1. affix patient label Care Pathway Assessment for Adult Patients with Suspected DVT Page 1 of 10 Document Version 1.1 (February 2013)Review Date: February 2015Author: Amanda Clark / Emma Kinnaird ON EXAMINATION: PAST MEDICAL HISTORY: Patient Tel No: BPIVDU?Never / current / previous PulseIndwelling intravenous catheter? (e.gPICC/Portacath/Hickman line) YES / NO SAO 2 (%) Temp 0 C weight KgFBC/COAG/U&E/LFTs/CalciumYES / NO PregnantYES / NO DateGP Name Time arrived Named NurseGP Address Time seen Referral Source CURRENT MEDICATION: SOCIAL HISTORY: ALLERGIES INVESTIGATIONSDateResults FBCHb MCV Platelets WBC U/ECreat. Urea Na K Calcium eGFR LFTBilirubin ALP ALT Protein Albumin Globulin Clotting ScreenPT secs INR APTT secs APTTR UrinalysisInform GP if urinalysis positive Pregnancy test Recommended in all women of childbearing potential if not known to be pregnant. THERE IS NO VALIDATED CLINICAL SCORING SYSTEM FOR UPPER LIMB DVT Assessment for Adult Patients with Suspected Upper Limb DVT

2. affix patient label Care Pathway Assessment for Adult Patients with Suspected DVT Page 2 of 10 Document Version 1.1 (February 2013)Review Date: February 2015Author: Amanda Clark / Emma Kinnaird SIGNATURE PRINT Discuss all positive results in pregnant women with the on call obstetric and Gynae registrar bleep 2922. Outcome of discussion: Inform referring Doctor of negative result. If yes please discuss with Haematology registrar Bleep 2677 Outcome of discussion: COMMENTS Any recent bleeding episodesYES / NO High alcohol intakeYES / NO Thrombocytopenia (platelets <75x10 9 /l)YES / NO Recent eye or neurosurgery within last month YES / NO RISK FACTORS FOR ANTICOAGULATION No DVT DVT confirmed Inconclusive Repeat in 1 week or earlier if symptoms worsen Refer patient for Duplex Scan. If the scan cannot be performed on the same day consider treatment dose of S/C Enoxaparin in the interim Refer back to Referring clinician Is there an indwelling long line? Inconclusive No DVT confirmed No DVT Explain results to patient Refer back to GP – send and fax …‘No evidence of DVT’ letter Advise patient to contact GP if …symptoms persist Discharge: Date / Time: CONTINUE Explain result to patient Send and fax ‘inconclusive …...doppler letter Rebook scan in 1 week Date: Time: Patient to return if symptoms …. worsen Result of repeat scan: Yes Refer back to team overseeing long line for assessment and decision on removal of central line and anticoagulation Assessment for Adult Patients with Suspected Upper Limb DVT

3. affix patient label Care Pathway Assessment for Adult Patients with Suspected DVT Page 3 of 10 Document Version 1.1 (February 2013)Review Date: February 2015Author: Amanda Clark / Emma Kinnaird MANAGEMENT OF PATIENTS WITH A CONFIRMED DEEP VEIN THROMBOSIS 1. CAN THE PATIENT BE MANAGED AS AN OUT-PATIENT? If YES to any of the following questions discuss with GPSU medical staff to agree a management plan aiming to manage in the community if possible. * circle those that apply Symptoms suggestive of pulmonary embolism: New shortness of breath; New cough; New chest pain; New haemoptysis* YES / NO Active or recent bleeding: (within last 4 weeks) Haemoptysis; Melaena; Haematemesis; Frank Haematuria; intra-cranial bleeding* YES / NO Bleeding risk e.g. liver disease, active peptic ulcerYES / NO Concurrent medical problem requiring admissionYES / NO Severe hepatic/renal impairmentYES / NO Patient frail/unsteady/unable to mobilise/in severe painYES / NO Unable to comply with return or follow-upYES / NO 2. SYMPTOMS REQUIRING FURTHER INVESTIGATION: If YES to any of the following questions: discuss with GPSU to organise urgent onward investigations (in most cases these will be done as an outpatient) Unintentional weight loss >7lbs 3Kg in last 6 monthsYES / NO Bilateral upper limb DVTYES / NO Persistent coughYES / NO Recent unexplained abdominal painYES / NO Abdominal distensionYES / NO Haematuria – if current refer directly to urology to consider admissionYES / NO New prostatic symptoms – nocturia, increased urinary symptoms, poor stream If yes or ALL men over 60yrs check PSA YES / NO N/A Unexplained pv bleeding - refer directly to gynaecologyYES / NO / N/A Breast lumps/ Breast changes noticed – refer to GP for Breast examination to exclude underlying pathology in patients with unprovoked upper limb DVT YES / NO Assessment for Adult Patients with Suspected Upper Limb DVT

