Venous thromboembolism (VTE) policy

1 Policy summary

1.1 What is venous thromboembolism (VTE)?

Venous thromboembolism (VTE) means a blood clot in a vein. A blood clot can happen:

• in the leg, called a deep vein thrombosis (DVT)
• in the lung, called a pulmonary embolism (PE)

Blood clots can make people very unwell and can sometimes be life-threatening. Many blood clots can be prevented.

1.2 Who may be at higher risk?

A person may have a higher risk of a blood clot if they:

• spend a lot of time in bed or sitting down
• are over 60 years old
• are overweight
• take some medicines
• have heart disease
• have lung disease
• have an infection
• are dehydrated
• have had a blood clot before

1.3 Venous thromboembolism risk assessment

All inpatients aged 16 years and over must receive a venous thromboembolism (VTE) risk assessment within 14 hours of admission. The assessment must be completed by a suitably qualified healthcare professional and reviewed if the patient’s condition changes.

1.4 Prevention and treatment

Where the risk of developing venous thromboembolism outweighs the risk of bleeding, patients may be offered:

• pharmacological prophylaxis (medicines such as low molecular weight heparin (LMWH) or Fondaparinux)
• mechanical prophylaxis, such as anti-embolism stockings where appropriate

The choice of preventative treatment must be based on an assessment of both venous thromboembolism risk and bleeding risk. Treatment should begin as soon as possible after assessment and continue while the patient remains at risk.

1.5 Reducing the risk of venous thromboembolism

Healthcare professionals should:

• encourage patients to mobilise as early as possible
• maintain adequate hydration where clinically appropriate
• monitor patients receiving venous thromboembolism prophylaxis
• review venous thromboembolism risk whenever a patient’s clinical condition changes
• provide advice on reducing the risk of blood clots during admission and after discharge

1.6 Patient information and involvement

Patients, and where appropriate their families or carers, should be involved in decisions about venous thromboembolism prevention. Information about the risks of venous thromboembolism, available treatment options and warning signs of deep vein thrombosis and pulmonary embolisms must be provided in a format that meets individual communication needs.

1.7 Discharge planning

Before discharge, patients must receive information about:

• signs and symptoms of deep vein thrombosis and pulmonary embolisms
• how long prophylaxis should continue, if required
• how to use anti-embolism stockings or medication correctly
• when and how to seek medical help
• practical steps to reduce their future risk of venous thromboembolism

The patient’s GP should be informed if ongoing venous thromboembolism prophylaxis is required following discharge.

1.8 Staff responsibilities

Qualified nursing, medical and clinical staff are responsible for ensuring that:

• venous thromboembolism (VTE) assessments are completed and documented
• patients receive appropriate prophylaxis when indicated
• patients are provided with verbal and written information
• concerns or omissions are escalated promptly

1.9 Training and monitoring

Relevant clinical staff must complete annual venous thromboembolism training. Compliance with venous thromboembolism risk assessments is monitored through monthly reporting arrangements to support safe practice and continuous improvement.

1.10 Key message

Every adult inpatient should have a venous thromboembolism assessment, receive the right treatment if needed, and be given information to help prevent blood clots during and after their stay in hospital.

2 Introduction and aim

This policy aims to help clinical colleagues identify people most at risk of venous thromboembolism (VTE) and describes interventions that can be used to reduce the risk of venous thromboembolism. The recommendations are based on National Institute for Health and Care Excellence (NICE) guidance and quality standards (guideline 89, guideline 158, quality standard 201). The policy is relevant to all inpatient clinical colleagues and the care of all inpatients.

Patients admitted to hospital, whether related to their mental and, or physical health, are more likely to have reduced mobility making them at higher risk of venous thromboembolism. Venous thromboembolism most frequently occurs in the deep veins of the legs or pelvis (a deep vein thrombosis (DVT)). It can dislodge and travel to the lungs, known as a pulmonary embolism (PE), which in some cases can be fatal. Venous thromboembolism is an important cause of death in hospital. It can also cause long-term morbidity for patients and is associated with considerable cost to the health service. However, though common, venous thromboembolism is potentially preventable. The risk of venous thromboembolism can be reduced by early identification of those at high risk, reviewing the risk of developing venous thromboembolism over the course of the admission and offering appropriate venous thromboembolism prophylaxis.

