VTE Risk Assessment

Dr Roopen Arya
Kings College Hospital
London

roopen.arya@kch.nhs.uk

Thrombosis prevention in the NHS

House of Common Health Committee Report

March 2005

Government response July 2005

CMO publishes Independent Expert Working Group

report April 2007

NICE guidance re: surgical patients April 2007

Health Committee: Key themes

Awareness
National guidelines
NICE guidelines (2007)
Education
Implementation
Risk assessment
Thrombosis Committees
Thrombosis Teams

Health Committee recommendations 2005

We recommend that procedures for counselling both

medical and surgical patients be supported by hospital
specialist thrombosis teams and included in the VTE
guidelines developed by NICE.

We recommend that all patients, both medical and

surgical, who are admitted to hospital undergo a risk
assessment for venous thrombosis.

CMO Recommendations April 2007

Published VTE expert working groups guidance in full

Documented mandatory risk assessment for all

hospitalised patients

VTE risk assessment embedded in local risk management

structure

Improved public/professional understanding of VTE

VTE exemplar centres

Guidance on thromboprophylaxis

NICE clinical guideline 46: VTE

Key priorities for implementation

Risk assessment

Thigh-length graduated compression / anti-embolism

stockings

In addition to mechanical prophylaxis, patient at

increased risk of VTE because they have individual risk
factors and patients having orthopaedic surgery should
be offered LMWH.

LMWH or fondaparinux continued for 4 weeks after hip

fracture surgery.

The way forward

Implementation of existing national guidance

National: Implementation working group

Develop a national risk assessment tool
Provide leadership
Exemplar Centres

Local:
thrombosis committees & teams
local guidelines
100% risk assessment

VTE Implementation Working

Group

Develop a national VTE risk

assessment tool

Develop Exemplar Centres

Raising awareness

Education

Risk Assessment & Clinical Governance

The highest ranking safety practice was the

appropriate use of prophylaxis to prevent VTE in
patients at risk.
AHRQ Making Health Safer: A Critical Analysis of Patient Safety
Practices 2001

We recommend that every hospital develop a

formal strategy that addresses the prevention of
thromboembolic complications. This should
generally be in the form of a written
thromboprophylaxis policy especially for high risk
groups.
ACCP guidelines Prevention of VTE 2004

Risk Assessment for VTE

Identifying at-risk patient
Counselling at-risk
patient
Prescribing
thromboprophylaxis

VTE risk assessment tool

Risk assessment is trigger for prophylaxis

Evolve from existing guidelines
Specialty-specific, procedure-specific
Template that may be adjusted for local
use
Standards for implementation and audit
Risk assessment key performance
measure

Risk assessment: practical

aspects

Specialty-specific policy agreed by hospital

thrombosis committee, owned by
specialties
Individualised vs Group-targeted risk
assessment
Appropriate evidence-based local
guidelines
Mechanical Pharmacological prophylaxis
Explicit guidance regarding aspirin

Risk assessment: key elements

Procedure-related risk of thrombosis

Patient-related risk of thrombosis

Bleeding risk & contraindications to

prophylaxis

Linked to ACTION of thromboprophylaxis

Risk assessment: practical

aspects

Who will perform VTE risk assessments?

Junior drs / nurses / pharmacists / patients

Stand-alone VTE RAM vs integration with other risk

assessments e.g. MRSA, falls, nutrition

Documentation:
Risk assessment forms / stickers / prescription charts /
wristbands

Computer alerts and prescriptions

VTE risk assessment

for medical patients

An Ideal RAM:
DVT Prophylaxis in Medical
Patients

Accurately identify patients at risk of DVT

Predict correct risk level
disease-specific and predisposing risk factors

Reliably exclude patients without a beneficial

risk:benefit ratio
Evidence based and validated
Methodologically transparent
Simple to use in clinical practice

KCH guidelines for medical thromboprophylaxis

VTE risk assessment

for surgery

Post surgical risk of DVT

Type of operation

Incidence of DVT

Knee surgery

75%

Hip fracture surgery

60%

Elective hip surgery

50-55%

Retropubic prostatectomy

40%

General abdominal surgery

30-35%

Gynaecological surgery

25-30%

Neurosurgery

20-30%

Transurethral resection of prostate

10%

Inguinal hernia repair

10%

Incidence of DVT according to

length of surgery and age
Incidence of DVT (%)
Length of surgery (hours)
12

20

23

46.5

>3

62.5

Age (years)
4060

20.1

6170

36.4

> 71

62.5

Borow M, Goldson H. Am J Surg. 1981;141:245-51.

Incidence of DVT (%)

The greater the number of risk factors,

the higher the risk of DVT
60

50%

50

36%

40
30

24%

20
10
0

n = 197

n = 152

n = 48

01

Total risk factor score

(based on number of risk factors*)
*Risk factors included age > 40 years, obesity, malignancy, recent surgery,
and history of VTE.
Wheeler HB. Am J Surg. 1985;150:7-13.

