Promotional Pack for
Out of Hospital DVT Pathway
July 2016
Target Audience GP’s, Primary Care Nursing staff, Out of Hour (OOHs) services, Community Nursing Teams, NEAS, City Hospitals Sunderland and Urgent Care Centre Staff
Introduction In April 2016 Sunderland CCG held an improvement event to review the existing DVT pathways within the community and the Ambulatory Emergency Care Unit (AECU) at City Hospitals Sunderland (CHS).
1 A number of issues were identified with the existing pathway which included:
Lack of clarity Lack of consistency in how patients were being managed Inapproproiate Emergency Department (ED) Attendances NICE guidance not being followed in respect of using the WELLS score. Over use of D Dimer testing, on occasions with no clinical presentation of DVT. Access to Low Molecular Weight Heparin (LMWH) in the community D Dimer results returning in OOH, resulting in patients being contacted by OOH’s GP to be admitted. Delays in transport often meant elderly patients were being woken during the night by NEAS to be transported to hospital. Lack of point of care tesing in the community A high precentage of patients referred from primary care to hosptial with suspected DVT were not suffereing from a DVT (national studies show this at 90%) Overuse of AECU for follow up appointments
A new pathway was developed by clinical staff from Primary Care, Ambulatory Emergency Care and ED at CHS, STFT, NEAS and Sunderland CCG. The main developments in the new pathway are:
To undertake a WELLS score before making a referral to secondary care Direct scan bookings at CHS in hours and out of hours avoiding patients attending ED Prescribing of Apixaban for patients with WELLS score of 2 and above who have to wait over 4 hours for a scan appointment. Use of Qualitative D Dimer Point of CareTesting in prmary care for patients with WELLS score below of 1 or below in order to rule out DVT
All the above changes are in line with NICE guidelines
2. New Pathway The new pathway is self explanatory within the following diagram (1). Diagram One
2 3. WELLS Score The first part of the pathway is to undertake a WELLS Score. A WELLS score electronic template will be available to use in EMIS and Map of Medicine
3 Suspected Deep Vein Thrombosis
Two-level DVT Wells score
Point Patient Clinical Feature s Score
Active cancer (treatment ongoing, within 6 months, or palliative) 1
Paralysis, paresis or recent plaster immobilisation of the lower 1 extremities Recently bedridden for 3 days or more or major surgery within 1 12 weeks requiring general or regional anaesthesia Localised tenderness along the distribution of the deep venous 1 system
Entire leg swollen 1
Calf swelling at least 3 cm larger than asymptomatic side 1
Pitting oedema confined to the symptomatic leg 1
Collateral superficial veins (non-varicose) 1
Previously documented DVT 1
An alternative is at least as likely as DVT -2
Clinical probability simplified score 0
DVT likely 2 points or more
DVT unlikely 1 point or less
A WELLS score calculator App is also available for smart phones or i phones as identified within diagram two. Diagram Two
4 A WELLS score of 2 or over If the outcome of the WELLS score is 2 or more ( DVT likely), then the patient must be booked in for a scan. A scan booking can be made in the following way. Between 8am and 9pm Phone City Hosptials Sunderland and ask to bleep the Emergency Ambulatory Care Coordinator/medical admissions on bleep number 52132. Between 9pm and 8am Phone City Hosptials Sunderland and ask to bleep the IAU Coordinator on bleep number 53998. If a scan can be booked within 4 hours of making the call, the patient should attend for their scan, arriving 15 minutes before the appointment time. If a scan cannot be booked within 4 hours, the patient shoud be given a prescription or over labelled drugs for a treatment dose of Apixaban to see them until their scan appointment. The patient again should arrive 15 before the appointment time A WELLS score of 1 or under If the outcome of the WELLS score is 1 or less ( DVT unlikely), then a qualtitiatve D Dimer test should be undertaken. This can be undertaken as neat patient testing (point of Care testing). Is the D Dimer test is positive then the patient should follow the pathway as if the WELLS score is 2 (as above) If the D Dimer is negative, a differential diagnosis should be made. 4. Qualitative D Dimer Testing in Primary care Part of the new pathway involves undertaking a qualitative D Dimer test on patients who have a WELLS score of 1 or under (WELLS score of 2 and above will mean referral for a scan).
5 The purpose of qualtitive D Dimer test is to detect elevated D Dimer in whoel blood or plasma specimens. The information can be used to detect rhombus and/or to exclude DVT’s. The result is visually interpretated giving a positive or negative result. The qualitative D Dimer test can use a fingerstick whole blood specimen or venous whole blood specimen. Instructions to collect a fingerstick whole blood specimen If using CLEARTEST D Dimer (for more information refer to manufacturers leaflet) Wash the patients hand with soap and warm water or clean with an alcohol swab – allow to dry. Remove D Dimer Test from packaging Massage the hand without touching the site where you will puncture by rubbing down the hand towards the finger tip of the middle or ring finger. Puncture the skin with a sterile lancet and wipe away the first sign of blood. Gently rub the hand from wrist to palm to form a rounded drop of blood over the puncture site. Use a capillary tube or pipette to draw up the blood Add 1 drop of capillary blood from the pipette onto the test device Immediately add 3 drops of the buffer, then start timing Read the results at 8 minutes. Do not interpet results after more than 9 minutes If using a BOSYNEX D Dimer (for more information refer to manufacturers leaflet) Wash the patients hand with soap and warm water or clean with an alcohol swab – allow to dry. Remove D Dimer Test from packaging Massage the hand without touching the site where you will puncture by rubbing down the hand towards the finger tip of the middle or ring finger. Puncture the skin with a sterile lancet and wipe away the first sign of blood. Gently rub the hand from wrist to palm to form a rounded drop of blood over the puncture site. Use a capillary tube or pipette to draw up the blood Add 2 drops of blood onto the test strip Immediately add 1 drop of the buffer, then start the timing
6 Interpret the blood results after 10 minutes. Do not interpret any results after more than 15 minutes Results Positive – Two lines appear, one line in the control line (C) area and in the test line (T) area Negative – 1 line appears which is I the control line (C) area. A negative results indicates that there was no D Dimer present in the specimen or that the concentration of D Dimer is below the detectin level of the test device. Invalid –The control line (C) fails to appear.This may be caused by insufficent volume, expired test componants or incorrect procedural techniques. Review the procedure and repeat the test. If the problem persists, discontinue to use the test kit immediately. 5. Evaluation DVT activity/data will be collected and monitored quarterly from across the system at regular Project Group Meetings to inform the key metrics below: Number of referrals from Sunderland GP’s to CHS ED Number of admissions from Sunderland GP’s to CHS Number of d-dimmers used within primary care (point of care testing) Prescribing of Apixaban Identify the number of practices operating the pathway
In preparation for the pathway launch in September 2016 the project team are further exploring coding options for recording d-dimmer within primary care (EMIS development) to identify and measure improvements of the DVT pathway.
6. Contact
If you have any queries or require any information relating to this project please don’t hesitate to contact: Name Designation Contact Details Natalie McClary Sunderland CCG 0191 5128456 [email protected] Jeannie Henderson Sunderland CCG [email protected] [email protected] Dr Tracey Lucas Sunderland CCG
7