1. health and fitness
2. disease

Venous Thromboembolism
Prophylaxis
Reference Number:
795
Author & Title:
Josephine Crowe, Consultant Haematologist
Responsible Director:
Dr Tim Craft, Medical Director
Review Date:
23 January 2016
Ratified by:
Dr Tim Craft – Medical Director
Date Ratified:
23 January 2013
Version:
1.2
Related Policies & Guidelines:
Oral Anticoagulation Guideline
Venous thromboembolism in pregnancy,
Labour and the Puerperium
including Thromboprophylaxis (NHS
provider of maternity services on RUH
site)
Document name: Venous Thromboembolism Prophylaxis Policy
th
Issue date:24 January 2013
Author: Dr Jo Crowe
Ref.:795
Status: Approved
Page 1 of 33
Index:
1.
Policy Summary _______________________________________________ 4
2.
Policy Statements _____________________________________________ 4
3.
Definition of Terms Used _______________________________________ 5
4.
Duties and Responsibilities _____________________________________ 5
4.1. Hospital Thrombosis Committee ____________________________________ 5
4.2. Admitting doctor _________________________________________________ 5
4.3. Pre-assessment clinic doctor, nurse or pharmacist _____________________ 5
4.4. Medical, nursing or pharmacy staff on wards __________________________ 5
4.5. Medical, nursing or pharmacy staff on ICU ____________________________ 5
5.
Risk assessment on admission and during stay ____________________ 6
6.
Information for patients_________________________________________ 6
6.1. Elective surgical patients before admission ___________________________ 6
6.2. All patients on admission __________________________________________ 6
6.3. All patients on discharge___________________________________________ 6
7.
Methods of VTE Prophylaxis ____________________________________ 7
7.1. General measures ________________________________________________ 7
7.2. Mechanical thromboprophylaxis ____________________________________ 7
7.3. Anti-platelet agents _______________________________________________ 7
7.4. Low Molecular Weight Heparin ______________________________________ 7
7.5. Vena Caval Filters ________________________________________________ 8
7.6. Regional Anaesthesia _____________________________________________ 8
8.
Extended Thromboprophylaxis __________________________________ 9
8.1. Procedure if Venous thromboembolism is suspected ___________________ 9
9.
Management following diagnosis of Venous Thromboembolism _______ 9
10. Hospital Acquired Thrombosis (HAT) _____________________________ 9
11. Education and Training ________________________________________ 10
12. Monitoring Compliance ________________________________________ 10
13. Review _____________________________________________________ 10
14. References __________________________________________________ 10
Appendix 1:
Consultation Schedule ________________________________ 13
Appendix 2:
in Adults
RUH Guideline for the Prevention of Venous Thromboembolism
14
Document name: Venous Thromboembolism Prophylaxis Policy
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Issue date:24 January 2013
Author: Dr Jo Crowe
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Status: Approved
Page 2 of 33
Appendix 3:
Methods of prophylaxis against VTE_____________________ 15
Pharmacological methods ____________________________________________ 15
Mechanical methods ________________________________________________ 16
Appendix 4:
Medical Thromboprophylaxis Guideline __________________ 17
Appendix 5:
Medical Flowchart ____________________________________ 18
Appendix 6:
Surgical Thromboprophylaxis Guideline _________________ 19
Appendix 7:
Day Surgery Thromboprophylaxis Guideline ______________ 21
Appendix 8:
Trauma and Orthopaedic Thromboprophylaxis Guideline ___ 22
Appendix 9: Trauma and Orthopaedic procedure specific
Thromboprophylaxis Guidance _____________________________________ 26
Appendix 10:
Critical Care Thromboprophylaxis Guideline ____________ 29
Pharmacological thromboprophylaxis __________________________________ 29
Mechanical methods ________________________________________________ 29
Document Control Information ______________________________________ 31
Ratification Assurance Statement _____________________________________ 31
Consultation Schedule _______________________________________________ 32
Equality Impact: (A) Assessment Screening ____________________________ 33
Amendment History
Issue Status
1.2
Approved
Date
January
2013
Reason for Change
Update reference to trust
drug chart and Millennium;
update format
Document name: Venous Thromboembolism Prophylaxis Policy
th
Issue date:24 January 2013
Author: Dr Jo Crowe
Authorised
Dr Tim Craft,
Medical Director
Ref.:795
Status: Approved
Page 3 of 33
1. Policy Summary
It is estimated that each year over 8, 500 people in England and Wales die as a
result of hospital acquired venous thromboembolism (VTE). Many of these deaths
are preventable through the use of thromboprophylaxis. The House of Commons
Select Committee Report on the Prevention of Venous Thromboembolism in
Hospitalised Patients Feb 2005 and The Venous Thromboembolism in Hospitalised
Patients Expert Working Group have been tasked with addressing this issue. NICE
Clinical Guideline 92 – “Reducing the risk of venous thromboembolism (deep vein
thrombosis and pulmonary embolism) in patients admitted to hospital” January 2010,
gives clear guidance regarding national standards.
Patients with cancer have an approximate 7 fold increased risk of VTE, accounting
for ~20% of the community presenting VTE. Cancer patients undergoing surgery
have a two-fold or greater increased risk for fatal PE compared with those without
cancer who are undergoing similar procedures. Patients with active cancer and
particularly those with central venous lines and those receiving chemotherapy are at
a significantly increased risk for VTE. Inpatients with cancer must be managed
according to the medical, surgical or critical care guidelines as appropriate.
The appropriate use of thromboprophylaxis will:
• Reduce morbidity due to VTE
• Reduce mortality rates due to VTE
• Reduce the cost of treatment of VTE
This policy summarises best practice based on current evidence for the prevention of
Hospital acquired VTE.
2. Policy Statements
All patients must be risk assessed on admission using the risk assessment tool on
the trust drug chart or Millennium
All patients must have this risk assessment reviewed within 24 hours of admission
If risk of VTE is identified and prophylaxis withheld, the reason(s) for this must be
documented clearly
Document name: Venous Thromboembolism Prophylaxis Policy
th
Issue date:24 January 2013
Author: Dr Jo Crowe
Ref.:795
Status: Approved
Page 4 of 33
3. Definition of Terms Used
AES
DH
DVT
FID
HAT
IPC
LMWH
PE
VTE
Anti-Embolic Stockings
Department of Health
Deep Vein Thrombosis
Foot Impulse Devices
Hospital Acquired Thrombosis
Intermittent Pneumatic Compression
Low Molecular Weight Heparin
Pulmonary Embolism
Venous Thromboembolism
4. Duties and Responsibilities
4.1.
