CHHS15/130

Canberra Hospital and Health ServicesClinical ProcedureVenous Thromboembolism (VTE) PreventionContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Alerts.........................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – VTE Prevention.......................................................................................................2

1. Risk Assessment.............................................................................................................2

2. Prophylaxis Prescribing..................................................................................................3

3. Prophylaxis Administration............................................................................................4

4. Patient Education...........................................................................................................4

Section 2 – VTE Prevention: Children........................................................................................5

Implementation........................................................................................................................ 6

Related Policies, Procedures, Guidelines and Legislation.........................................................6

References................................................................................................................................ 6

Definition of Terms: Abbreviations...........................................................................................6

Search Terms............................................................................................................................ 6

Attachments..............................................................................................................................7

Attachment 1: Venous Thromboembolism Prophylaxis Guidelines......................................8

Attachment 2: “Stop the Clot” Patient Brochure................................................................12

Doc Number Version Issued Review Date Area Responsible PageCHHS15/130 1 8/5/2015 1/3/2019 CACHS 1 of 13

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS15/130

Purpose

The purpose of this procedure is to:1. Provide guidance to clinicians on the appropriate use of thromboprophylaxis 2. Specify procedures to be followed to identify patients in need of thromboprophylaxis.

Back to Table of Contents

Scope

Alerts

Venous thromboembolism is a serious risk to acutely unwell patients, being a well recognised cause for morbidity and mortality related to hospitalisation, immobilisation, medical illness or surgical procedures. This risk can be reduced with the use of prophylactic measures according to identified risk assessment.

Back to Table of Contents

Scope

The Procedure will be applied to all patients admitted to Canberra Hospital. It describes the procedures by which members of the clinical staff will undertake a venous thromboembolism risk assessment and consider appropriate prophylactic measures.

For information on Anticoagulation medications and management, see the Anticoagulation Procedure.

Back to Table of Contents

Section 1 – VTE Prevention

Procedure 1. Risk AssessmentAll patients will have their VTE risk assessed within 24 hours of hospital admission. The risk assessment must be carried out by a medical officer.

The risk assessment will be carried out according to the Venous Thromboembolism Prophylaxis Guidelines (Attachment 1) which can be found in the bedside folder of every patient. More detailed prophylaxis guidelines for obstetric patients (both inpatient and outpatient) are provided in the CHHS Anticoagulation Management Clinical Procedure-Section 9

The medical officer who conducts the risk assessment will document the risk assessment outcome, and any contraindications identified to either pharmacological or mechanical

Doc Number Version Issued Review Date Area Responsible PageCHHS15/130 1 8/5/2015 1/3/2019 CACHS 2 of 13

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS15/130

prophylaxis, on the VTE Prophylaxis section of the National Inpatient Medication Chart (NIMC).

VTE risk needs to be assessed and documented weekly, or when the patient’s condition changes, on the medication chart.Any discrepancies between clinicians risk assessment must be discussed with the managing team.

2. Prophylaxis Prescribinga. Pharmacological ProphylaxisMedical Officers will prescribe appropriate VTE prophylaxis using the Venous Thromboembolism (VTE) Risk Assessment and Prophylaxis Guide (Attachment 1) and risk assessment results.

Pharmacological prophylaxis will be prescribed on the ‘Medication’ field of the VTE Prophylaxis section on the patient’s medication chart.

If pharmacological prophylaxis is contraindicated, clear documentation on the VTE prophylaxis section on the patient’s medication chart and in the patient’s medical record is required, along with the reason for the contraindication.

Pharmacists will review the prophylaxis prescription using the Venous Thromboembolism(VTE) Risk Assessment and Prophylaxis Guide (Attachment 1) and risk assessment results and ensure any discrepancies are discussed with the managing team.

b. Mechanical ProphylaxisMedical Officers will assess the need for mechanical prophylaxis using the Venous Thromboembolism (VTE) Risk Assessment and Prophylaxis Guide (Attachment 1) and risk assessment results.

