Care Pathway
Assessment for Adult Patients with
Suspected DVT
affix patient label
Patient Tel No:
Page 1 of 10
Date
Time arrived
Named Nurse
Time seen
GP Name
BP
Pulse
SAO2 (%)
Temp
weight
Calf Diameter
Pregnant
IVDU?
If IVDU ?groin injector
If yes ?same side as symptoms
D-Dimer
FBC/COAG/U&E/LFTs/Calcium
GP Address
0C
Kg
L=
YES / NO
Never / current / previous
YES / NO
YES / NO
YES / NO
YES / NO
R=
WELLS CRITERIA: (Clinical Probability)
Lower limb trauma/immobilisation in POP
+1 Pitting oedema confined to symptomatic leg
Bedridden>3 days/surgery in last 4 weeks
+1 Entire limb swollen
Tenderness along lines of femoral/popliteal veins +1 Dilated superficial collateral veins
Malignancy (treatment ongoing or within previous +1 Previous DVT/PE/thrombophilia
6 months or palliative)
(diagnostic D-Dimer)
Difference in calf circumference 3cms or more
+1 Alternative diagnosis as/more likely than DVT
Total Wells Score
+1
+1
+1
+1
-2
ON EXAMINATION:
PAST MEDICAL HISTORY:
ALLERGIES
CURRENT MEDICATION:
SOCIAL HISTORY:
COMMENTS
RISK FACTORS FOR ANTICOAGULATION
Any recent bleeding episodes
Thrombocytopenia (platelets
YES
<75x109/l)
YES
Eye or neurosurgery within last month
YES
Multiple comorbidities:
e.g. interacting meds/falls risk
High alcohol intake (especially binge drinker)
YES
Abnormal liver function tests (if known)
YES
Concerns over compliance
YES
YES
If yes to any of the above book an above knee scan only
Document Version 1.1 (February 2013)
Review Date: February 2015
Author: Amanda Clark / Emma Kinnaird
Care Pathway
Assessment for Adult Patients with
Suspected DVT
affix patient label
Page 2 of 10
Score <1
LOW RISK
D dimer indicated
Result =
IVDU
D dimer not indicated – direct to imaging. Send bloods to pathology
Refer patient for DUPLEX SCAN
NB if risk factors for bleeding above knee only scan
D dimer raised
Send bloods to
pathology
D dimer not
raised
PREGNANT⃰
Score >2
HIGH RISK
Score 1-2
MODERATE RISK
If the scan cannot be performed on the same day consider treatment
dose Enoxaparin in the interim (especially in pregnant women)
Full leg
scan No
DVT
No Above Knee
DVT
Calf not scanned
No DVT
Discharge with advise to see
GP if symptoms persist:
Date / Time:
Isolated Superficial
Thrombophlebitis
DVT
confirmed
Explain result to patient send and fax
Take blood for D dimer (if not done)
Explain results to patient
Refer back to GP send and
fax ‘No evidence of DVT’ letter
Inconclusive
‘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 DVT
INVESTIGATIONS
FBC
U/E
LFT
Date
Repeat scan
CONTINUE
ON
PATHWAY
DVT
confirmed
Urinalysis
Results
Hb
MCV
Platelets
Creat.
Urea
Na
K
Bilirubin
ALP
Protein
Albumin
PT
secs
INR
APTT
secs
APTTR
Inform GP if urinalysis positive
Pregnancy test
Recommended in all women of childbearing potential if not known to be pregnant.