Hospital Thrombosis Committee
This comprises representatives from Medicine, Surgery, Obstetrics,
Orthopaedics, Pharmacy and Haematology
•
•
•
•
4.2.
To promote best practice through local policies based on National
Guidelines
Lead multi professional audit of the use of thromboprophylaxis
Promote education and training
Report quarterly to the Operational Governance Committee.
Admitting doctor
Responsible for documenting the risk assessment and prescribing
prophylaxis if indicated.
4.3.
Pre-assessment clinic doctor, nurse or
pharmacist
Responsible for documenting the risk assessment and prescribing
prophylaxis for elective surgery patients.
4.4.
Medical, nursing or pharmacy staff on wards
Responsible for ensuring risk assessments are repeated every 72
hours
4.5.
Medical, nursing or pharmacy staff on ICU
Responsible for ensuring risk assessments are repeated every 24
hours
Document name: Venous Thromboembolism Prophylaxis Policy
th
Issue date:24 January 2013
Author: Dr Jo Crowe
Ref.:795
Status: Approved
Page 5 of 33
5. Risk assessment on admission and during stay
All patients must be risk assessed on admission and have this assessment reviewed
within 24 hours of admission using the risk assessment tool which is on the trust
drug chart or Millennium.
If VTE prophylaxis is withheld for any reason (e.g. bleeding risk) this must be
documented clearly.
The responsibility for documenting the risk assessment and prescribing
thromboprophylaxis lies with the admitting doctor. For elective surgery patients, the
responsibility lies with the pre-assessment clinic doctor, nurse or pharmacist.
Inpatients must be re-assessed for risk factors every 72 hours (every 24 hours for
ICU patients) or sooner if clinically indicated. This can be done by medical staff (a
doctor, nurse or pharmacist).
6. Information for patients
6.1.
Elective surgical patients before admission
•
•
6.2.
All patients on admission
•
6.3.
Surgical patients must be informed that immobility associated with
continuous travel of more than 3 hours in the 4 weeks before or
after surgery may increase the risk of VTE.
Surgical patients on the combined oral contraceptive pill should
consider stopping 4 weeks before elective surgery. Alternative
contraceptive measures should be advised.
All patients must be given verbal and written information on
admission about the risks of VTE and the effectiveness of
prophylaxis.
All patients on discharge
•
All patients must be given verbal and written information on the
following, as part of their discharge plan:
o The signs and symptoms of DVT
o The correct use of extended prophylaxis (if appropriate).
o The implications of not using prophylaxis (if appropriate).
Document name: Venous Thromboembolism Prophylaxis Policy
th
Issue date:24 January 2013
Author: Dr Jo Crowe
Ref.:795
Status: Approved
Page 6 of 33
7. Methods of VTE Prophylaxis
7.1.
General measures
Early mobilisation and leg exercises
• Patients will be encouraged to mobilise as soon as possible.
• Patients who are unable to mobilise will be encouraged to do
regular leg exercises.
Hydration
• Ensure patients are adequately hydrated.
7.2.
Mechanical thromboprophylaxis
Mechanical thromboprophylaxis is recommended primarily where the
bleeding risk is high or as adjunct to pharmacological measures. The
options for mechanical thromboprophylaxis include:
7.3.
•
Anti-embolic stockings (AES): Patients using anti-embolic
stockings (AES) should be shown how to wear them correctly
by healthcare professionals trained in the use of that product.
Stocking use will be monitored and assistance provided if they
are not being worn properly.
•
Intermittent pneumatic compression devices (IPC), foot impulse
devices (FID) or venous foot pumps may be used as
alternatives or in addition to anti-embolic stockings (AES) where
appropriate in surgical inpatients.
Anti-platelet agents
Aspirin is NOT recommended as prophylaxis against VTE in any
patient group
7.4.
Low Molecular Weight Heparin
See clinical guideline for dose of Low Molecular Weight Heparin (see
Appendix 3)
Potential side effects of Heparin
Document name: Venous Thromboembolism Prophylaxis Policy
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Issue date:24 January 2013
Author: Dr Jo Crowe
Ref.:795
Status: Approved
Page 7 of 33
7.5.
•
Bleeding – LMWH should be stopped. Consideration of use of a
reversal agent depends on the severity of the bleeding.
Protamine sulphate will only partially reverse the anticoagulant
effect. The Haematologist on call is available for advice.
•
Heparin Induced Thrombocytopenia (HIT) – All patients should
have a baseline platelet count. HIT is much less likely with
LMWH than with unfractionated heparin but should be
considered if the platelet count falls by >50%. Always discuss
management of these patients with a Consultant Haematologist.
•
Osteoporosis – Heparins are associated with an increased risk
of osteoporosis and bone fracture with prolonged use (>12
weeks at prophylactic doses). This risk is greater in pregnancy
and older women.
Vena Caval Filters
These should be considered for surgical patients with recent (within 1
month) or existing VTE in whom anticoagulation is contraindicated.
7.6.
Regional Anaesthesia
Regional anaesthesia reduces the risk of VTE compared to general
anaesthesia. The suitability of regional anaesthesia for an individual
patient should be considered, in addition to any other planned method
of thromboprophylaxis.
Document name: Venous Thromboembolism Prophylaxis Policy
th
Issue date:24 January 2013
Author: Dr Jo Crowe
Ref.:795
Status: Approved
Page 8 of 33
8. Extended Thromboprophylaxis
Extended thromboprophylaxis with low molecular weight heparin or rivaroxaban or
dabigatran is recommended in patients with:
• elective total hip arthroplasty
• elective knee arthroplasty
• fractured neck of femur
• major cancer surgery in the abdomen or pelvis
8.1.
Procedure if Venous thromboembolism is
suspected
If an inpatient already receiving thromboprophylaxis is suspected to
have a DVT or PE they should be treated with therapeutic dose LMWH
and have the appropriate radiological investigations (either a duplex
Doppler scan of the lower limb or a CT pulmonary angiogram). See
Acute Medicine Guidelines (1) Pulmonary Embolism Acute (034/2012),
(2) Deep vein thrombosis (DVT) Acute 027/2012
9. Management following diagnosis of Venous
Thromboembolism
If a DVT or PE is confirmed the patient should be loaded with warfarin (unless
contraindicated). Follow the Acute Medicine Guidelines
• Pulmonary Embolism Acute (034/2012),
• Deep vein thrombosis (DVT) Acute 027/2012.
