DVT Management

for

Primary Care

A simple guide …… v1.0

DGaS Commissioning Commissioning Group Page1 of 6

DVT Management for Primary Care, v1.1

(DW+RPD, January 2007)

Managing DVT in Primary Care …. Your LCG’s recommendation

To be used in conjunction with the DVT pathway

OVERVIEW:

This new service for diagnosing and managing patients with DVT is now available to all Practices in the DGaS, (Dartford, Gravesham & Swanley), locality. It has been devised and commissioned by the GP members of the Locality Commissioning Group, in conjunction with their commissioning managers – to benefit patients & practitioners in the initial diagnosis & subsequent management of this relatively common condition.

This “guidance document” is the first we have produced and is aimed at all health care professionals who may be involved with the pathway – and we would welcome feedback .

This service provides a faster and more convenient service for your patients. Obviously the patient’s overall condition must be taken into account when diagnosing and treating DVTs and additional consideration must be given to the underlying cause for the thrombosis.

This is general guidance to help facilitate the use of the Doppler service and the initiation of warfarin for DVT where required.

BACKGROUND:

  • DVTs are the 3rd most common cardiovascular event after acute coronary syndrome & stroke.
  • They occur on average in 1:2000 of the population
  • ranging from 1:3000 under the age of 40yr up to 1:500 in those over 80yrs.
  • For a full background to the management of DVT please refer to …

PRESENTATION:

The patient presents in “primary care” with symptoms suggestive of a suspected DVT.

The strength of symptoms & signs to support the diagnosis are scored using the Well’s Score

(attached).

Plus the patient’s D-Dimer is checked,

Then, by following the pathway, the appropriate action is taken.

Consider whether there are complicating issues that may mean the patient can’t be managed in a primary care setting, and where referral for specialist care is required.

  • e.g. DVT in pregnancy, clotting problems, etc

The consultant haematologist @ DVH is still available for advice.

D-Dimer:

  • This is a Near Patient Test (NPT)

You will need to ensure that you are familiar with how to use the kit. Instructions are included with the kit

(Training is available from the company rep if you missed the original sessions).

  • This test is used to help refine your decision making process through the pathway and is only done once at the start of the pathway

and is NOT diagnostic of a DVT.

  • Remember to order more test slides from PCT via KPCA when you are down to the last THREE
  • Please keep a list of patients (by Vision or NHS No) tested – for audit purposes … (details later)

Requesting a Doppler:

  • Complete the Doppler request form either electronically with the clinical system or by hand, (or both) - then fax this form to the radiology dept at either DVH or FMH.

(Copy of blank form attached – “vision ready” forms will be e-mailed or sent on media)

Ensure your practice fax number is clearly marked – for return information

  • Make sure the patient contact number is on the form so that the department can phone the patient with an appointment. (plus Mobile number if appropriate)

Transport:

  • Transport to DVH/ FMH is available under the usual criteria. (previously issued)
  • Contact Primary Care Transport Co-ordinator @ DVH on 01322 – 428877

(A swollen painful leg may be enough to get patient into the “transport criteria” on this occasion only, if no other private transport available – but financial constraints apply + service will be audited)

DGaS Commissioning Commissioning Group Page1 of 6

DVT Management for Primary Care, v1.1

(DW+RPD, January 2007)

Interim Treatment – pending Definitive Diagnosis:

Commencing Low molecular weight heparin …. “Clexane”.

(Please refer to guidance sheet for additional detail)

  • The preferred drug locally for this is currently CLEXANE.

It is recommended that Clexane is given once daily until the DVT is excluded or the patient has commenced warfarin; then it is administered for at least 5days, and until warfarin has brought the INR into the therapeutic range for 2successive days. Target INR 2.5 ( range 2-3)

  • DOSE RANGE

The dose is 1.5mg / Kg sc (as per BNF), preferably into the anterior abdominal wall.

  • MECHANICS OF ADMINISTRATION

The practice needs to decide who is most appropriate to give the medication, (sub cutaneously).

(This can cause some local discomfort and local bruising and the area should not be rubbed after administration).

Many patients are happy to self administer. (If patients are unable to self administer then this service will need to be made available via their GP, or practice nurse)

  • HOUSEBOUND PATIENTS

If patients are unable to self administer, and genuinely housebound then this service will need to be made available via the community nursing team.

