VTE: clinical focus

Published: 18 May 2011

About 25,000 hospitalised patients die each year in the UK due to venous thromboembolism (VTE). It takes the lives of more patients than breast cancer, Aids and traffic accidents combined and is responsible for 25 times more hospital deaths than those caused by MRSA.

As deaths caused by VTE are the most preventable in hospital, the RCN has produced an online Learning Zone resource to help reduce fatalities. The information below provides a quick summary of the guidance.

What is VTE?

VTE VTE is a collective term for deep vein thrombosis (DVT) and pulmonary embolism (PE). A DVT is a blood clot in the deep veins of the leg. A PE is when all or part of the DVT breaks off, travels through the body and blocks pulmonary arteries.

VTE can be difficult to diagnose, and can be confused with less serious conditions. For example, a DVT does not always cause swelling or changes in the leg, sometimes just pain, and can be mistaken for a torn leg muscle or a sprain.

Most hospital-acquired VTEs occur after discharge – the average DVT after surgery is on day seven, while the average pulmonary embolism is on day 21. So health professionals looking after patients in hospital sometimes don’t know the condition exists.

Post-thrombotic syndrome is a condition where anything from pain and swelling, to varicose veins or brown and white pigmentation, can occur in the leg after a clot. This is due to permanent vein damage after a DVT, so the veins cannot drain blood from the leg properly. If the situation is bad, ulcers may develop on the inner side of the leg above the ankle due to this area being susceptible to poor drainage.

Assessing risk

The Department of Health requires VTE risk assessments to be carried out for every patient, with the results closely monitored. All nursing staff should understand VTE prevention procedures and the reasons why they’re required.

The National Institute for Health and Clinical Excellence (NICE) recommends all patients be regularly assessed for risk of developing thrombosis. This should be on admission to hospital, 24 hours after admission, whenever their medical condition changes, and before discharge. NICE also says every patient should receive information on how to continue preventative measures at home.

The Scottish Intercollegiate Guidelines Network also recommends regular risk assessments so the most appropriate ongoing care is offered.

Points to remember when conducting the risk assessment:

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 monitored and further risk assessed
examine the factors indicating whether a patient is likely to develop a DVT, such as: previous history of blood clots, obesity, whether they have undergone surgery, pregnancy, or taking a contraceptive pill. If at least one factor is present, the patient may require an anti-coagulant medicine such as heparin following NICE guidelines and if 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 prevention.
There is more in the RCN Learning Zone resource on risk assessing patients undergoing surgery or with medical conditions.

Prevention

Following the risk assessment, there are a number of ways to help patients identified as having a high risk of VTE from developing it while in hospital and after discharge.

Patients with a high risk, especially those having orthopaedic surgery, should be offered a form of anti-coagulant medicine – provided they have a low risk of bleeding – to reduce the risk of developing clots. Anti-coagulant medicines may be low molecular weight heparin, or an anti-coagulant medicine by another name. Medicines can be given in different ways, including orally or injected. While aspirin prevents blood clots in the arteries – it can help prevent heart attacks and strokes – it is poor at preventing clots in the veins and so is not recommended for prevention of VTE.

Meanwhile, anti-embolism stockings can decrease the risk of DVT. They may be used alongside anti-coagulants, intermittent pneumatic compression and/or foot pumps. Anti-embolism stockings help to prevent the pooling of blood in the leg veins and venous distension which can trigger formation of blood clots. Thigh-length stockings are used most frequently for surgical inpatients but they should not be used in patients with diabetes or peripheral arterial disease as they narrow blood vessels and will do more harm than good.

Other options include intermittent pneumatic compression devices like compression sleeves and foot pumps.