4. affix patient label Care Pathway Assessment for Adult Patients with Suspected DVT Page 4 of 10 Document Version 1.1 (February 2013)Review Date: February 2015Author: Amanda Clark / Emma Kinnaird SIGNATURE PRINT Unprovoked thrombosis (including patients with weak risk factors e.g. travel, minor injuries Recurrent VTE (if <50; all events provoked; or concerns regarding long term anticoagulation) Women of childbearing potential Strong Family history of VTE or thrombophilia Referral to Haematology clinic: (Tick which apply) RISK FACTORACTION Had Surgery within last 90 days YES / NO if yes please specify Hospital admission in last 90 days YES / NO if yes please specify PregnancyYES / NO Discuss with on call obstetric registrar bleep 2922 Enoxaparin 1mg/Kg twice daily Combined oral contraceptive pill/ Hormone replacement YES / NO Advise patient to discuss alternative contraception/symptom control with their GP Known underlying malignancyYES / NO Refer back to oncologist Enoxaparin 1.5mg/Kg once a day Known IVDUYES / NO Rivaroxaban OR Enoxaparin 1.5mg/Kg once a day 3. WAS THERE A CLEAR PROVOKING FACTOR? If No to all of the following questions request a Chest X-ray and add name to GPSU weekly X-ray review list. Tick here if CXR requested reviewed by GPSU reported by radiology Treatment choice after discussion with the patient: Rivaroxaban Enoxaparin then warfarin Enoxaparin only Assessment for Adult Patients with Suspected Upper Limb DVT

5. affix patient label Care Pathway Assessment for Adult Patients with Suspected DVT Page 5 of 10 Document Version 1.1 (February 2013)Review Date: February 2015Author: Amanda Clark / Emma Kinnaird CARE PLAN FOR PATIENTS WITH CONFIRMED DVT REQUIRING RIVAROXABAN  Explain result of scan and plan of treatment  Explain anticoagulant treatment and drug interaction, safety and side effects.  Give rivaroxaban patient information leaflet  Give UHB DVT leaflet  Send and fax “confirmed DVT requiring rivaroxaban” letter to GP  Give a three week supply of rivaroxaban 15mg twice daily  NB if Creatine Clearance <15ml/min DO NOT give rivaroxaban – discuss with MAU team,  However do not delay giving first dose if renal function not available Duration of treatment: 3 months Follow up  Appointment in 5-10 days to assess and if appropriate fit compression hosiery Appointment date………………time……………….location…………………….  Appointment for review in 3 weeks to switch to once daily treatment 20mg once daily rivaroxaban Appointment date………………time……………….location……………………. Record all visits below. It is important to record all adverse events and discuss with GP/Haematology Date/timeCommentsSignature Assessment for Adult Patients with Suspected Upper Limb DVT

6. affix patient label Care Pathway Assessment for Adult Patients with Suspected DVT Page 6 of 10 Document Version 1.1 (February 2013)Review Date: February 2015Author: Amanda Clark / Emma Kinnaird Date/timeCommentsSignature Assessment for Adult Patients with Suspected Upper Limb DVT