10. Hospital Acquired Thrombosis (HAT)
A hospital acquired thrombosis (DVT or PE) is defined as occurring within 3 months
of a hospital admission. Collection of data on patients with possible hospital
acquired thrombosis is reported via ICE and Assura Minerva (the community DVT
Doppler service in BANES).
A root cause analysis investigation should be done on all patients who are
suspected of having HAT. The incidence of hospital acquired thrombosis and root
cause analysis findings should be reported to the Thrombosis committee for
assessment of trends across the organisation and the identification of actions
required to reduce identified risks.
Document name: Venous Thromboembolism Prophylaxis Policy
th
Issue date:24 January 2013
Author: Dr Jo Crowe
Ref.:795
Status: Approved
Page 9 of 33
11. Education and Training
Staff must refer to the Mandatory Training Matrix, available on the intranet
at http://webserver.ruhbath.swest.nhs.uk/development/mandatory/documents/matrix_roles.xls to identify what
training in relation to venous thromboembolism is relevant to their role. The
Mandatory Training Matrix identifies when training needs to be undertaken, the
method of delivery and frequency of the training.
The Mandatory Training policy identifies how training non attendance will be
followed up and managed and is available on the intranet at http://webserver.ruhbath.swest.nhs.uk/staff_resources/governance/policies/documents/non_clinical_policies/bla
ck_hr/HR_148.pdf
12. Monitoring Compliance
The Trust-wide Audit of VTE prophylaxis is mandatory. This is part of the
Commissioning for Quality and Innovation (CQUIN) target contract.
Audit data on completion of risk assessment on patients admitted to hospital is
collected and reported to Trust Board every month.
A review of risk assessment compliance and findings is also monitored as part of the
South West Region Quality and Patient Safety Improvement Programme and is
included in the quarterly reports to the Trust Board.
13. Review
This policy will be in effect for three years. Prior to the third anniversary of the policy
the author will be asked to review it and make any necessary changes prior to further
ratification.
The policy will be reviewed prior to this if national guidelines or significant new
research is released.
14. References
Document name: Venous Thromboembolism Prophylaxis Policy
th
Issue date:24 January 2013
Author: Dr Jo Crowe
Ref.:795
Status: Approved
Page 10 of 33
1. Scottish Intercollegiate Guidelines Network (SIGN), Prevention and Management
of Venous Thromboembolism. 122. Dec 2010
2. Report of the independent expert working group on the prevention of venous
thromboembolism in hospitalised patients. Department of Health, A report to Sir
Liam Donaldson, Chief Medical Officer. 2007
3. Government Response to the House of Commons Health Committee report on
the prevention of venous thromboembolism in Hospitalised Patients – second
report of session 2004-5. July 2005.
4. Collins R, Baigent C, Sandercock P, Peto RO. Antiplatelet therapy for
thromboprophylaxis: the need for careful consideration of the evidence from
randomised trials. Antiplatelet trialists collaboration. BMJ 1994; 309; 1215-7
5. NICE Clinical Guideline 92 Venous thromboembolism: reducing the risk.
Reducing the risk of venous thromboembolism (deep vein thrombosis and
pulmonary embolism) in patients admitted to hospital. January 2010
6. All-party parliamentary thrombosis group Thrombosis: Awareness, Management
and Prevention November 2007
7. Kakkar AK, Coleman R et al. Prevention and Treatment of Cancer-Associated
Thrombosis: A Report on a Roundtable Meeting. British Journal of Cancer vol
102, supplement 1, 13 April 2010
8. Haemostasis, Anticoagulation & Thrombosis (HAT) Committee, UK Clinical
Pharmacy Association. UKMi Medicines Q&A 326.1: What doses of
thromboprophylaxis are appropriate for adult patients at extremes of body
weight? April 2010. Available from www.nelm.nhs.uk, date accessed: 21st
February, 2011.
9. Templeman, E. UKMi Medicines Q&A 257.2: Should prophylactic doses of low
molecular weight heparins be used in patients with renal impairment? July 2010.
Available from www.nelm.nhs.uk, date accessed: 21st February, 2011.
10. Ashley, C and Currie, A. Renal Drug Handbook 3rd Edition. Dalteparin.
11. Gould MK et al. Prevention of VTE in nonorthopedic surgical patients:
Antithrombotic therapy and prevention of thrombosis. 9th edition: American
College of Chest Physicians evidence based Clinical Practice Guidelines. Chest
2012; 141(2_suppl): e227S-e277S
12. Falck-Ytter Y et al. Prevention of VTE in orthopedic surgical patients:
Antithrombotic therapy and prevention of thrombosis. 9th edition: American
College of Chest Physicians evidence based Clinical Practice Guidelines. Chest
2012; 141(2_suppl):e278S-e325S
Document name: Venous Thromboembolism Prophylaxis Policy
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Author: Dr Jo Crowe
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Status: Approved
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13. Kahn SR et al. Prevention of VTE in nonsurgical patients: Antithrombotic therapy
and prevention of thrombosis. 9th edition: American College of Chest Physicians
evidence based Clinical Practice Guidelines. Chest 2012; 141(2_suppl):3195Se226S
Document name: Venous Thromboembolism Prophylaxis Policy
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Status: Approved
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Appendix 1: Consultation Schedule
Original document:
Name and Title of Individual
Dr Tim Craft, Deputy Medical Director
Regina Brophy, Head Pharmacist
Dr. William Hubbard, Clinical Director of Medicine
Dr. Chris Gallegos, Clinical Director for Surgery
Elizabeth Beech, prescribing adviser BANES PCT
Date Consulted
28/10/09
28/10/09
28/10/09
29/10/09
28/10/09
Name of Committee
Hospital Thrombosis Committee
Clinical reference group
Operational Governance Committee
Clinical Governance Committee
Date of Committee
04/11/2009
12/01/2010
14/07/2010
Document revised to include dalteparin:
Name and Title of Individual
Caroline Quinn, Surgical Pharmacist
Gayle Wynn, Admissions Pharmacist
Matthew Jones, Medicines Information Pharmacist
Mark Mallet, Consultant Physician, Acute Medicine
Date Consulted
14/3/11
14/3/11
14/3/11
14/3/11
Document revised to clarify recording of VTE assessment:
January 2013
Name and Title of Individual
Jo Crowe, Consultant Haematologist
Date Consulted
17/1/13
Document name: Venous Thromboembolism Prophylaxis Policy
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Issue date:24 January 2013
Author: Dr Jo Crowe
Ref.:795
Status: Approved
Page 13 of 33
Appendix 2: RUH Guideline for the Prevention of
Venous Thromboembolism in Adults
1. All in-patients and day case surgery patients should have a documented risk
assessment performed on admission or at the preoperative assessment clinic
leading to a clinical decision regarding appropriate measures to prevent venous
thromboembolism (VTE).
