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

7

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

8

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

9

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

10

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

11

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

12

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

13

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

14

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

15

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

16

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

18

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

19

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

Policy Number LCH-131

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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

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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