7. affix patient label Care Pathway Assessment for Adult Patients with Suspected DVT Page 7 of 10 Document Version 1.1 (February 2013)Review Date: February 2015Author: Amanda Clark / Emma Kinnaird CARE PLAN FOR PATIENTS WITH CONFIRMED DVT REQUIRING WARFARIN THERAPY Target INR: Duration of treatment: 3 months Explain results of scan and plan of treatment. Explain anticoagulant therapy, drug interactions, safety and side effects Give NPSA oral anticoagulation packUHB “Deep vein Thrombosis” leaflet Send and fax “Confirmed DVT requiring Warfarin therapy” letter to GP If baseline INR>1.3 repeat and discuss with Haematology Administer Clexane as per PGD, to continue until INR is >2.0 for two consecutive days or for five …days minimum. Check INR daily:If INR >5 Cross check Coagucheck machine on a venous sample If INR > 6 discuss with Haematologist Dose adjust warfarin on INR according to PGD and write NPSA anticoagulation record Ensure adequate level of analgesia and observe for any signs of cellulitis. On day 5, assess and if appropriate fit for compression hosiery. When INR has been stable and therapeutic for 2 days: Discharge to Anticoagulation pharmacist or …GP Time/DateCommentsSignature INR Enoxaparin Warfarin INR Enoxaparin Warfarin INR Enoxaparin Warfarin INR Enoxaparin Warfarin INR Enoxaparin Warfarin Assessment for Adult Patients with Suspected Upper Limb DVT

8. affix patient label Care Pathway Assessment for Adult Patients with Suspected DVT Page 8 of 10 Document Version 1.1 (February 2013)Review Date: February 2015Author: Amanda Clark / Emma Kinnaird Time/DateCommentsSignature INR Enoxaparin Warfarin INR Enoxaparin Warfarin INR Enoxaparin Warfarin INR Enoxaparin Warfarin INR Enoxaparin Warfarin INR Enoxaparin Warfarin INR Enoxaparin Warfarin INR Enoxaparin Warfarin INR Enoxaparin Warfarin INR Enoxaparin Warfarin INR Enoxaparin Warfarin INR Enoxaparin Warfarin Assessment for Adult Patients with Suspected Upper Limb DVT

9. affix patient label Care Pathway Assessment for Adult Patients with Suspected DVT Page 9 of 10 Document Version 1.1 (February 2013)Review Date: February 2015Author: Amanda Clark / Emma Kinnaird CARE PLAN FOR PATIENTS WITH CONFIRMED DVT REQUIRING ENOXAPARIN ONLY TREATMENT This care plan is for use in:Pregnant women Patients with known malignancy Intravenous drug users (consider rivaroxaban 1 st ) Other indications require discussion with Haematology Duration of treatment: 3 months Explain results of scan and plan of treatment: If pregnant discuss result with on call Obstetric Registrar. If scan is equivocal they may wish to assess or reassess and proceed with treatment if there is a high index of clinical suspicion Teach patient and/or relative to self-inject Give Clexane pack and sharps bin Send and fax “Confirmed DVT requiring Warfarin / Enoxaparin therapy” letter to GP Ensure adequate level of analgesia and observe for any signs of Cellulitis Dose: Standard patients Enoxaparin 1.5mg/kg daily Pregnant Patients Enoxaparin 1mg/kg twice daily Follow up: Between days 5 and 10 - Assess and if appropriate fit for compression hosiery. Check FBC. Arranged.Date: …………………………………………………….. Thereafter: Pregnant women: Ensure Obstetric Team book into first available antenatal clinic Patients with underlying malignancy: refer back to Oncologist Intravenous drug users: refer back to GP SIGNATURE PRINT Assessment for Adult Patients with Suspected Upper Limb DVT