2. The Trust risk assessment tool on the drug chart or Millennium should be used to
record the risk assessment. A decision on the use or otherwise of
pharmacological or mechanical prophylaxis should be clearly documented.
3. General preventative measures (early mobilisation, leg exercises and ensuring
adequate hydration) are appropriate for all patients.
4. The decision on how to manage the risk of VTE will be based on an assessment
of the risks of VTE against the bleeding risk of preventative treatment for each
individual patient
5. The risk assessment should be reviewed within 24 hours of admission.
Subsequently the risk assessment should be reviewed every 72 hours (every 24
hours for ICU patients) or whenever the clinical situation changes.
6. Before starting VTE prophylaxis patients and/or their families or carers should be
given verbal +/- written information on their risk of VTE, the importance of VTE
prophylaxis and possible side effects, the correct use of VTE prophylaxis and
how they can reduce their risk of VTE (i.e. keep well hydrated, do leg exercises
and mobilise if possible).
7. On discharge patients and/or their families or carers should be given verbal +/written information on:
• the signs and symptoms of deep vein thrombosis and pulmonary embolism
• The importance of seeking medical help and who to contact if deep vein
thrombosis or pulmonary embolism is suspected.
• If discharged with prophylaxis:
o the correct and recommended duration of use of VTE prophylaxis
o how to use VTE prophylaxis correctly
o the signs and symptoms of adverse events related to VTE prophylaxis
o the importance of seeking help and who to contact if they have any
problems using the prophylaxis
Document name: Venous Thromboembolism Prophylaxis Policy
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Issue date:24 January 2013
Author: Dr Jo Crowe
Ref.:795
Status: Approved
Page 14 of 33
Appendix 3: Methods of prophylaxis against VTE
Pharmacological methods
LMWH: Dalteparin
Dose
2500 units once daily
5000 units once daily
5000 units twice daily
7500 units twice daily
Weight (kg)
<50kg
50-100kg
100-150kg
>150kg
Renal Impairment: eGFR<10ml/min: unfractionated heparin 5000 units sc twice daily.
Duration of treatment
Medical patients: for at least 6 days or until patient ambulant; maximum licensed
duration 14 days (reassess need at that time).
Surgical patients: see surgical guidelines
Reversal of LMWH if significant bleeding:
Protamine sulphate will partially reverse the anticoagulant effect. Discuss with
Haematologist on call.
Rivaroxaban
Licensed in elective hip or knee replacement. See orthopaedic guidelines.
Cautions and contraindications to pharmacological thromboprophylaxis: Low
molecular weight heparin (dalteparin) and rivaroxaban
This list is not exhaustive. Consider other factors in an individual patient.
• Active bleeding
• Acquired bleeding disorders (e.g. acute liver failure)
• concurrent use of anticoagulants known to increase bleeding risk (eg warfarin with INR
>2)
• Lumbar puncture / epidural / spinal anaesthesia within the previous 4 hours or expected
within the next 12 hours
• Acute stroke
• Thrombocytopenia (platelets < 75 x 109/L)
• Uncontrolled systolic hypertension (BP ≥ 230/120 mmHg)
• Untreated inherited bleeding disorders (e.g. haemophilia or von Willebrand’s disease)
• Surgery expected within the next 12-24 hours
• Surgery in the past 48 hours +/- risk of clinically important bleeding
• Hypersensitivity to heparin or low molecular weight heparins
• History of heparin induced thrombocytopenia
• neurosurgery, spinal, eye surgery or other procedure with high bleeding risk
• Renal failure: rivaroxaban: contraindicated if eGFR < 15mls/min (use unfractionated
heparin 5,000 units sc twice daily.
Document name: Venous Thromboembolism Prophylaxis Policy
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Author: Dr Jo Crowe
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Status: Approved
Page 15 of 33
Mechanical methods
Anti-embolic stockings (AES)
Use as an adjunct or alternative to pharmacological prophylaxis when there is
increased risk of bleeding from heparin use due to patient or procedure related
factors.
NICE guidance recommends against the use of anti-embolic stockings in patients
with acute stroke.
Intermittent Pneumatic Compression (IPC) devices (full or knee length)
Use when pharmacological prophylaxis is contraindicated as part of speciality
specific guidelines.
Foot Impulse Devices
Require correct use and should only be used as part of speciality specific guidelines
(see orthopaedics and trauma guideline)
Contraindications to mechanical thromboprophylaxis
Anti-embolic stockings
• Suspected or proven peripheral arterial disease
• Peripheral arterial bypass grafting
• Peripheral neuropathy or other causes of sensory impairment
• Local condition in which stockings may cause damage e.g. fragile tissue paper
skin, leg ulcers, dermatitis, gangrene or recent skin graft
• Known allergy to material of manufacture
• Cardiac failure
• Massive leg oedema
• Pulmonary oedema from congestive cardiac failure
• Unusual leg shape or size
• Major limb deformity preventing correct fit
Leg or foot ulcers or wounds; use caution or clinical judgement
Flowtron® intermittent pneumatic compression
• Known allergy to material of manufacture
• Known or suspected acute DVT or PE
• Peripheral arterial disease
• Local skin condition precluding application
• Severe congestive cardiac failure
• Do not apply if the legs are elevated during surgery
Foot impulse devices (FID)
• Pre-existing thrombophlebitis, DVT or PE
• Severe congestive cardiac failure
• Use cautiously on an infected or insensate extremity
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Page 16 of 33
Appendix 4: Medical Thromboprophylaxis Guideline
Stroke
Do not use anti-embolism stockings
Consider LMWH if: non-haemorrhagic stroke, and risk of haemorrhagic
transformation is low, and one or more of:
Major restricted mobility
• Previous VTE
• Dehydration
• Other comorbidities (e.g. cancer)
Palliative care
If patient in terminal care or end-of-life pathway do not use pharmacological or
mechanical thromboprophylaxis.
