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VTE risk assessments
From 1 June 2010, the Department of Health (DH) requires that VTE risk assessments take place for every patient, and that results are closely monitored in order to reduce the 25,000 preventable deaths that occur in UK hospitals every year. All nurses and health care assistants need to understand VTE prevention procedures, and the reasons why these procedures take place.
An e-version of this risk assessment tool will shortly be available, which will be instrumental in collating data regarding the appropriate completion of VTE risk assessments. The current CQUIN target for England is to achieve at least 90% risk assessment of all adult in-patients. Failure to meet this target will have financial implications for the hospital. Risk assessment requires that patients are checked for their mobility status and their thrombosis and bleeding risks.
When to risk assess people for VTE
The National Institute for Clinical Excellence (NICE, 2010) recommends that all patients should be assessed for risk of developing thrombosis (blood clots) on a regular basis, as follows:
- every patient should be assessed on admission to hospital
- every patient should be assessed again, 24 hours after admission to hospital
- every patient should be assessed again, whenever their medical condition changes
- every patient should be assessed again before discharge
- every patient should receive information on how to continue preventative measures at home.
The Scottish Intercollegiate Guidelines Network (SIGN) also recommends regular risk assessments to ensure that the most appropriate ongoing care is offered as a patient's condition develops. An updated guideline is anticipated for release in December 2010.
How to conduct a VTE risk assessment
The Department of Health advises that all students, nurses and healthcare assistants who have been appropriately trained and are approved to carry out risk assessments, do so in the following way:
- Routinely assess all patients on admittance to hospital for their level of mobility.
- All surgical patients, and all medical patients with significantly reduced mobility, should be considered as potentially at risk of developing VTE, and should be regularly monitored and further risk assessed.
- Look at the factors that may indicate a patient is likely to develop a DVT, such as: whether they have previous history of blood clots; whether they are obese; whether they have undergone surgery; whether they are pregnant or taking a contraceptive pill, etc. If at least one factor is present, the patient may require an anti-coagulant medicine such as heparin in accordance with NICE guidelines and only provided they are not at risk of bleeding.
- Provide verbal and written information to the patient and their carer on the symptoms, risks and possible consequences of VTE, including information on various forms of prophylaxis.
'Prophylaxis' means 'preventative measure'. The phrase 'pharmacological prophylaxis' refers to a drug-related preventative measure, whereas 'mechanical prophylaxis' refers to a preventative measure that involves a physical device. When you talk to your patient and carer about how they can prevent VTE you need to discuss all available options, including:
- The importance of VTE pharmacological prophylaxis (i.e. anticoagulants used as a preventative measure) and their possible side effects.
- The correct use of VTE mechanical prophylaxis (i.e. such as 'anti-embolism' stockings used as a preventative measure).
- How the patient can reduce his/her risk of VTE (such as keeping well-hydrated and, if possible, exercising gently and becoming more mobile overall).
- Some patients will have factors (such as acute liver failure, active bleeding, stroke or haemophilia) that indicate they are likely to develop acute bleeding if administered with anticoagulants. Patients who are at risk of bleeding, are unlikely to be prescribed anticoagulants but instead, alternative preventative measures such as anti-embolism stockings will be prescribed in addition to keeping well hydrated and being as mobile as possible.
Carrying out a risk assessment on a patient undergoing surgery
Although VTE is a widespread health issue, only a very small percentage of people know what it is, and even fewer understand how serious it can be. Some patients may have heard of VTE, or of pulmonary embolism; others will better understand ‘blood clots’; some may have heard about DVT from media stories about long-haul flights. It’s important to discuss VTE with your patient to help them understand how serious it is, but you also need to reassure them that there are a number of methods of helping to prevent VTE.
The VTE risk assessment document will indicate whether a particular patient is at high risk of developing blood clots. This may be as a result of their own individual risk factors (their age, medical history etc) as well as their reason for being admitted to a surgical ward (e.g. a condition which will result in them being bed-bound). If your patient is at high risk of developing blood clots, you will need to explain that they are in the high risk category, and that it will be important to take action early to prevent blood clots from developing while they are in hospital.