Mechanical prophylaxis requirements will be documented on the ‘Mechanical Prophylaxis’ field of the VTE Prophylaxis section on the patient’s medication If mechanical prophylaxis is contraindicated, clear documentation on the VTE Prophylaxis section the patient’s medication chart and in the patient’s medical record is required, along with the reason for the contraindication.

Doc Number Version Issued Review Date Area Responsible PageCHHS15/130 1 8/5/2015 1/3/2019 CACHS 3 of 13

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS15/130

3. Prophylaxis AdministrationNursing staff will administer pharmacological prophylaxis according to the medication prescription on the VTE Prophylaxis section on the patients medication chart and document the administration.

Nursing staff will apply appropriate mechanical prophylaxis and document the application and checking (twice daily, once in the AM and once in the PM) on the VTE Prophylaxis section of the patient’s medication chart.

4. Patient EducationNursing staff, Pharmacists and Medical Officers will provide education to patients and carers to help raise awareness of the importance of VTE prevention, describe the treatments to prevent VTE and outline what patients should do to reduce risk both during admission and upon discharge.

A patient information brochure “Blood Clots: Reducing your Risk” is available in English from the National Health and Medical Research Council website:http://www.nhmrc.gov.au/_files_nhmrc/file/nics/material_resources/stop_the_clot_patient_brochure_crop.pdf.

The consumer brochure is also available in 13 other languages: Arabic, Chinese, Croatian, French, Greek, Italian, Macedonian, Polish, Russian, Serbian, Spanish, Turkish and Vietnamese at the following site:https://www.nhmrc.gov.au/guidelines-publications/cp134a

See Attachment 2 for the information Brochure.

5. Reassessing Risk at Discharge and Continuity of CarePatients who have been identified as being at risk of VTE during their admission are required to be reassessed at the point of discharge to determine if there is a need for extended prophylaxis. The recommended duration of pharmacological prophylaxis depends on the patient’s medical and mobility status as per the Venous Thromboembolism Prophylaxis Guidelines (Attachment 1).

Patients who require extended prophylaxis should have a thorough plan handed over from the assessing medical officer to the patient’s continuing care provider, and this should be explained to patients and carers. Further information on appropriate clinical handover can be found in the Clinical Handover Procedure.

Prior to discharge home or to another care facility, an ongoing supply of required prophylaxis should be organised to ensure uninterrupted treatment. Plans relating to the continued supply of prophylaxis once discharged should be clearly communicated to patients and carers. The patient should understand the reason for and importance of continued prophylaxis and the plan for its continuation.

Back to Table of Contents

Doc Number Version Issued Review Date Area Responsible PageCHHS15/130 1 8/5/2015 1/3/2019 CACHS 4 of 13

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS15/130

Section 2 – VTE Prevention: Children

In general children are at extremely low risk of VTE. Specific prophylaxis is rarely required in the paediatric population.

Early mobilisation and adequate hydration should be routinely practiced to minimise the risk of VTE. However, VTE does occasionally occur in paediatric patients and paediatric patients at risk should be considered for VTE thromboprophylaxis1-3.

Mechanical thromboembolism prophylaxis is not recommended2.

Low molecular weight heparin (LMWH) is recommended for VTE prophylaxis for high risk paediatric patients.

Procedure Paediatric patients at high risk of VTE should be identified using the following guidelines2,4:1. High risk paediatric surgical patients2. A prior history of VTE not related to an intravenous line3. Paediatric patients with any four of the following identified risk factors:

Age: less than 3 months, or older than 15 years, or post-pubertal. Significant co-morbidities – any infection, or inflammatory disease (e.g. inflammatory

bowel disease, connective tissue diseases, Kawasaki disease, nephrotic syndrome) or congenital heart disease.