If patient has potentially reversible acute pathology consider using dalteparin if no
contraindications.
Cancer patients
If patient having oncological treatment and ambulant – mechanical and
pharmacological thromboprophylaxis not indicated.
If patient having oncological treatment and not ambulant – risk assess & if high risk
use dalteparin if no contraindications.
Patients with central venous catheters
If the patient is not ambulant risk assess. If high risk consider dalteparin if no
contraindications.
Pregnancy and up to 6 weeks postpartum
Consider pharmacological prophylaxis or anti-embolic stockings if one or more of the
following:
• Expected to have significantly reduced mobility for 3 or more days
• Active cancer or cancer treatment
• Age > 35 years
• Critical care admission
• Dehydration
• Excess blood loss or transfusion
• Known thrombophilia
• Obesity (pre-pregnancy or early pregnancy BMI > 30 kg /m2)
• medical comorbidity (e.g. heart disease; metabolic, endocrine or respiratory
pathologies; acute infectious diseases; inflammatory conditions)
• Personal or first-degree relative history of VTE
• Pregnancy-related risk factor (ovarian hyperstimulation, hyperemesis,
multiple pregnancy, pre-eclampsia)
• Varicose veins with phlebitis
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Author: Dr Jo Crowe
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Status: Approved
Page 17 of 33
Appendix 5: Medical Flowchart
First assessment carried
out by admitting doctor
Patient has had or is expected to have significantly
reduced mobility for 3 or more days (ie bedbound,
unable to walk unaided, or likely to spend a
substantial proportion of the day in bed or in a chair)
yes
no
patient is expected to have ongoing
reduced mobility relative to normal and
has one or more risk factors (box 1)?
Box 1. VTE risk factors:
• Active cancer or cancer treatment
• Age over 60 years
• Critical care admission
• Dehydration
• Known thrombophilia
• BMI > 30 kg/m2
• Personal or first-degree relative history of VTE
• One or more significant medical comorbidities
(heart disease; metabolic, endocrine or respiratory
pathologies; acute infectious diseases; inflammatory
conditions)
• HRT or oestrogen-containing contraceptive
• Varicose veins with phlebitis
• Pregnant or given birth within last 6 weeks
no
No VTE prophylaxis needed
yes
Risk of bleeding from
pharmacological prophylaxis
(box 2)?
no
no
Use LMWH
Check renal function
yes
yes
Contraindication
to antiembolism stockings (box 3)?
no
yes
Prescribe dalteparin (see full guideline).
If renal impairment (eGFR <10ml/min)
use unfractionated heparin 5000 units
sc twice dialy.
Use anti-embolism stockings.
Need to be measured and correctly fitted
Wear day and night.
Remove once a day to inspect the skin
Document assessment and management
Avoid dehydration
Encourage mobility
Give patient information leaflet
Box 2. Patients at risk of bleeding:
•Active bleeding
•Acquired bleeding disorders (eg acute liver failure)
•Concurrent anticoagulant use (eg warfarin with INR >2)
•Lumbar puncture / epidural / spinal anaesthesia within
next 12 hours or previous 4 hours
•Acute stroke
•Platelets < 75 x 109
•Hypertension ≥ 230 /120 mmHg
•Untreated inherited bleeding disorders (eg
haemophilia, von Willebrand’s)
•Anticipated or recent procedure
All VTE prophylaxis contraindicated
Box 3. Contraindications to anti-embolism
stockings:
•Suspected or proven peripheral arterial disease
•Peripheral arterial bypass graft
•Peripheral neuropathy or other sensory impairment
•Fragile skin, dermatitis, gangrene, recent skin graft
•Allergy to material
•Heart failure
•Severe leg oedema
•Unusual leg size or shape
•Major deformity preventing correct fit
•Caution with venous ulcers or wounds
Reassess VTE and bleeding risks within 24
hrs
Ensure prophylaxis is being given correctly
Reassess again every 72 hours
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Author: Dr Jo Crowe
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Status: Approved
Page 18 of 33
Appendix 6: Surgical Thromboprophylaxis Guideline
For patients age >18. Excluding orthopaedic and trauma patients
Elective patients
Risk assessed in pre-operative assessment clinic.
The preoperative assessment nursing staff complete:
• whether the patient is high or low risk
• the patient’s bleeding risk
If in doubt the nursing staff should seek advice from a doctor.
The medical staff complete:
• which thromboprophylaxis should be used
• if thromboprophylaxis is contraindicated
• timing of starting pharmacological thromboprophylaxis
Emergency patients
Risk assessed by the admitting doctor / nurse practitioner who should complete risk
assessment tool on drug chart or Millennium and:
• which thromboprophylaxis should be used,
• if thromboprophylaxis is contraindicated
• timing of starting pharmacological thromboprophylaxis
STEP 1
Identify the patient’s VTE risk factors
STEP 2
Identify the risk of thrombosis of the procedure
Risk group
Low risk
High risk
•
•
•
•
•
•
Recommended Thromboprophylaxis
Mobilisation
Adequate hydration
Dalteparin
Use unfractionated heparin if eGFR<10min
Mechanical thromboprophylaxis
Consider extended thromboprophylaxis with dalteparin (up
to 28 days) in major cancer surgery in the abdomen or
pelvis
STEP 3
Review bleeding risk i.e. contraindications for pharmacological
thromboprophylaxis
STEP 4
Review contraindications to mechanical thromboprophylaxis
Document name: Venous Thromboembolism Prophylaxis Policy
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Issue date:24 January 2013
Author: Dr Jo Crowe
Ref.:795
Status: Approved
Page 19 of 33
STEP 5
Additional points to consider
1. Patients on COCP
Consider stopping COCP 1 month prior to MAJOR surgery;
ensure using alternative contraception
2. Patients already
taking anticoagulants
e.g. warfarin
Seek senior advice
Refer to Periprocedural Anticoagulation Guideline 2011 on
trust intranet.
3. Timing of
administration of
dalteparin
Elective surgery: post op 18.00
Emergency Admission: prescribe on admission (unless
surgery expected within 12-24 hours) & 18.00 thereafter
If surgery finishes in the afternoon delay until 22.00 or d/w
consultant surgeon
4. Renal impairment
If eGFR<10ml/min use unfractionated heparin 5000units BD
5. Monitoring
(if on LMWH)
6. Regional
anaesthesia
FBC day 4 + 12 for HIT (heparin induced thrombocytopenia)
Insertion: dalteparin must not be administered within 12
hours prior to spinal or epidural insertion or within 4 hours
post insertion.