Clotting Screen
WBC
Calcium
eGFR
ALT
Globulin
D-dimer
Pregnant women: discuss all women with positive scans in with the on call obstetric and gynae registrar bleep
2922. If no DVT inform referring Dr
SIGNATURE
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Author: Amanda Clark / Emma Kinnaird
Care Pathway
Assessment for Adult Patients with
Suspected DVT
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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 ulcer
YES / NO
Concurrent medical problem requiring admission
YES / NO
Severe hepatic/renal impairment
YES / NO
Patient frail/unsteady/unable to mobilise/in severe pain
YES / NO
Unable to comply with return or follow-up
YES / 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 months
YES / NO
Bilateral DVT
YES / NO
Persistent cough
YES / NO
Recent unexplained abdominal pain
YES / NO
Abdominal distension
YES / NO
Haematuria – if current refer directly to urology to consider admission
YES / 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 gynaecology
YES / 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)
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Review Date: February 2015
YES / NO
Author: Amanda Clark / Emma Kinnaird
Care Pathway
Assessment for Adult Patients with
Suspected DVT
affix patient label
Page 4 of 10
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
RISK FACTOR
ACTION
Surgery within last 90 days
YES / NO
Hospital admission in last 90 days
YES / NO
Immobility following lower limb fracture
(including POP)
YES / NO
if yes please specify
if yes please specify
Pregnancy
YES / NO
Combined oral contraceptive pill/
Hormone replacement
YES / NO
Known underlying malignancy
YES / NO
Known IVDU
YES / NO
Report as a clinical incident and inform
the consultant responsible for the initial
episode of care
Report as a clinical incident
Discuss with on call obstetric registrar
bleep 2922
Enoxaparin 1mg/Kg twice daily
Advise patient to discuss alternative
contraception/symptom control with
their GP
Refer back to oncologist
Enoxaparin 1.5mg/Kg once a day
Rivaroxaban OR
Enoxaparin 1.5mg/Kg once a day
5. Does the patient need Referral to Haematology clinic?: (Tick which apply)
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
Treatment choice after discussion with the patient:
Rivaroxaban
Enoxaparin then warfarin
Enoxaparin only
SIGNATURE
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Care Pathway
Assessment for Adult Patients with
Suspected DVT
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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/time
Comments
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Review Date: February 2015
Signature
Author: Amanda Clark / Emma Kinnaird
Care Pathway
Assessment for Adult Patients with
Suspected DVT
affix patient label
Page 6 of 10
Date/time
Comments
Document Version 1.1 (February 2013)
Signature
Review Date: February 2015
Author: Amanda Clark / Emma Kinnaird
Care Pathway
Assessment for Adult Patients with
Suspected DVT
affix patient label
Page 7 of 10
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
UHB “Deep vein Thrombosis” leaflet
Give NPSA oral anticoagulation pack
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/Date
Comments
Signature
INR
Enoxaparin
Warfarin
INR
Enoxaparin
Warfarin
INR
Enoxaparin
Warfarin
INR
Enoxaparin
Warfarin
INR
Enoxaparin
Warfarin
Document Version 1.1 (February 2013)
Review Date: February 2015
Author: Amanda Clark / Emma Kinnaird
Care Pathway
Assessment for Adult Patients with
Suspected DVT
affix patient label
Page 8 of 10
Time/Date
Comments
Signature
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
Document Version 1.1 (February 2013)
Review Date: February 2015
Author: Amanda Clark / Emma Kinnaird
Care Pathway
Assessment for Adult Patients with
Suspected DVT
affix patient label
Page 9 of 10
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 1st)
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
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Review Date: February 2015
Author: Amanda Clark / Emma Kinnaird
Care Pathway
Assessment for Adult Patients with
Suspected DVT
affix patient label
Page 10 of 10
CARE PLAN FOR PATIENTS WITH SUPERFICIAL THROMBOPHLEBITIS
Scan confirms Superficial Thrombophlebitis only
Clot extends to within 3cm of sapheno-femoral junction?
YES: Therapeutic anticoagulation
should be considered for 6 weeks
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
Scan Rebooked
Date:
Time:
No:
NSAIDS have been tried with no improvement?
NSAIDS are contraindicated †
>5cm area affected
Risk factors present
YES/NO
YES/NO
YES/NO
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
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.
Recommend trial of
NSAID
Review if deterioration
or no resolution at 1
week
* 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.
Send and fax “Superficial Thrombophlebitis ” letter to GP
SIGNATURE
Document Version 1.1 (February 2013)
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Review Date: February 2015
Author: Amanda Clark / Emma Kinnaird