Presence of cancer - this includes haematological cancer such as leukaemia. Severe injury – this includes chest injury, abdominal injury, limb fractures

(particularly lower limb), head injury, multiple injuries etc. Major surgery – e.g. chest, abdominal, spinal, lower limb orthopaedic, craniotomy. Presence of a central venous catheter. Previous line-related VTE – i.e., thrombosis at the site of a central venous catheter or

PICC line. “Oestrogenic states” – pregnancy, use of the oral contraceptive, or miscarriage

/termination in the last 3 months. Known (or strongly suspected to have) Inherited thrombophilia (factor V Leiden gene

mutation, prothrombin gene mutation, protein C deficiency, protein S deficiency, antithrombin deficiency, raised plasma factor VIII, raised plasma homocysteine) or antiphospholipid syndrome.

High risk patients should be administered LMWH prophylaxis starting 6-12 hours post operatively, where there is adequate haemostasis.

Enoxaparin is recommended in high risk patients at the following doses2: 0.5mg/kg/dose bd ( to a maximum of 20mg bd) if ≥ 2 months old 0.75mg/kg/dose bd if < 2 months old

It should be ceased when the patient is mobile or on discharge.

Doc Number Version Issued Review Date Area Responsible PageCHHS15/130 1 8/5/2015 1/3/2019 CACHS 5 of 13

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS15/130

Back to Table of Contents

Implementation

Email notification to all medical staff

Back to Table of Contents

Related Policies, Procedures, Guidelines and Legislation

ProceduresCHHS Anticoagulation Management procedure, CHHS15/131

Guidelines National Health and Medical Research Council “Blood Clots: Reducing your Risk” Brochure

Back to Table of Contents

References

1. Stein PD, Kayali F, Olson RE: Incidence of venous thromboembolism in infants and children: data from the National Hospital Discharge Survey. J Pediatr 145:563-5, 2004

2. Westmead TCsHa: Thromboprophylaxis in surgical and trauma paediatric patients practice guideline, in Health n (ed), NSW health, 2010

3. Vavilala MS, Nathens AB, Jurkovich GJ, et al: Risk factors for venous thromboembolism in pediatric trauma. J Trauma 52:922-7, 2002

4. Jackson PC, Morgan JM: Perioperative thromboprophylaxis in children: development of a guideline for management. Paediatr Anaesth 18:478-87, 2008

Back to Table of Contents

Definition of Terms: Abbreviations

VTE - Venous thromboembolismLMWH - Low molecular weight heparinNIMC - National Inpatient Medication Chart

Back to Table of Contents

Search Terms

Venous thrombosisPulmonary embolismVenous thromboembolismAnticoagulation

Back to Table of ContentsDoc Number Version Issued Review Date Area Responsible PageCHHS15/130 1 8/5/2015 1/3/2019 CACHS 6 of 13

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS15/130

Attachments

Attachment 1: Venous Thromboembolism Prophylaxis GuidelinesAttachment 2: “Stop the Clot” Patient Brochure

Disclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and ACT Health assumes no responsibility whatsoever.

Date Amended Section Amended Approved By05/08/2016 Section 1 CHHSPC Chair

Doc Number Version Issued Review Date Area Responsible PageCHHS15/130 1 8/5/2015 1/3/2019 CACHS 7 of 13

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS15/130

Attachment 1: Venous Thromboembolism Prophylaxis Guidelines

Doc Number Version Issued Review Date Area Responsible PageCHHS15/130 1 8/5/2015 1/3/2019 CACHS 8 of 13

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS15/130

Doc Number Version Issued Review Date Area Responsible PageCHHS15/130 1 8/5/2015 1/3/2019 CACHS 9 of 13

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS15/130

Doc Number Version Issued Review Date Area Responsible PageCHHS15/130 1 8/5/2015 1/3/2019 CACHS 10 of 13

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS15/130

Doc Number Version Issued Review Date Area Responsible PageCHHS15/130 1 8/5/2015 1/3/2019 CACHS 11 of 13

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS15/130

Attachment 2: “Stop the Clot” Patient Brochure

Doc Number Version Issued Review Date Area Responsible PageCHHS15/130 1 8/5/2015 1/5/2017 CACHS 12 of 13

CHHS15/130

Doc Number Version Issued Review Date Area Responsible PageCHHS15/130 1 8/5/2015 1/5/2017 CACHS 13 of 13