Withdrawal: Removal of an epidural catheter should be
delayed 12 hours post administration of dalteparin. The
subsequent doses of dalteparin should be given no sooner
than 4 hours after catheter removal.
7. Extended
prophylaxis
(dalteparin for up to
28 days post
operatively)
If major cancer surgery in the abdomen or pelvis
Monitor FBC day 4 and 12 (risk of heparin induced
thrombocytopenia)
Note extended prophylaxis on the discharge summary and
complete the monitoring form for HIT and fax to the GP.
Document name: Venous Thromboembolism Prophylaxis Policy
th
Issue date:24 January 2013
Author: Dr Jo Crowe
Ref.:795
Status: Approved
Page 20 of 33
Appendix 7: Day Surgery Thromboprophylaxis
Guideline
The following patients are low risk:
•
•
•
Opthalmological procedures with local anaesthetic/regional
anaesthetic/sedation and not full general anaesthetic
Non-cancer ENT surgery lasting less than 90 minutes with local anaesthetic /
regional anaesthetic / sedation and not full general anaesthetic
Non-cancer dental and maxillo-facial surgery lasting less than 90 minutes with
local anaesthetic / regional anaesthetic / sedation and not full general
anaesthetic
If VTE risk increased:
•
•
Offer mechanical VTE prophylaxis at admission and continue mechanical
thromboprophylaxis until mobility no longer significantly reduced
If risk of major bleeding low, consider use of dalteparin and continue until
mobility no longer significantly reduced, including after discharge (generally 57 days).
Document name: Venous Thromboembolism Prophylaxis Policy
th
Issue date:24 January 2013
Author: Dr Jo Crowe
Ref.:795
Status: Approved
Page 21 of 33
Appendix 8: Trauma and Orthopaedic
Thromboprophylaxis Guideline
Refer to the Surgical VTE Risk Assessment to assess the patient’s VTE risk. The
procedure specific guidance outlines which combination of prophylaxis to use.
1.
Low risk patients
•
2
Early mobilisation
High risk patients
•
•
All should be considered for mechanical and pharmacological
prophylaxis
Total hip and knee arthroplasty patients and fractured neck of femur
patients require extended thromboprophylaxis (see 2c below)
Mechanical prophylaxis
Below knee anti embolic stockings (AES): wear day and night until discharge or
no longer significantly immobile.
Flowtron® intermittent pneumatic compression (IPC): apply intraoperatively and
consider post-operatively if pharmacological thromboprophylaxis contraindicated
IPC contraindications
Peripheral arterial disease
Local skin condition precluding
Known or suspected acute DVT or PE
application
Severe CCF
Do not apply if the legs are elevated
during surgery
Foot impulse devices (FID): apply post operatively to patients while sitting and in
bed
FID contraindications
Pre-existing thrombophlebitis, DVT or
Use cautiously on the infected or
PE
insensate extremity
Severe CCF where increased fluid to
the heart may be detrimental
Temporary IVC filters: consider using if either mechanical or pharmacological
prophylaxis methods contraindicated
Document name: Venous Thromboembolism Prophylaxis Policy
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Issue date:24 January 2013
Author: Dr Jo Crowe
Ref.:795
Status: Approved
Page 22 of 33
Pharmacological prophylaxis
Bleeding risk assessment: review the bleeding risk below. Pharmacological VTE
prophylaxis should not be used where the bleeding risk outweighs the VTE risk.
Refer to the procedure specific guidance.
Bleeding risks
Active bleeding or risk of bleeding
Acquired bleeding disorders (e.g. acute
liver failure)
Concurrent use of anticoagulants known
to increase the risk of bleeding
Acute stroke
Thrombocytopenia (plt < 75 x 109/L)
Untreated inherited bleeding disorders
(e.g. haemophilia)
BP ≥230/120 mmHg
Spinal surgery
Epidural / spinal anaesthesia
expected within the next 12 hours
Epidural / spinal anaesthesia within
the previous 4 hours
Renal impairment eGFR < 30ml/min
Weight < 50kg
Prescribing Notes for Pharmacological
Thromboprophylaxis
(For patients already on therapeutic anticoagulation with warfarin see
intranet Periprocedural Anticoagulation Guideline 2011 For patients on
clopidogrel / aspirin see intranet Perioperative management of antiplatelet
agents (Haem 013/2012)
Dalteparin
Rivaroxaban 10mg po OD
Total knee and hip arthroplasty only
Timing
All chemical
thromboproph
ylaxis to
prescribed at
18.00
Dose
adjustment
Elective: post op 18.00
Trauma: prescribe on
admission and 18.00
thereafter.
Ideally allow 6-12 hours post
surgery before administering.
If surgery finishes in the
afternoon consider delaying
administration until day 1 post
op.
Weight:
<50kg: 2500 units once daily
50-100kg: 5000 units once
daily
100-150kg: 5000units twice
daily
>150kg: 7500 units twice
Administer day 3 post op at
18.00.
Day 1 and 2 post op:
TKA: Dalteparin 5000 units od
unless contraindicated
THA: FID's until day 3 post
operatively
Do not use if eGFR < 15ml/min.
Use unfractionated heparin 5000
units sc twice daily
Document name: Venous Thromboembolism Prophylaxis Policy
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Issue date:24 January 2013
Author: Dr Jo Crowe
Ref.:795
Status: Approved
Page 23 of 33
Dalteparin
Rivaroxaban 10mg po OD
Total knee and hip arthroplasty only
Neuraxial
anaesthesia spinal
daily
eGFR<10ml/min
unfractionated heparin 5000
units sc twice daily
Administer ≥ 12 hours preinsertion or pre-removal
Administer ≥ 6 hours post
insertion
Neuraxial
anaesthesia epidural
Administer ≥ 12 hours pre
insertion or pre-removal
Administer ≥ 6 hours post
insertion or removal
Post op
vomiting
N/A
Drug
interactions
Nil
Contraindicati
ons
Anticoagulated (INR > 2.0),
treatment dose LMWH, iv
heparin or abnormal clotting
New onset stroke
Hypertension (BP >
230/120)
Platelets < 75 x 109/l
Active bleeding
Heparin allergy / previous
HIT
Known bleeding disorder
Other bleeding risk
Check anti Xa level. Discuss
with haematologist on call.