The trust will adhere to the following National Institute for Health and Care Excellence (NICE) guidance around venous thromboembolism where the recommendations and standards are applicable:

• guideline 89 venous thromboembolism in over 16s reducing the risk of hospital acquired deep vein thrombosis or pulmonary embolism
• guideline 158 venous thromboembolic diseases diagnosis, management and thrombophilia testing
• quality standard 201 venous thromboembolism in adults

Venous thromboembolism (VTE) is a condition in which a blood clot (thrombus) forms in a vein. It most commonly occurs in the deep veins of the legs; this is called deep vein thrombosis. The thrombus may dislodge from its site of origin to travel in the blood, a phenomenon called embolism.

Venous thromboembolism is an important cause of death in hospital patients and treatment of nonfatal symptomatic venous thromboembolism and related long-term morbidities is associated with considerable cost to the health service.

The risk of developing venous thromboembolism depends on the condition and, or procedure for which the patient is admitted and on any predisposing risk factors.

This policy makes recommendations on assessing and reducing the risk of venous thromboembolism in patients in hospital. The recommendations take into account the potential risks of the various options for prophylaxis and patient preferences.

3 Procedure

3.1 Guidance

The following guidance is based on the best available evidence. Throughout this policy significantly reduced mobility is used to denote patients who are unable to leave their bed, unable to walk unaided or likely to spend a substantial proportion of the day in bed or in a chair.

Regard patients as being at increased risk of venous thromboembolism (VTE) if they either:

• have had or are expected to have significantly reduced mobility for 3 days or more
• are expected to have ongoing reduced mobility relative to their normal state and have one or more of the risk factors that may increase risk:
  • age over 60 years
  • active cancer or cancer treatment
  • acute or chronic lung disease
  • acute or chronic inflammatory disease
  • chronic heart failure
  • acute infectious disease, for example, pneumonia
  • dehydration or poor oral intake
  • known thrombophilia
  • obesity (body mass index (BMI) over 30kg/m2)
  • lower limb paralysis (excluding aortic stroke)
  • personal history or first-degree relative with a history of venous thromboembolism
  • use of oestrogen-containing contraceptive therapy or hormone replacement therapy
  • varicose veins with phlebitis
  • injecting illicit drugs
  • antipsychotics
  • restraint
  • catatonia and other presentations associated with reduced mobility and, or poor fluid intake
  • neuromuscular syndrome

Assess patient’s risks of bleeding and venous thromboembolism within 14 hours of admission and reassess whenever the clinical situation changes to:

• ensure that the methods of venous thromboembolism prophylaxis being used are suitable
• ensure that venous thromboembolism prophylaxis is being used correctly
• identify adverse events resulting from venous thromboembolism prophylaxis
• prescribers should consult the summary of product characteristics for the pharmacological venous thromboembolism prophylaxis being used or planned for further details

3.2 Assessing the risk of venous thromboembolism (VTE) inpatient services

3.2.1 Interim COVID-19 related assessment for venous thromboembolism (VTE)

Colleagues should refer to COVID-19 rapid guideline: managing COVID-19 for the most up-to-date COVID-19 related National Institute for Health and Care Excellence (NICE) guidance.

3.2.2 All trust inpatient wards

• All inpatients over 16 years must undergo a mandatory risk assessment for the prevention of venous thromboembolism (VTE).
• The risk assessment must be signed by a doctor or nurse or other suitably qualified registered professional.
• The clinical decision on how to manage the risk of venous thromboembolism will be based on an assessment of the risk of venous thromboembolism against the risks of preventative treatment for each individual patient and the decision will be informed by available published evidence. Following this the pharmacological and mechanical prophylaxis should be prescribed.
• The venous thromboembolism risk assessment and clinical decision must be completed by a doctor or suitably trained qualified nurse in the patients records as soon as possible within 14 hours after admission.
• Consider pharmacological venous thromboembolism prophylaxis with low molecular weight heparin (LMWH) for patients admitted to an inpatient service whose risk of venous thromboembolism outweighs their risk of bleeding.
• Consider pharmacological venous thromboembolism prophylaxis with Fondaparinux sodium if low molecular weight heparin is contraindicated for patients admitted to an inpatient service whose risk of venous thromboembolism outweighs their risk of bleeding.
• Continue pharmacological venous thromboembolism prophylaxis for people admitted to an inpatient service until the patient is no longer at risk of venous thromboembolism.
• A risk management plan or care plan will be put into place giving clear guidance to clinical colleagues as to how the venous thromboembolism risk is to be managed.
• The venous thromboembolism risk assessment is to be reviewed if the patient’s clinical condition changes or at the point of consultant review.

3.2.3 Intermediate care: Hazel and Hawthorn

Step down patients from the acute trust will have had their venous thromboembolism assessment in the acute trust.

