Venous thromboembolic diseases:

the management of venous thromboembolic diseases and the role of thrombophilia testing

Two-level Wells score: templates for deep vein thrombosis and pulmonary embolism

June 2012

NICE clinical guideline 144

These two-level DVT (deep vein thrombosis) and PE (pulmonary embolism) Wells score templates accompany the clinical guideline: Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing (available at www.nice.org.uk/guidance/CG144). Issue date: June 2012.

This is a support tool for implementation of NICE guidance. It is not NICE guidance. Implementation of the guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in the guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

What do you think? Did this tool meet your requirements, and did it help you put the NICE guidance into practice? We value your opinion and are looking for ways to improve our tools. Please complete this short evaluation form. If you are experiencing problems using this tool, please email implementation@nice.org.uk.

National Institute for Health and Clinical Excellence Level 1A, City Tower, Piccadilly Plaza, Manchester M1 4BT www.nice.org.uk National Institute for Health and Clinical Excellence, 2012. All rights reserved. This material may be freely reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the express written permission of NICE.

NICE clinical guideline 144: Two-level Wells score templates for deep vein thrombosis and pulmonary embolism 2

Introduction
Clinical probability scores help to stratify people into different risk categories, so that the most appropriate diagnostics pathway or treatment pathways can be followed. Wells scores are a clinical prediction rule for estimating the probability of DVT and PE. There are a number of versions of Wells scores available. The NICE clinical guideline 144 recommends the use of the two-level DVT and PE Wells scores to aid diagnosis of PE or DVT (see recommendations 1.1.2 and 1.1.8 in the guideline). This document contains a template two-level DVT and PE Wells score. Print the template you require (either page 5 or 6), complete during your patient assessment and then file in the patients records.

Wells score background

Deep-vein thrombosis The original 1997 DVT Wells score used a three-level risk stratification system. The 2003 version (which is referred to in the literature as updated, modified, revised or two-level) uses two levels of risk stratification: Wells score (1997) (original) In 1997, Wells et al.1 developed a ninecomponent clinical prediction rule for DVT. Two points are deducted if an alternative diagnosis to DVT is at least as likely. This gives a possible score range of 2 to 8. There were three risk categories: high (3 points or more), intermediate (12 points) and low (less than 1 point). This is also sometimes referred to as the Hamilton score, with a slight change of wording. Wells score (2003) (two level) In 2003 a further component, previously documented DVT, was added to the original Wells score. Additionally, the duration of risk after surgery was increased from 4 weeks to 12 weeks2. This gives a possible score range of 2 to 9. This version reduced the number of risk categories from three to two: likely (2 points or more) and unlikely (less than 2 points).

NICE clinical guideline 144: Two-level Wells score templates for deep vein thrombosis and pulmonary embolism 3

Pulmonary embolism PE Wells score (1998) (original) In 1998, Wells et al.3 developed a sevencomponent clinical prediction rule for PE. Points are given based on criteria in the history and examination, for example, signs of DVT, tachycardia greater than 100 beats per minute, active cancer and recent immobilisation. This gives a possible score range of 0 to 12.5 points. A score of greater than 6 is classified as high risk of PE; a score of 2 to 6 as intermediate risk of PE; and a score less than 2 as low risk. PE Wells score (2000) (two level) In 2000 the Wells score for PE was revised to reduce the number of risk categories to two: likely (more than 4 points) and unlikely (4 points or less)4.

References 1.Wells PS, Anderson DR, Bormanis J et al. (1997). Value of assessment of pretest probability of 6 deep-vein thrombosis in clinical management. Lancet 350: 17958 2. Wells PS, Anderson DR, Rodger M et al. (2003). Evaluation of D-dimer in the diagnosis of 8 suspected deep-vein thrombosis. New England Journal of Medicine 349: 122735. 3. Wells PS, Ginsberg JS, Anderson DR et al (1998) Use of a clinical model for safe management of patients with suspected pulmonary embolism. Annals of Internal Medicine 129: 9971005. 4. Wells PS, Anderson DR, Rodger M et al. (2001) Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Annals of Internal Medicine. 135: 98107.

NICE clinical guideline 144: Two-level Wells score templates for deep vein thrombosis and pulmonary embolism 4

Insert your organisations logo

Suspected deep vein thrombosis

Patient name......................................................................................................... Patient hospital number......................................................................................... Date of assessment............................................................................................... Assessors name (print)..............................................Signed................................

Two-level DVT Wells score

Clinical feature Active cancer (treatment ongoing, within 6 months, or palliative) Paralysis, paresis or recent plaster immobilisation of the lower extremities Recently bedridden for 3 days or more or major surgery within 12 weeks requiring general or regional anaesthesia Localised tenderness along the distribution of the deep venous system Entire leg swollen Calf swelling at least 3 cm larger than asymptomatic side Pitting oedema confined to the symptomatic leg Collateral superficial veins (non-varicose) Previously documented DVT An alternative diagnosis is at least as likely as DVT Clinical probability simplified score DVT likely DVT unlikely

Points 1 1 1 1 1 1 1 1 1 2

Patient score

2 points or more 1 point or less

Adapted with permission from: - Wells PS et al. (2003) Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. New England Journal of Medicine 349: 122735 - The National Clinical Guideline Centre

Template Two-level DVT Wells score From NICE clinical guideline 144 VTE diseases (June 2012)

Insert your organisations logo

Suspected pulmonary embolism

Patient name......................................................................................................... Patient hospital number........................................................................................ Date of assessment.............................................................................................. Assessors name (print).............................................. Signed..............................

Two-level PE Wells score

Clinical feature Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins) An alternative diagnosis is less likely than PE Heart rate > 100 beats per minute Immobilisation for more than 3 days or surgery in the previous 4 weeks Previous DVT/PE Haemoptysis Malignancy (on treatment, treated in the last 6 months, or palliative) Clinical probability simplified scores PE likely PE unlikely

Points 3 3 1.5 1.5 1.5 1 1

Patient score

More than 4 points 4 points or less

Adapted with permission from - Wells PS et al. (2000) Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thrombosis and Haemostasis 83: 41620 - The National Clinical Guideline Centre

Template Two-level PE Wells score From NICE clinical guideline 144 VTE diseases (June 2012)