Presentation is loading. Please wait.

Presentation is loading. Please wait.

Affix patient label Care Pathway Assessment for Adult Patients with Suspected DVT Page 1 of 10 Document Version 1.1 (February 2013)Review Date: February.

Similar presentations


Presentation on theme: "Affix patient label Care Pathway Assessment for Adult Patients with Suspected DVT Page 1 of 10 Document Version 1.1 (February 2013)Review Date: February."— Presentation transcript:

1 affix patient label Care Pathway Assessment for Adult Patients with Suspected DVT Page 1 of 10 Document Version 1.1 (February 2013)Review Date: February 2015Author: Amanda Clark / Emma Kinnaird ON EXAMINATION: PAST MEDICAL HISTORY: Patient Tel No: BPIVDU?Never / current / previous PulseIf IVDU ?groin injectorYES / NO SAO 2 (%)If yes ?same side as symptomsYES / NO Temp 0 CD-DimerYES / NO weight KgFBC/COAG/U&E/LFTs/CalciumYES / NO Calf DiameterL= R= PregnantYES / NO DateGP Name Time arrived Named NurseGP Address Time seen WELLS CRITERIA: (Clinical Probability) Lower limb trauma/immobilisation in POP+1Pitting oedema confined to symptomatic leg+1 Bedridden>3 days/surgery in last 4 weeks+1Entire limb swollen+1 Tenderness along lines of femoral/popliteal veins+1Dilated superficial collateral veins+1 Malignancy (treatment ongoing or within previous 6 months or palliative) +1Previous DVT/PE/thrombophilia (diagnostic D-Dimer) +1 Difference in calf circumference 3cms or more+1Alternative diagnosis as/more likely than DVT-2 Total Wells Score CURRENT MEDICATION: SOCIAL HISTORY: ALLERGIES RISK FACTORS FOR ANTICOAGULATION COMMENTS Any recent bleeding episodesYES Thrombocytopenia (platelets <75x10 9 /l)YES Eye or neurosurgery within last monthYES Multiple comorbidities: e.g. interacting meds/falls risk YES High alcohol intake (especially binge drinker)YES Abnormal liver function tests (if known)YES Concerns over complianceYES If yes to any of the above book an above knee scan only

2 affix patient label Care Pathway Assessment for Adult Patients with Suspected DVT Page 2 of 10 Document Version 1.1 (February 2013)Review Date: February 2015Author: Amanda Clark / Emma Kinnaird SIGNATURE PRINT Pregnant women: discuss all women with positive scans in with the on call obstetric and gynae registrar bleep If no DVT inform referring Dr Score <1 LOW RISK Score 1-2 MODERATE RISK Score >2 HIGH RISK PREGNANTIVDU D dimer not indicated – direct to imaging. Send bloods to pathology D dimer indicated Result = Refer patient for DUPLEX SCAN NB if risk factors for bleeding above knee only scan If the scan cannot be performed on the same day consider treatment dose Enoxaparin in the interim (especially in pregnant women) D dimer raised Send bloods to pathology D dimer not raised Full leg scan No DVT Inconclusive Isolated Superficial Thrombophlebitis DVT confirmed No DVT Explain results to patient Refer back to GP send and fax ‘No evidence of DVT’ letter Discharge with advise to see GP if symptoms persist: Date / Time: CONTINUE ON PATHWAY Explain result to patient send and fax Take blood for D dimer (if not done) ‘inconclusive scan’ letter OR ‘No above knee DVT’ letter Rebook above knee scan in 1 week Date: Time: Advise to return sooner if symptoms worsen No Above Knee DVT Calf not scanned Repeat scan DVT confirmed No DVT INVESTIGATIONSDateResults FBCHb MCV Platelets WBC U/ECreat. Urea Na K Calcium eGFR LFTBilirubin ALP ALT Protein Albumin Globulin Clotting ScreenPT secs INR APTT secs APTTR D-dimer UrinalysisInform GP if urinalysis positive Pregnancy test Recommended in all women of childbearing potential if not known to be pregnant.