The professional receiving the referral will check an assessment has been undertaken and ascertain if a management plan is in place, they will document this information on the referral form. They will request that the assessment and any management plan are sent with the patient. Step up patients received from community will have a venous thromboembolism assessment within 14 hours undertaken by the nurse. If a risk is identified they will contact the advanced nurse practitioner (ANP) to make the clinical and prescribing decision. If this cannot be actioned immediately by the advanced nurse practitioner, the admitting nurse will contact the contracted general practitioner (GP) or out of hour’s service for advice on the appropriate management plan.

3.2.4 Mental health and forensic inpatients including rehabilitation wards

• The risk assessment must be completed by a doctor or suitably trained qualified nurse and filed in the patients records as soon as possible within 14 hours after admission (appendix A).
• Advice is to be sought from the District Nursing team regarding to the management of the identified risk.
• A risk management plan or care plan will be put into place giving clear guidance to clinical colleagues as to how the risk is to be managed.
• The risk assessment is to be reviewed if the patient’s clinical condition changes or at the point of consultant review.
• A venous thromboembolism assessment must be completed for all patients prior to electroconvulsive therapy (ECT).
• Consider pharmacological venous thromboembolism prophylaxis with low molecular weight heparin (LMWH) for patients admitted to an acute psychiatric ward whose risk of venous thromboembolism outweighs their risk of bleeding.
• Consider pharmacological venous thromboembolism prophylaxis with Fondaparinux sodium if low molecular weight heparin is contraindicated for patients admitted to an acute psychiatric ward whose risk of venous thromboembolism outweighs their risk of bleeding.
• Continue pharmacological venous thromboembolism prophylaxis for people admitted to an acute ward until the patient is no longer at risk of venous thromboembolism.
• A venous thromboembolism assessment must be completed for all patients prior to electroconvulsive therapy.
• Balance the persons individual risk of venous thromboembolism against their risk of bleeding when deciding whether to offer pharmacological thromboprophylaxis to patients.

3.3 All patients

Offer mechanical or pharmacological venous thromboembolism prophylaxis to patients assessed to be at increased risk of venous thromboembolism.

Start pharmacological venous thromboembolism prophylaxis if indicated as soon as possible after risk assessment has been completed. Continue until the patient is no longer at increased risk of venous thromboembolism or as indicated in National Institute for Health and Care Excellence (NICE) guidance.

3.3.1 Patients with central venous catheters

Do not routinely offer pharmacological or mechanical venous thromboembolism prophylaxis to patients with central venous catheters who are ambulant.

Consider offering pharmacological venous thromboembolism prophylaxis to patients with central venous catheters who are at increased risk of venous thromboembolism.

3.3.2 Patients in palliative care

Consider offering pharmacological venous thromboembolism prophylaxis to patients in palliative care who have potentially reversible acute pathology. Take into account potential risks and benefit and the views of patients and their families and, or carers.

Do not routinely offer pharmacological or mechanical venous thromboembolism prophylaxis to patients admitted for terminal care or those commenced on an end-of-life care pathway.

Review decisions about venous thromboembolism prophylaxis for patients in palliative care daily, taking into account the view of patients, their families and, or carers and the multidisciplinary team.

3.3.3 Venous thromboembolism (VTE) prophylaxis and actions to be taken if patients taking antiplatelet and anticoagulants for other conditions

3.3.4 Patients with uncontrolled bleeding

In the event of uncontrolled bleeding contact the ambulance service on 999 and arrange transfer to the local acute hospital.

3.4 Reducing the risk of venous thromboembolism (VTE)

The prescriber and clinical decision maker will advise and discuss with ward colleagues and patient how to reduce risk.

Do not allow patients to become dehydrated unless clinically indicated. Encourage patients to mobilise as soon as possible.

Patients already having antiplatelet agents or anticoagulant therapy to treat other medical conditions. For patients admitted on dual antiplatelet therapy, for example, Aspirin and Ticagrelor seek advice from consultant cardiologist.

Consider venous thromboembolism prophylaxis for patients who are having antiplatelet agents for other conditions and whose risk of venous thromboembolism outweighs their risk of bleeding. Take into account the risk of bleeding and of co-morbidities such as arterial thrombosis.

Consider venous thromboembolism prophylaxis for patients at increased risk of venous thromboembolism who are interrupting anticoagulant therapy.

3.5 Using venous thromboembolism (VTE) prophylaxis

3.5.1 Anti-embolism stockings

Anti-embolism stockings can only be issued via a prescription. Do not offer anti-embolism stockings to patients who have:

• suspected or proven peripheral arterial disease
• peripheral arterial bypass grafting
• peripheral neuropathy or other causes of sensory impairment
• any local conditions in which anti-embolism stockings may cause damage, for example, fragile “tissue paper” skin, dermatitis, gangrene or recent skin graft
• known allergy to material or manufacture
• severe leg oedema
• unusual leg size or shape
• major limb deformity preventing correct fit

Use caution and clinical judgement when applying anti-embolism stockings over venous ulcers or wounds.