Provided there are no contra-indications to pharmacological prophylaxis - such as a history of bleeding, high blood pressure - the doctor may prescribe low molecular weight heparin or another form of anti-coagulation, to help reduce the risk of clot formation. Provided there are no contra-indications to mechanical prophylaxis (such as massive oedema or arteriosclerosis), the NICE clinical guideline recommends that all surgical patients should be fitted with anti-embolism stockings. The doctor may also request that the patient is shown how to exercise gently and safely while in hospital, to help keep the blood flowing in their legs and to prevent the risk of clot formation.
You can explain to your patient that as long as they do not have any contra-indications, they may be able to take anticoagulation medication to help prevent blood clots. This medication may be administered as a tablet, as an injection, or via a drip into their arm while in hospital. You can explain that they may be fitted with anti-embolism stockings before surgery to help prevent blood clots, or perhaps with intermittent pneumatic compression or foot pumps to help keep the blood pumping around their legs during surgery. You should also stress that there are things they can do themselves, to help prevent blood clots. For example, patients who have been fitted for anti-embolism stockings should not to roll them down; should wear the stockings as much as possible; and should perform regular, gentle leg exercises to reduce the risk of venous stasis or pooling of blood in the deep veins of the legs.
You can also describe some of the warning signs that could indicate they have a blood clot. These include a painful, swollen or hot leg; new, prominent veins in the leg that look like varicose veins; chest pains, being out of breath or coughing up blood. If your patient experiences any of these symptoms, instruct them to notify the medical team immediately.
Remember: A patient who understands the risks associated with VTE, and who knows what to do to help prevent it, will be more likely to want to help themselves, and more likely to follow your guidance.
This video, kindly provided by e-Learning for Healthcare, demonstrates how staff who are approved to carry out risk assessments, conduct the risk assessment interview with a patient including a discussion about VTE risks with a patient who is due to have a planned surgical procedure, e.g. such as a hip replacement, or heart surgery. To view a transcript of the video, select the link to the version of the transcipt you'd prefer to view: Transcript - VTE risk assessment of a patient for surgery (Word 33KB) or Transcript - VTE risk assessment of a patient for surgery (PDF 17KB). [How to access PDF files]
Carrying out a risk assessment on a patient with a medical condition
As with patients scheduled for surgery, it is important to discuss VTE risks with patients scheduled for a medical hospital admission to help them understand how serious it is, and to reassure them that there are a number of ways of helping to prevent VTE. For example, you can explain to your patient what methods can be used to help prevent VTE while they’re in hospital, such as taking prescribed anti-coagulants. If anticoagulants are contraindicated, then medical patients will be assessed for anti-embolism stockings. Some groups of medical patients may not be suitable for either method of prophylaxis, so alternative methods should be discussed with their doctor (NICE, 2010).
You can also discuss what they can do themselves, to help prevent blood clots from developing. Explain that if they get up out of bed as soon as it is medically appropriate and they feel able to and walk around regularly, this will help to keep the blood flowing in their legs and to prevent the risk of clot formation. It is important to remind those medical patients who have been fitted for anti-embolism stockings not to roll them down; to wear the stockings as much as possible; and to do regular, gentle leg exercises to reduce the risk of venous stasis or pooling of blood in the deep veins of the legs.
It is also important to describe some of the warning signs that could indicate they have a blood clot as already detailed above, making sure they know to notify the medical team immediately.
Remember: As with the patient's undergoing surgery, patients who are admitted for a medical reason who understand the risks associated with VTE, and who know what he or she can do to help prevent it, will be more likely to want to help themselves, and more likely to follow your guidance.
This video, kindly provided by e-Learning for Healthcare provides a demonstration of one way to conduct a VTE risk assessment for a patient who is being admitted to a medical ward. To view a transcript of the video, select the link to the version of the transcipt you'd prefer to view: VTE risk assessment for a medical admission (Word 26KB) or VTE risk assessment for a medical admission (PDF 12KB).