1. P.C. 26
PATIENTS AT RISK FOR DEVELOPING VENOUS
THROMBOEMBOLISM ARE IDENTIFIED AND
MANAGED.
( ESSENTIAL SAFETY REQUIREMENTS )
Joven Botin Bilbao, RN, MAN
Deputy Chief Nurse Officer
Clinical and Accreditation Educator

2. PC.26.1
Patients are screened for the risk of
developing venous thromboembolism

3.  Initial assessment / system
review will be undertaken
to ensure patients are
being assessed for VTE
risk on and within 24 hours
of admission using the
ADULT VENOUS
THROMBOEMBOLISM
RISK ASSESSMENT
TOOL.

4. PATIENT’S NAME:_______________________________
FILE NO : _____________________________________
ADULT VENOUS THROMBOEMBOLISM RISK ASSESSMENT TOOL
EACH RISK FACTOR REPRESENTS 1 POINT EACH RISK FACTOR REPRESENTS 2 POINTS
Age 41-60 years Acute myocardial infarction Age 61-74 years
Swollen legs (current) Congestive heart failure (<1 month) Arthroscopic surgery
Varicose veins Medical patient currently at bed rest Central venous access
Obesity (BMI >25) History of inflammatory bowel disease Major surgery (>45 minutes)
Minor surgery planned History of prior major surgery (<1 month) Malignancy (present or previous)
Sepsis (<1 month) Abnormal pulmonary function (COPD) Laparoscopic surgery (>45 minutes)
Serious Lung disease including pneumonia (<1 month) Patient confined to bed (>72 hours)
Oral contraceptives or hormone replacement therapy Immobilizing plaster cast (<1 month)
Pregnancy or postpartum (<1 month) SUBTOTAL
History of unexplained stillborn infant, recurrent spontaneous abortion (>
3), premature birth with toxemia or growth-restricted infant
EACH RISK FACTOR REPRESENTS 3 POINTS
Age 75 years or older
Other risk factors___________________ History of DVT/PE
SUBTOTAL Positive Factor V Leiden
EACH RISK FACTOR REPRESENTS 5 POINTS Elevated serum homocysteine
Stroke (<1 month) Family History of thrombosis
Multiple trauma (<1 month) Positive Prothrombin 20210A
Elective major lower extremity arthroplasty Positive Lupus anticoagulant
Hip, pelvis or leg fracture (<1 month) Elevated anticardiolipin antibodies
Acute spinal cord injury (paralysis) (<1 month) Heparin-induced thrombocytopenia (HIT) (Do not use
heparin or any low molecular weight heparin)Major Surgery lasting 3 hours
SUBTOTAL Other congenital or acquired thrombophilia If
TOTAL RISK FACTOR SCORE
yes: Type_____________________________
SUBTOTAL
Very low ( 0) Low Risk ( 1-2 ) Moderate Risk ( 3-4) High Risk ( 5 or More)
PRESCRIBE APPROPRIATE PROPHYLAXIS

5.  Audit/ system review will be undertaken to ensure
that appropriate changes to VTE prophylaxis occur
when clinical status of a patient changes: regular
audit of patients notes will be used to identify if a
change has occurred during a patient admission. If
such a change is identified, then assessment will be
made to assess whether prescription/ administration
of VTE prophylaxis was reviewed and amended if
appropriate.

6. All acute patient undertake VTE Risk assessment at
least twice weekly by most responsible physician
and nurse in charge to review patient status and
treatment.
Patients being admitted for surgery may be
assessed as part of the pre assessment process.

7. PC.26.2
Patients at risk receive
prophylaxis according to
current evidence-based
practice.

8. IMS/HNH
SUBTOTAL
Very low ( 0) Low Risk ( 1-2 ) Moderate Risk ( 3-4) High Risk ( 5 or More)
PROPHYLAXIS SAFETY CONSIDERATION
Anticoagulants: Factors Associated with Increased Bleeding Intermittent Pneumatic Compression (IPC)
Is patient experiencing any active bleeding? Does patient have severe peripheral arterial disease?
Does patient have (or has had history of) heparin-induced
thrombocytopenia?
Does patient have congestive heart failure?
Is patient’s platelet count <100,000/mm
3
?
Does patient have an acute superficial/ deep vein thrombosis?
Is patient taking oral anticoagulants, platelet inhibitors (e.g.,
NSAIDS, Clopidogrel, Salicylates)?
If any of the above boxes are checked, then patient may not be
a candidate for intermittent compression therapy and you
should consider alternative prophylactic measures.Is patient’s creatinine clearance abnormal? If yes, please indicate
value ___________
If any of the above boxes are checked, the patient may not be a candidate for anticoagulant therapy and you should consider alternative
prophylactic measures: elastic stockings and/or IPC
Assessed by: _________________________________________________________ _____________________________
Nurse Name/ID number/ Signature Date/ Time
_________________________________________________________ _____________________________
Doctors Name/ ID Number/Signature/ Stamp Date/ Time
PRESCRIBE APPROPRIATE PROPHYLAXIS
HIGH RISK MODERATE RISK
Select one pharmacological option:
Enoxaparin 40 mg subcutaneous daily
Enoxaparin 20 mg subcutaneous daily if Creatinine Clearance <
30mL/min (or use Heparin 5,000 units subcutaneous 8- or 12-
hourly)§
Dalteparin 5,000 units subcutaneous daily
Alternative oral agent for Orthopaedic Surgical
patients (see below)* OR
No pharmacological prophylaxis because of
contraindication or not advised
Select one mechanical device
Graduated compression stockings / anti-embolic
stockings
Intermittent pneumatic compression
Foot impulse device
No mechanical prophylaxis because of contraindication
PLUS Early mobilization and Patient education
Select one pharmacological option:
Enoxaparin 40 mg subcutaneous daily
Enoxaparin 20 mg subcutaneous daily if Creatinine Clearance
< 30mL/min (or use heparin)
Dalteparin 5,000 units subcutaneous daily
Heparin 5,000 units subcutaneous 8- or 12-hourly
OR
No pharmacological prophylaxis because of
contraindication or not advised
OR Select one mechanical device for patients if not
prescribing pharmacological prophylaxis:
Graduated compression stockings / anti-embolic
stockings
Intermittent pneumatic compression
Foot impulse device
No mechanical prophylaxis because of contraindication
PLUS Early mobilization and Patient education
LOW RISK
Prophylaxis Not Required Early Mobilization Patient Education

9.  VTE Prophylaxis ( Chemical and
Mechanical)should given according to
the risk score.
 Patients transferred in from other
inpatient facilities must have VTE
prophylaxis reviewed on transfer.

10.  Patients who are receiving full anticoagulant therapy
should not be offered additional pharmacological or
mechanical VTE prophylaxis.
 Patients in palliative care on end-of-life pathway should
not routinely be offered pharmacological or mechanical
VTE prophylaxis.
 All staff should ensure that the patient and/or their
families or carers are offered verbal and written
information before starting VTE prophylaxis