NICS Venous Thromboembolism
Risk Assessment Form Version 2 2008
1. Treating doctor or nurse to determine and document
highest VTE risk category
2. Check for contraindications to VTE prophylaxis
3. Record drugs and orders for GCS/IPC as per hospital
policy
4. Print name, sign and date on completion
Surgical VTE Risk▲
Tick
AFFIX PATIENT LABEL
Recommended VTE prophylaxis▲
LMWH or Fondaparinux#
AND IPC
(with or without GCS)
Hip arthroplasty
Knee arthroplasty
Major trauma
Hip fracture surgery
HIGH
LMWH or LDUH or Fondaparinux#
AND GCS (with or without IPC)
Other surgery with prior VTE &/or active cancer
LMWH or LDUH
AND GCS (with or without IPC)
Major surgery and age >40 yrs
(Major surgery refers to intra-abdominal surgery and all other operations >45 mins)
Other risk (please state):
All other surgery
LOWER
Consider GCS
All other surgery with additional VTE risk factors☼ (see over)
Medical VTE Risk▲ (see over)
Consider LMWH or LDUH & GCS
Tick
Ischaemic stroke
History of VTE
LMWH or LDUH
Active cancer
OR
Decompensated heart failure
HIGH
Acute on chronic lung disease
GCS &/or IPC
If heparin contraindicated
Acute inflammatory disease
Age > 60 years
Other risk (please state):
LOW
None of the above risk factors
No prophylaxis recommended
Are there any contraindications to chemical or mechanical prophylaxis? (indicate below)
Chemical
Tick
Mechanical
Tick
Active bleeding
Severe peripheral arterial disease
High risk of bleeding
e.g. Haemophilia, thrombocytopenia (platelet count <50 x 109/L),
history of GI bleeding
Severe peripheral neuropathy
Severe hepatic disease (INR >1.3)
Severe leg deformity
Adverse reaction to heparin
Recent skin graft
On current anticoagulation
Other (please state):
Other (please state):
No contraindications to mechanical prophylaxis
No contraindications to chemical prophylaxis
Patient risk status
Prophylaxis required?
→ Document risk status as per hospital policy
High
Lower/
Low
→
Document risk status as per hospital policy
Yes
→ All drugs and orders for GCS/IPC must be documented as per
hospital policy
No
→ Reason:
Patient assessed by
Name (PRINT):
Position:
Signature:
Date:
Key:
# Fondaparinux for orthopaedic surgery only
▲ Based on Prevention of Venous Thromboembolism: Best Practice
Guidelines for Australia and New Zealand 4th Edition, December 2007.
Abbreviations: LMWH
LDUH
GCS
IPC
Low molecular weight heparin
Low dose unfractionated heparin
Graduated compression stockings
Intermittent pneumatic compression
Details of risk stratification and recommended prophylaxis
Surgical Risk Stratification
Recommended VTE Prophylaxis
Duration
HIGH
LMWH(Enoxaparin 40mg/day OR
Dalteparin 5000 units/day) OR
Fondaparinux# 2.5mg/day
AND IPC (with or without GCS)
LMWH(Enoxaparin 40mg/day or
Dalteparin 5000 units/day)
OR Fondaparinux# 2.5mg/day OR LDUH
5000 units/TDS
AND GCS (with or without IPC)
LMWH (Enoxaparin 20mg/day OR
Dalteparin 2500 units/day) OR LDUH
5000 units BD or TDS
AND GCS (with or without IPC)
Consider GCS
If additional VTE risk factors☼ consider
LMWH(Enoxaparin 20mg/day or
Dalteparin 2500 units/day) or LDUH 5000
units BD or TDS
5-10 days
28-35 days for hip
arthroplasty
Hip arthroplasty
Knee arthroplasty
Major trauma
Hip fracture surgery
Other surgery with prior VTE &/or
active cancer
LOWER
Major surgery & age >40 years
(Major surgery refers to intraabdominal surgery and all other
operations >45 mins)
All other surgery
Medical Risk Stratification
HIGH
Ischaemic stroke
History of VTE
Active cancer
Decompensated heart failure
Acute on chronic lung disease
Acute inflammatory disease
Age >60 years
Other risk
LOW
None of the above
5-10 days
28-35 days for hip
fracture surgery
5-10 days
Until hospital discharge
LMWH(Enoxaparin 40mg/day OR
Dalteparin 5000 units/day)
OR LDUH 5000 units BD or TDS
OR
GCS (with or without IPC) if heparin
contraindicated
Until resolution of acute
medical illness or
hospital discharge
No prophylaxis recommended
Notes for Medical Risk Stratification
Please note: This is a guide only. If unsure please consult the treating doctor.
Ischaemic stroke: acute, confirmed by CT or MRI and unable to walk unassisted because of motor impairment with a
score of 2 or more (NIHSS) for motor function of the leg.
History of VTE: Previous PE or DVT.
Active cancer: prophylaxis is recommended for hospitalised or bed-ridden patients and ambulatory patients receiving
thalidomide or lenalidomide with chemotherapy or dexamethasone.
Decompensated heart failure: symptoms of heart failure that occur with minimal activity or at rest (NYHA Class III or IV).
Acute on chronic lung disease: respiratory failure or exacerbation of respiratory disease with or without ventilation.
Acute inflammatory disease: eg rheumatoid arthritis, systemic lupus erythematosus.
☼ Additional Risk Factors
Immobility: patients with permanent immobility or significant period of past immobilisation
Thrombophilia: evidence of a disorder of the haemostatic system which increases risk of thrombosis eg: antithrombin 3,
protein C, or protein S deficiencies.
Oestrogen therapy
Pregnancy: current or puerperium.
Active inflammation
Strong family history of VTE and/or obesity
References
1. Nicolaides AN, et al. Prevention and treatment of venous thromboembolism. International Consensus Statement
(Guidelines according to scientific evidence).International Angiology. 2006; 25(2):101-61.
2. Sherman DG, et al. PREVAIL Study, Lancet. 2007; 369:1347-55.
3. Lyman G, et al. American Society of Clinical Oncology guideline: Recommendations for venous thromboembolism
prophylaxis and treatment in patients with cancer. Journal of Clinical Oncology. 2007; 25(34):5490-505.
NOTE: All hospitals should have a venous thromboembolism (VTE) prophylaxis policy for assessment of VTE risk in admitted
patients. The policy should include information about appropriate prophylactic measures to minimise the risk of deep vein
thrombosis and pulmonary embolism in every admitted patient based on best practice recommendations. This sample risk
assessment form was developed by the National Institute of Clinical Studies in collaboration with the Private Hospital VTE
Prevention Program Advisory Committee. The recommendations used in this form are based on Prevention of Venous
Thromboembolism: Best Practice Guidelines for Australia and New Zealand, 4th Edition, December 2007, by the ANZ Working
Party on the Management and Prevention of Venous Thromboembolism.
This work was developed by NICS/NHMRC as part of the Private Hospital VTE Prevention Program. It may be reproduced in
whole or part subject to inclusion of an acknowledgement of the source. It may not be reproduced for commercial use or sale.