3 affix patient label Care Pathway Assessment for Adult Patients with Suspected DVT Page 3 of 10 Document Version 1.1 (February 2013)Review Date: February 2015Author: Amanda Clark / Emma Kinnaird MANAGEMENT OF PATIENTS WITH A CONFIRMED DEEP VEIN THROMBOSIS 1.Does the patient have risk factors for bleeding? Discuss with Haematology: (registrar bleep 2677) Outcome of the discussion: 2. Can the patient be managed as an out-patient? If YES to any of the following questions discuss with GPSU medical staff to agree a management plan aiming to manage in the community if possible. * circle those that apply Symptoms suggestive of pulmonary embolism: New shortness of breath; New cough; New chest pain; New haemoptysis* YES / NO Active or recent bleeding: (within last 4 weeks) Haemoptysis; Melaena; Haematemesis; Frank Haematuria; intra-cranial bleeding* YES / NO Bleeding risk e.g. liver disease, active peptic ulcerYES / NO Concurrent medical problem requiring admissionYES / NO Severe hepatic/renal impairmentYES / NO Patient frail/unsteady/unable to mobilise/in severe painYES / NO Unable to comply with return or follow-upYES / NO 3. Symptoms requiring further investigation: If YES to any of the following questions: discuss with GPSU to organise urgent onward investigations (in most cases these will be done as an outpatient) Unintentional weight loss >7lbs 3Kg in last 6 monthsYES / NO Bilateral DVTYES / NO Persistent coughYES / NO Recent unexplained abdominal painYES / NO Abdominal distensionYES / NO Haematuria – if current refer directly to urology to consider admissionYES / NO New prostatic symptoms – nocturia, increased urinary symptoms, poor stream If yes or ALL men over 60yrs check PSA YES / NO N/A Unexplained pv bleeding - refer directly to gynaecologyYES / NO / N/A Breast lumps/ Breast changes noticed (If they do not perform regular self examination or are uncertain consider GP referral to exclude pathology) YES / NO

4 affix patient label Care Pathway Assessment for Adult Patients with Suspected DVT Page 4 of 10 Document Version 1.1 (February 2013)Review Date: February 2015Author: Amanda Clark / Emma Kinnaird SIGNATURE PRINT Unprovoked thrombosis (including patients with weak risk factors e.g. travel, minor injuries Recurrent VTE (if <50; all events provoked; or concerns regarding long term anticoagulation) Women of childbearing potential Strong Family history of VTE or thrombophilia 5. Does the patient need Referral to Haematology clinic?: (Tick which apply) RISK FACTORACTION Surgery within last 90 days YES / NO if yes please specify Report as a clinical incident and inform the consultant responsible for the initial episode of care Hospital admission in last 90 days YES / NO if yes please specify Immobility following lower limb fracture (including POP) YES / NO PregnancyYES / NO Report as a clinical incident Discuss with on call obstetric registrar bleep 2922 Enoxaparin 1mg/Kg twice daily Combined oral contraceptive pill/ Hormone replacement YES / NO Advise patient to discuss alternative contraception/symptom control with their GP Known underlying malignancyYES / NO Refer back to oncologist Enoxaparin 1.5mg/Kg once a day Known IVDUYES / NO Rivaroxaban OR Enoxaparin 1.5mg/Kg once a day 4. Was there a clear provoking factor? If No to all of the following questions request a Chest X-ray and add name to GPSU weekly X-ray review list. Tick here if CXR requested reviewed by GPSU reported by radiology Treatment choice after discussion with the patient: Rivaroxaban Enoxaparin then warfarin Enoxaparin only

5 affix patient label Care Pathway Assessment for Adult Patients with Suspected DVT Page 5 of 10 Document Version 1.1 (February 2013)Review Date: February 2015Author: Amanda Clark / Emma Kinnaird CARE PLAN FOR PATIENTS WITH CONFIRMED DVT REQUIRING RIVAROXABAN  Explain result of scan and plan of treatment  Explain anticoagulant treatment and drug interaction, safety and side effects.  Give rivaroxaban patient information leaflet  Give UHB DVT leaflet  Send and fax “confirmed DVT requiring rivaroxaban” letter to GP  Give a three week supply of rivaroxaban 15mg twice daily  NB if Creatine Clearance <15ml/min DO NOT give rivaroxaban – discuss with MAU team,  However do not delay giving first dose if renal function not available DURATION OF TREATMENT: AS PER WARFARIN AND ENOXAPARIN Follow up  Appointment in 5-10 days to assess and if appropriate fit compression hosiery Appointment date………………time……………….location…………………….  Appointment for review in 3 weeks to switch to once daily treatment 20mg once daily rivaroxaban Appointment date………………time……………….location……………………. Record all visits below. It is important to record all adverse events and discuss with GP/Haematology Date/timeCommentsSignature

6 affix patient label Care Pathway Assessment for Adult Patients with Suspected DVT Page 6 of 10 Document Version 1.1 (February 2013)Review Date: February 2015Author: Amanda Clark / Emma Kinnaird Date/timeCommentsSignature