Consider delaying surgery or
procedure for 24 hours.
Consider the use of
protamine sulphate
Emergency
surgery or
procedures
Only to be given post op
Administer ≥ 6 hours post
insertion or removal
Administer ≥ 21 hours pre
removal
Only to be given post op
Administer ≥ 6 hours post
insertion or removal
Administer ≥ 21 hours pre
removal
If unable to take first dose of
rivaroxaban (eg vomiting), give a
stat dose of dalteparin and start
rivaroxaban 24hrs after
dalteparin.
CYP3A4 inducers eg rifampicin
reduce the levels of rivaroxaban.
CYP3A4 inhibitors eg
ketaconazole, ritonavir increase
the levels of rivaroxaban
eGFR < 15ml/min
hepatic disease associated
with a coagulopathy
clinically relevant bleeding
risk
There is no antidote to
rivaroxaban. The half life of
rivaroxaban is 21 hours.
If possible delay surgery or
procedure for 36 hours. If this is
not possible then inform on call
haematologist and proceed with
surgery. If bleeding cannot be
controlled consider use of
Beriplex.
Document name: Venous Thromboembolism Prophylaxis Policy
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Issue date:24 January 2013
Author: Dr Jo Crowe
Ref.:795
Status: Approved
Page 24 of 33
Extended (post discharge) prophylaxis
Surgery
Total hip
arthroplasty
Total knee
arthroplasty
Fractured neck
of femur
Other high risk
patients:
personal history
of VTE, lower
limb surgery
requiring
extended postoperative
immobilisation.
Prophylaxis
Rivaroxaban
10mg PO OD
for 4 weeks
post-operatively
Rivaroxaban
10mg PO OD
for 2 weeks
post operatively
Dalteparin for 4
weeks postoperatively
Dalteparin for
the duration of
the
immobilisation
Monitoring
Nil
Dose adjustment
Renal impairment:
eGFR<15ml/min use
unfractionated heparin 5000
units sc twice daily
Nil
Nil
Nil
Weight adjusted dalteparin:
< 50kg: 2500 units once
daily
50kg-100kg: 5000 units
once daily
100kg-150kg 5000 units
twice daily
>150kg: 7500 units twice
daily
Renal impairment:
eGFR<10ml/min use
unfractionated heparin 5000
units sc twice daily
Discharge with sufficient rivaroxaban/dalteparin for extended thromboprophylaxis
Document name: Venous Thromboembolism Prophylaxis Policy
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Issue date:24 January 2013
Author: Dr Jo Crowe
Ref.:795
Status: Approved
Page 25 of 33
Appendix 9: Trauma and Orthopaedic procedure
specific Thromboprophylaxis Guidance
Hip surgery prophylaxis
Primary and revision THA
• IPC in theatre
• Early mobilisation
• FID for 48 hours post surgery
• Rivaroxaban starting day 3 post op and continuing for 4 weeks. Dalteparin
where rivaroxaban is contraindicated.
Neck of femur fracture patients
• Ensure adequate hydration
• Dalteparin from day of admission continued for 4 weeks post surgery
• IPC in theatre
Hip surgery procedures <60 mins. i.e. LOW risk:
Hip injections and hip arthrograms
All other hip surgery procedures take >60 mins. and are high risk
Knee surgery prophylaxis
Arthroscopy
• Early mobilisation
• AES for two weeks post surgery +/- dalteparin perioperatively in high risk
patients
Ligament reconstruction surgery
• Early mobilisation
• Consider AES for two weeks post surgery
High tibial osteotomy
• Early mobilisation
• AES for six weeks post surgery
UKA, TKA, revision TKA
• IPC in theatre
• Early mobilisation
• Dalteparin starting post surgery and continuing until day 2 post op. Start
rivaroxaban day 3 post op and continue for 2 weeks. Use dalteparin
throughout if rivaroxaban contraindicated.
Knee surgery procedures <60 mins. i.e. LOW risk:
Knee arthroscopy
All other knee surgery procedures take >60 mins. and are high
risk
Document name: Venous Thromboembolism Prophylaxis Policy
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Issue date:24 January 2013
Author: Dr Jo Crowe
Ref.:795
Status: Approved
Page 26 of 33
Foot and ankle surgery prophylaxis
•
•
Early mobilisation.
If extended immobilisation required after surgery then consider extended
thromboprophylaxis with dalteparin until mobility restored
Foot and ankle surgery procedures <60 mins. i.e. LOW risk:
Ankle arthroscopy
Excisions Morton's neuroma
Lesser toe correction surgery
Isolated bunion correction surgery
Cheilectomy of big toe
Excision of lump, ganglion or soft tissue mass
All other foot and ankle surgery procedures take >60 mins and are
high risk
Upper limb surgery prophylaxis
•
•
Early mobilisation
High risk patients undergoing surgery and general anaesthetic ≥90 mins
use IPC in theatre and AES post surgery until fully mobile.
Hand surgery procedures >90 mins ie HIGH risk:
MCPJ replacement
Total elbow replacement
Total wrist replacement
Complex multi finger Dupuytrens surgery
All other hand surgery procedures take <90 mins and are low risk
Shoulder surgery procedures <90 mins ie LOW risk:
Diagnostic arthroscopy
Arthroscopic sub-acromial decompression (ASAD)
Excision of acromioclavicular joint (ACJ)
ASAD + excision ACJ
Frozen shoulder release
Arthroscopic debridement
All other shoulder surgery procedures take >90 mins and are high
risk
Document name: Venous Thromboembolism Prophylaxis Policy
th
Issue date:24 January 2013
Author: Dr Jo Crowe
Ref.:795
Status: Approved
Page 27 of 33
Spinal surgery prophylaxis
•
•
•
•
AES continued until fully mobile
IPC in theatre
Early mobilisation
If extended immobilisation necessary discuss with consultant prior to
commencing any chemical thromboprophylaxis.
Spinal surgery procedures <90 mins ie LOW risk:
Simple discectomy
Simple unilateral fenestration / decompression for lateral recess
stenosis
All injection procedures
All other spinal surgery procedures take >90 mins and are high
risk
Document name: Venous Thromboembolism Prophylaxis Policy
th
Issue date:24 January 2013
Author: Dr Jo Crowe
Ref.:795
Status: Approved
Page 28 of 33
Appendix 10:
Guideline
Critical Care Thromboprophylaxis
Assess risks of VTE and bleeding on admission to critical care unit.