Ensure that patients who need anti-embolism stockings have their legs measured and that the correct size of stocking is provided. Anti-embolism stockings should be fitted and patients shown how to use them by colleagues trained in their use.

Ensure that patients who develop oedema or post-operative swelling have their legs re-measured and anti-embolism stockings re-fitted.

If arterial disease is suspected, seek expert opinion before fitting antiembolism stockings. Referral process may differ in different parts of the inpatient areas within the organisation.

Use anti-embolism stockings that provide graduated compression and produce a calf pressure of 14mmHg to 15mmHg (this relates to a pressure of 14mmHg to 18mmHg at the ankle and is in line with British Standard 6612:1985 specification for graduated compression hosiery and British Standard 7672:1993 specification for compression, stiffness and labelling of anti-embolism hosiery.

Encourage patients to wear their anti-embolism stockings day and night until they no longer have significantly reduced mobility.

Remove anti-embolism stockings daily for hygiene purposes and to inspect skin condition. In patients with a significant reduction in mobility, poor skin integrity or any sensory loss, inspect the skin two or three times per day, particularly over the heels and bony prominences. Patients should have two pairs prescribed to facilitate a change of stocking.

Discontinue the use of anti-embolism stockings if there is marking, blistering or discoloration of the skin, particularly over the heels and bony prominences, or if the patient experiences pain or discomfort.

Show patients how to use anti-embolism stockings correctly and ensure they understand that this will reduce their risk of developing venous thromboembolism.

Monitor the use of anti-embolism stockings and offer assistance if they are not being worn correctly.

3.5.2 Pharmacological venous thromboembolism (VTE) prophylaxis

3.5.2.1 Principles of pharmacological venous thromboembolism prophylaxis

Assess all patients for risk of bleeding before offering pharmacological venous thromboembolism prophylaxis. Prescribers should consult the summary of product characteristics for the pharmacological venous thromboembolism prophylaxis being used or planned for further details and individual drug contra-indications.

Do not offer pharmacological venous thromboembolism prophylaxis to patients with any of the risk factors for bleeding below, unless the risk of venous thromboembolism outweighs the risk of bleeding:

• untreated inherited bleeding disorders (such as haemophilia and von Willebrand’s disease
• acute stroke in previous month (haemorrhagic or ischaemic)
• uncontrolled systolic hypertension (230 systolic and 120 diastolic (mmHg) or higher)
• severe liver disease (prothrombin time above normal or known varices)
• major bleeding risk, existing anticoagulant therapy
• thrombocytopenia (platelet count less than 75 times 10 to the power of 9 per litre)
• active bleeding

3.5.2.2 Choice of low molecular weight heparin (LMWH)

Different low molecular weight heparin has been chosen by the acute trusts working in the different localities of Rotherham, Doncaster and South Humber NHS Foundation Trust. The following are the first-choice low molecular weight heparin in each of the localities (as of February 2015):

• Doncaster area: Dalteparin
• Rotherham area: Tinzaparin
• Scunthorpe area: Tinzaparin 12
• fondaparinux sodium should be used in individuals who are allergic to heparin

3.5.2.3 Dose recommendations

3.5.2.3.1 Dalteparin

• Prophylaxis for patients assessed as at risk of venous thromboembolism.
• Patients whose weight is between 45kg to 100kg.

This lower dose should also be used in all those with evidence of acute kidney injury (oliguria over 12 hours or doubling or serum creatinine), including obese patients. Prophylaxis in extremes of body weight (unlicensed).

3.5.2.3.2 Tinzaparin

It is administered subcutaneously once daily until patients no longer significantly immobile, generally 5 to 7 days.

Extended duration is recommended after some surgical procedures, for example, Orthopaedic (hip and knee replacement and hip fracture) and patients undergoing abdominal and pelvic surgery for cancer. This should be initiated by the acute trust.

For contraindications to Tinzaparin see risk assessment form (appendix A).

Consider 50 units per kg at extremes of weight, for example, less than 30kg or more than 130kg.

All low molecular weight heparin is derived from animal origin. Alternatives may be considered following discussion with the haematologists.

Fondaparinux 2.5mg once daily.