Levels of VTE risk in surgical patients without

prophylaxis
Risk

ICS1

ACCP2

Highest

Patients > 60 years

with additional risk
factors

High

Moderat
e

Low

Major surgery for

benign disease in
patients > 40 years

Minor surgery without

additional risk factors

Surgery in patients with multiple risk

factors
THA, TKA, HFS
Major trauma, spinal cord injury
Non-major surgery in patients > 60 years
or with additional risk factors
Major surgery in patients > 40 years
or with additional risk factors
Non-major surgery in patients aged
4060 years or with additional risk factors
Major surgery in patients < 40 years
with no additional risk factors
Minor surgery in patients < 40 years
without additional risk factors

ACCP = American College of Chest Physicians; HFS = hip

fracture surgery; ICS = International Consensus Statement;
THA = total hip arthroplasty; TKA = total knee arthroplasty;
VTE = venous thromboembolism.

Nicolaides AN, et al. Int Angiol. 2006;25:101-61.

Geerts WH, et al. Chest. 2004;126(3 Suppl):338S-400S.
1

Frequency of VTE/PE according

to risk
Events

Low risk Moderate

(%)
risk (%)

Calf vein
thrombosis

10-20

20-40

40-80

Proximal vein 0.4

thrombosis

2.4

4.8

10-20

Clinical PE

1-2

2-4

4-10

0.4-1.0

1-5

Fatal PE

2.0

High
Very high
risk (%) risk (%)

0.2
0.002

0.1-0.4

Chest 1998;114:531S-60S

VTE Risk Assessment for Adult Surgical Patients

Patient name:
Hospital no:

Please fill in this form, sign and file in notes

Prescribe appropriate prophylaxis on drug chart

DOB:

Risk
Category

Surgery

HIGH

MODERATE

LOW

Tick

Recommended Prophylaxis

Hip fracture, hip or knee

arthroplasty
Major trauma /spinal cord
injury
Major surgery with
additional risk factors (ARF)
Major surgery upto age 59
years with no ARF
Minor surgery with ARF

Enoxaparin 40 mg daily
+
TED stockings
+/Sequential compression device

Minor surgery with no ARF

Early mobilisation

Tick

Enoxaparin 40 mg daily
+
TED stockings

Additional Risk Factors (ARF)

Age >60 years
Personal or family history of VTE
Thrombophilia
Active cancer or treatment
Acute exacerbation of heart failure
Recent MI or ischaemic stroke
Acute on chronic respiratory disease
Sepsis
Contraindications
Enoxaparin
Creatinine >175 mol/l (CrCl< 30ml/min)
use unfractionated heparin 5000 u BD
Active bleeding
Thrombocytopenia (platelet count<50)
Known bleeding disorder
Previous HIT or allergy to enoxaparin
On therapeutic anticoagulation

Tick Additional Risk Factors (ARF)

Tick
Acute inflammatory disorder
Pregnancy and the post partum period
Hormone therapy e.g. HRT/COCP
Obesity (BMI >30kg/m2)
Immobility
Travel>3 hrs within 4 weeks of surgery
Nephrotic syndrome
Varicose veins
Tick Contraindications
Tick
Mechanical measures (TEDs / SCD)
SCD contraindicated if acute DVT present
Severe peripheral vascular disease
Severe dermatitis
Leg oedema
Leg deformity
Peripheral neuropathy
Recent skin graft

Doctors name

Doctors signature

Timing:

Duration:

Date

Thromboprophylaxis should start 6 hours post op and at 6pm daily thereafter.

Epidural/spinal analgesia - placement or removal of catheter should be delayed for 12 hrs after
administration of enoxaparin. Enoxaparin should not be given sooner than 4 hrs after catheter
removal.
At least 10 days prophylaxis is recommended for all high risk orthopaedic patients.
Extended prophylaxis (28 days) is recommended for elective hip replacement and hip fracture
patients.
Extended prophylaxis is recommended for selected high-risk general surgery patients e.g. major
cancer surgery.

High BMI (>30 mg/m2): use enoxaparin 40mg twice daily (or enoxaparin 60 mg bd if body weight >150kg)
Sequential compression device (SCD): Consider in high-risk patients & those unable to receive LMWH due to
high bleeding risk.

Electronic Alerts to Prevent VTE

in Medical Patients

Freedom from
DVT or PE (%)

100
98
96

Intervention group

94
92

Control group
P<0.001

90
88
0

No. at risk
Intervention group 1,255
Control group
1,251

30

60

90

Time (days)
977
876

900
893

853
839

Kucher N, et al. N Engl J Med. 2005;352:969-77.

Conclusion

Thromboprophylaxis
guidelines

Risk assessment
tools

Varied approaches:
one size DOES NOT fit all

Local leadership + agreement by users &

thrombosis committees essential

National guidance on risk assessment will be available