  • NB: POSSIBLY A SINGLE DOSE ONLY NEEDED

As many dopplers are NEGATIVE, majority of patients will get a single dose at most.

  • SOURCING “CLEXANE”

Practices need to keep a small stock of Clexane Forte 150mg - stored in drug cupboard, not fridge and the practice can issue a P.A. prescription to cover the cost of the first dose and maintain a practice stock)

The clinician will need to waste the correct amount so that the correct dose is given.

If the patient needs to stay on Clexane (LMH) for a while, (for whatever reason), an FP10 for the correct dose/size syringe can be issued, for the patient to collect from a pharmacist. (see clexane advice sheet)

  • Sharps container

Sharps containers will need to be prescribed, on FP10, for those patients needing Clexane for more than the first dose.

The box can be returned to the practice for disposal, not the community pharmacist.

(Practice should ensure bin is sealed, endorsed with practice postcode & disposed along with their sharps bins)

The Doppler result

The result is faxed back to the practice and then the patient can be informed of the result.

  • if EQUIVOCAL, a repeat scan will have been booked & patient informed

… if so the LMH needs to carried on until the diagnosis is confirmed or excluded.

  • If NEGATIVE then the appropriate clinical action needs to be taken.

… another cause for the swollen leg should be assumed

A repeat Doppler may be required depending on Doppler + D-Dimer result … (see pathway)

… if so the LMH needs to carried on until the diagnosis is confirmed or excluded.

If clinician decides a repeat scan is required, new request & note reason on the fax form.

  • If POSITIVE, diagnosis of DVT now confirmed - patient needs to commence warfarin ….. and some thought should be given to the underlying cause ….

If patient is under 45 with a “spontaneous DVT”, ie no obvious reason, (eg flight, surgery), then consider referring to thrombophilia clinic, as well as starting warfarin, (and instigating further Ix, depending on clinical scenario).

If very recent surgery, you may wish to discuss with their consultant team before starting warfarin – but continue Clexane to provide prophylaxis against extension of clot, PE, etc.

Commencing WARFARIN

  • The patient needs to have a baseline FBC, coagulation profile, eGFR*, and LFT

…… *If considering long term Clexane, check eGFR not significantly low (may need reduced dose)

….. You will need a baseline INR before starting warfarin.

  • Check no contra-indications to warfarin therapy + check current prescribed & OTC Rx
  • Suggest use of DVH “screening tool”, as used by Heather Smith’s team (attached)
  • Decide duration of anticoagulation
  • usually 3 months if this is “first ever” calf vein DVT, and no persistent risk factors.
  • usually 6 months if this is “first ever” proximal vein DVT, and no persistent risk factors*

*risk factors, eg: swelling & pain … to be reassessed at end of 3 or 6-month period

  • Decide on target INR – usually 2.5 ……. (ranges are somewhat “old hat” now)
  • If recurrent DVT WHILST ON WARFARIN, target INR = 3.5
  • Continue on same dose of Clexane, until INR is above 2.0, on 2 consecutive checks (days)
  • If your practice does not offer an anticoagulation service, or this service is not yet up and running then there are two options available to offer your patient:
  • Refer patient to Heather Smith (specialist nurse in charge of warfarin dosing at DVH) to commence warfarin under their control. She will need a GP to been the named clinician responsible for this and if there are more complex issues then will consult with a consultant from the hospital, The practice will need to ensure the patient is kept on clexane as long as needed.
  • Refer the patient to a local practice who has agreed to take on the anticoagulation therapy for other practice’s patients. This will be the preferred route for all practices not offering in-house warfarin monitoring. For those practices following this route it would be prudent to discuss how this will be managed with the other practice or practices. Eventually the choice for this service may well appear in Choose and book.

A separate overview to warfarin dosing and commencing warfarin will follow surely.

For those practices who are offering a warfarin dosing service the new INR STAR web based service is now available. The web site is . Details of local supervisor access details will follow shortly and all users for the system will need a valid email address ( preferably NHS NET).

DGaS Commissioning Commissioning Group Page1 of 6

DVT Management for Primary Care, v1.1

(DW+RPD, January 2007)