Reassess risks of VTE and bleeding daily
Pharmacological thromboprophylaxis
LMWH: dalteparin
Dose
Standard dose 5000units od
Reduced dose 2500units od
Increased dose 5000units bd
Increased dose 7500units bd
Weight (kg)
50-100 kg
< 50 kg
100 – 150 kg
> 150 kg
eGFR
eGFR <10 ml/min: use
unfractionated heparin 5000
units sc twice daily
Reversal of LMWH if significant bleeding
Protamine sulphate will partially reverse the anticoagulant effect. Discuss with
Haematologist on call.
Mechanical methods
Anti-embolic stockings (AES)
Use as an adjunct or alternative to pharmacological prophylaxis when there is
increased risk of bleeding from heparin use due to patient or procedure related
factors.
Intermittent Pneumatic Compression (IPC) devices (full or knee length)
Use when pharmacological prophylaxis is contraindicated as part of speciality
specific guidelines.
Foot Impulse Devices
Require correct use and should only be used as part of speciality specific guidelines
Document name: Venous Thromboembolism Prophylaxis Policy
th
Issue date:24 January 2013
Author: Dr Jo Crowe
Ref.:795
Status: Approved
Page 29 of 33
Contraindications to mechanical thromboprophylaxis
Anti-embolic stockings
• Suspected or proven peripheral arterial disease
• Peripheral arterial bypass grafting
• Peripheral neuropathy or other causes of sensory impairment
• Local condition in which stockings may cause damage e.g. fragile tissue
paper skin, leg ulcers, dermatitis, gangrene or recent skin graft
• Known allergy to material of manufacture
• Cardiac failure
• Massive leg oedema
• Pulmonary oedema from congestive cardiac failure
• Unusual leg shape or size
• Major limb deformity preventing correct fit
Leg or foot ulcers or wounds; use caution or clinical judgement
Flowtron® intermittent pneumatic compression
• Known allergy to material of manufacture
• Known or suspected acute DVT or PE
• Peripheral arterial disease
• Local skin condition precluding application
• Severe congestive cardiac failure
• Do not apply if the legs are elevated during surgery
Foot impulse devices (FID)
• Pre existing thrombophlebitis, DVT or PE
• Severe congestive cardiac failure
• Use cautiously on an infected or insensate extremity
ICU specific guidance
•
•
•
•
•
Activated Protein C is not a contraindication to prophylactic doses of dalteparin
Prophylaxis can be introduced within 24 hours post-operatively in vascular
surgery.
In spinal injuries, prophylaxis can generally be commenced after 24 hours postoperatively or post-injury if the management is to be conservative: discuss with
the orthopaedic team.
In head injuries, prophylaxis can be commenced 24 hours post-injury provided
haemostasis is achieved and surgery is not planned within the next 12 hours.
Inferior vena cava filters are only indicated to prevent PE in patients with DVT
who have a contraindication to anticoagulation. Where possible removable filters
should be used.
Document name: Venous Thromboembolism Prophylaxis Policy
th
Issue date:24 January 2013
Author: Dr Jo Crowe
Ref.:795
Status: Approved
Page 30 of 33
Document Control Information
Ratification Assurance Statement
Dear
Dr Tim Craft
Please review the following information to support the ratification of the below named
document.
Name of document:
Name of author:
Dr Jo Crowe
Job Title:
Consultant Haematologist
I, the above named author confirm that:
•
The Policy presented for ratification meets all legislative, best practice and other
guidance issued and known to me at the time of development of the Policy;
•
I am not aware of any omissions to the Policy, and I will bring to the attention of the
Executive Director any information which may affect the validity of the Policy
presented as soon as this becomes known;
•
The Policy meets the requirements as outlined in the document entitled Trust-wide
Policy for the Development and Management of Policies (v4.0);
•
The Policy meets the requirements of the NHSLA Risk Management Standards to
achieve as a minimum level 2 compliance, where applicable;
•
I have undertaken appropriate and thorough consultation on this Policy and I have
documented the names of those individuals who responded as part of the
consultation within the document. I have also fed back to responders to the
consultation on the changes made to the Policy following consultation;
•
I will send the Policy and signed ratification checklist to the Policy Coordinator for
publication at my earliest opportunity following ratification;
•
I will keep this Policy under review and ensure that it is reviewed prior to the review
date.
Signature of Author:
Name of Person
Ratifying this policy:
Date:
Dr Tim Craft
Job Title:
Medical Director
Signature:
Date:
To the person approving this policy:
Please ensure this page has been completed correctly, then print, sign and
post this page only to: The Policy Coordinator, John Apley Building.
The whole policy must be sent electronically to: [email protected]
Document name: Venous Thromboembolism Prophylaxis Policy
th
Issue date:24 January 2013
Author: Dr Jo Crowe
Ref.:795
Status: Approved
Page 31 of 33
Consultation Schedule
Name and Title of Individual
Not applicable – only editing changes made
Date Consulted
The following people have submitted responses to the consultation process:
Name and Title of Individual
Date Responded
Name of Committee/s (if applicable)
Date of
Committee
Document name: Venous Thromboembolism Prophylaxis Policy
th
Issue date:24 January 2013
Author: Dr Jo Crowe
Ref.:795
Status: Approved
Page 32 of 33
Equality Impact: (A) Assessment Screening
To be completed when submitted to the appropriate Executive Director for
consideration and approval.
Person responsible for the assessment:
Name:
Job Title:
Jo Crowe
Consultant Haematologist
Does the document/guidance affect one
group less or more favourably than another
on the basis of:
Yes/No
Race
Yes
No
Ethnic origins (including gypsies and travellers)
Yes
No
Nationality
Yes
No
Gender (including gender reassignment)
Yes
No
Culture
Yes
No
Religion or belief
Yes
No
Sexual orientation
Yes
No
Age
Yes
No
Yes
No
Is there any evidence that some groups are affected
differently?
Yes
No
If you have identified potential discrimination, are there
any valid exceptions, legal and/or justifiable?
Yes
No
Is the impact of the document/guidance likely to be
negative?
Yes
No
If so, can the impact be avoided?
Yes
No
What alternative is there to achieving the
document/guidance without the impact?
Yes
No
Can we reduce the impact by taking different action?
Yes
No
Disability
(learning disabilities, physical disability, sensory impairment and
mental health problems)
Document name:
Issue date:
Author:
Comments
Ref.:
Status:
Page 33 of 33