7 affix patient label Care Pathway Assessment for Adult Patients with Suspected DVT Page 7 of 10 Document Version 1.1 (February 2013)Review Date: February 2015Author: Amanda Clark / Emma Kinnaird CARE PLAN FOR PATIENTS WITH CONFIRMED DVT REQUIRING WARFARIN THERAPY Target INR: Duration of treatment: Explain results of scan and plan of treatment. Explain anticoagulant therapy, drug interactions, safety and side effects Give NPSA oral anticoagulation packUHB “Deep vein Thrombosis” leaflet Send and fax “Confirmed DVT requiring Warfarin therapy” letter to GP If baseline INR>1.3 repeat and discuss with Haematology Administer Clexane as per PGD, to continue until INR is >2.0 for two consecutive days or for five …days minimum. Check INR daily:If INR >5 Cross check Coagucheck machine on a venous sample If INR > 6 discuss with Haematologist Dose adjust warfarin on INR according to PGD and write NPSA anticoagulation record Ensure adequate level of analgesia and observe for any signs of cellulitis. On day 5, assess and if appropriate fit for compression hosiery. When INR has been stable and therapeutic for 2 days: Discharge to Anticoagulation pharmacist or …GP Time/DateCommentsSignature INR Enoxaparin Warfarin INR Enoxaparin Warfarin INR Enoxaparin Warfarin INR Enoxaparin Warfarin INR Enoxaparin Warfarin

8 affix patient label Care Pathway Assessment for Adult Patients with Suspected DVT Page 8 of 10 Document Version 1.1 (February 2013)Review Date: February 2015Author: Amanda Clark / Emma Kinnaird Time/DateCommentsSignature INR Enoxaparin Warfarin INR Enoxaparin Warfarin INR Enoxaparin Warfarin INR Enoxaparin Warfarin INR Enoxaparin Warfarin INR Enoxaparin Warfarin INR Enoxaparin Warfarin INR Enoxaparin Warfarin INR Enoxaparin Warfarin INR Enoxaparin Warfarin INR Enoxaparin Warfarin INR Enoxaparin Warfarin

9 affix patient label Care Pathway Assessment for Adult Patients with Suspected DVT Page 9 of 10 Document Version 1.1 (February 2013)Review Date: February 2015Author: Amanda Clark / Emma Kinnaird CARE PLAN FOR PATIENTS WITH CONFIRMED DVT REQUIRING ENOXAPARIN ONLY TREATMENT This care plan is for use in:Pregnant women Patients with known malignancy Intravenous drug users (consider rivaroxaban 1 st ) Other indications require discussion with Haematology Duration of treatment: Explain results of scan and plan of treatment: If pregnant discuss result with on call Obstetric Registrar. If scan negative or equivocal they may wish to assess or reassess and proceed with treatment if there is a high index of clinical suspicion Teach patient and/or relative to self-inject Give Clexane pack and sharps bin Send and fax “Confirmed DVT requiring Warfarin / Enoxaparin therapy” letter to GP Ensure adequate level of analgesia and observe for any signs of Cellulitis Dose: Standard patients Enoxaparin 1.5mg/kg daily Pregnant Patients Enoxaparin 1mg/kg twice daily Follow up: Between days 5 and 10 - Assess and if appropriate fit for compression hosiery. Check FBC. Arranged.Date: …………………………………………………….. Thereafter: Pregnant women: Ensure Obstetric Team book into first available antenatal clinic Patients with underlying malignancy: refer back to Oncologist Intravenous drug users: refer back to GP SIGNATURE PRINT

10 affix patient label Care Pathway Assessment for Adult Patients with Suspected DVT Page 10 of 10 Document Version 1.1 (February 2013)Review Date: February 2015Author: Amanda Clark / Emma Kinnaird Scan confirms Superficial Thrombophlebitis only Clot extends to within 3cm of sapheno-femoral junction? YES to any Risk assess for Clexane Advise Clexane at prophylactic dose* FBC at 1 week Review at 2 weeks or if symptoms progress and consider therapeutic Enoxaparin. * Standard prophylactic dose Enoxaparin 40mg once daily. Weight <50kg 20 mg Enoxaparin b.d Weight >100kg 40 mg Enoxaparin b.d Renal failure GFR<30mls/min max enoxaparin 20mg od – discuss risk / benefit with haematology. YES: Therapeutic anticoagulation should be considered for 6 weeks No: NSAIDS have been tried with no improvement? YES/NO NSAIDS are contraindicated † YES/NO >5cm area affected YES/NO Risk factors present YES/NO (PH VTE, active malignancy, anticipated prolonged immobility) † Known allergy to NSAIDS Known asthma Renal Impairment Previous GI bleed / known peptic ulcer disease Discuss with GPSU If risk factors present: (PH VTE, active malignancy, anticipated prolonged immobility) Anticoagulate with warfarin (or therapeutic low molecular weight heparin if active malignancy) for 6 weeks No risk factors present: Prophylactic low molecular weight heparin Rescan at 1 week change to therapeutic anticoagulation if no change in scan or progression CARE PLAN FOR PATIENTS WITH SUPERFICIAL THROMBOPHLEBITIS Recommend trial of NSAID Review if deterioration or no resolution at 1 week SIGNATURE PRINT Send and fax “Superficial Thrombophlebitis ” letter to GP Scan Rebooked Date: Time:


Download ppt "Affix patient label Care Pathway Assessment for Adult Patients with Suspected DVT Page 1 of 10 Document Version 1.1 (February 2013)Review Date: February."

Similar presentations


Ads by Google