3.5.2.4 Monitoring requirements

3.5.2.4.1 Investigations prior to initiating a low molecular weight heparin

Before prescribing a low molecular weight heparin the following baseline investigations should be checked:

• weight
• full blood count (FBC)
• urea and electrolytes (U and E), estimated glomerular filtration rate (eGFR) and platelet count

3.5.2.4.2 Ongoing monitoring

Low molecular weight heparins can cause hyperkalemia. The risk appears to increase with increased duration of therapy. Patients at increased risk include patients with:

• diabetes mellitus
• chronic renal failure
• acidosis
• raised plasma potassium or those on potassium sparing diuretics
• angiotensin-converting enzyme (ACE) inhibitors

Routine monitoring or dose adjustment of low molecular weight heparin prophylaxis is not required for once daily treatment regimen and not generally necessary for twice daily regimen treatment. If the patient’s condition changes baseline investigations and venous thromboembolism risk reassessed.

3.6 Patient information and planning for discharge

3.6.1 Patient information

Good communication between health and social care professionals and patients is essential. Treatment and care, and the information given about it, should be culturally appropriate. It should also be accessible to patients with additional needs such as physical, sensory, or learning disabilities, and to patients who do not speak or read English.

Colleagues should be mindful that heparins are of animal origin and this may be of concern to some patients with certain preferences and religious beliefs, to not accept medications containing animal products (see religion or belief, a practical guide for the NHS 2009). For patients who have concerns about using animal products, consider offering synthetic alternatives (Fondaparinux sodium) based on clinical judgement and after discussing their suitability, advantages and disadvantages with the patient. This should be documented in the patient’s record.

Patients (and relatives and carers as appropriate) should have the opportunity to be involved in decisions regarding prophylaxis for the prevention of venous thromboembolism.

Before starting venous thromboembolism prophylaxis, patients and, or their families or carers must be offered the venous thromboembolism information leaflet (appendix B).

3.6.2 Planning for discharge

As part of the discharge plan, ensure that the venous thromboembolism information leaflet has been given to patients and, or carers which provides written information on:

• the signs and symptoms of deep vein thrombosis (DVT) and pulmonary embolism (PE)
• the correct and recommended duration of use of venous thromboembolism prophylaxis at home (if discharged with prophylaxis)
• the importance of using venous thromboembolism prophylaxis correctly and continuing treatment for the recommended duration (if discharged with prophylaxis)
• the signs and symptoms of adverse events related to venous thromboembolism prophylaxis (if discharged with prophylaxis)
• the importance of seeking help and who to contact if they have any problems using the prophylaxis (if discharged with prophylaxis)
• the importance of seeking medical help and who to contact if deep vein thrombosis, pulmonary embolism or other adverse events are suspected
• how patients can reduce their risk of venous thromboembolism (such as keeping well hydrated and, if possible, exercising and becoming more mobile)

Ensure that patients who are discharged with anti-embolism stockings:

• understand the benefits of wearing them
• understand the need for daily hygiene removal
• can remove and replace them, or have someone available who will be able to do this for them
• know what to look for, such as skin marking, blistering or discolouration, particularly over the heels and bony prominences
• know who to contact if there is a problem
• understands the importance of wearing them correctly
• know when to stop wearing them

Ensure that patients who are discharged with pharmacological and, or mechanical venous thromboembolism prophylaxis can use it correctly, or have arrangements made for someone to be available who will be able to help them.

Notify the patient’s GP if the patient has been discharged with pharmacological and, or mechanical venous thromboembolism prophylaxis to be used at home.

4 Responsibilities

4.1 All staff

All qualified nursing and medical staff are responsible for:

• ensuring that patients in their care have been assessed for their risk of venous thromboembolism
• ensure venous thromboembolism documentation is accurate and up-to-date
• ensure patients receive verbal and written information on their risk of venous thromboembolism and methods of prevention on admission and as part of the discharge process
• ensure escalation to the appropriate medical colleagues and, or senior nursing colleagues regarding any omissions in venous thromboembolism risk assessment and treatment

4.2 Matron or ward manager

The matron or ward managers are responsible for the safe and effective implementation of this policy. In addition:

• monitoring compliance with venous thromboembolism risk assessment within their service area
• monitoring compliance relating to staff training and competency outlined in this policy

4.3 Medical staff and advance nurse practitioners

Consultants, medical staff and advance nurse practitioners are responsible for the safe and effective implementation and monitoring of this policy. In addition, ensuring venous thromboembolism risk assessments are completed within 14 hours of admission to the ward and as the patient’s condition changes.

5 Training implications

5.1 Venous thromboembolism (VTE) prevention in primary care

• Who by: all in patient non-medical colleagues including registered and non-registered nurses.
• How often should this be undertaken: annually.
• Length of training: 30 minutes.
• Delivery method: e-learning.
• Training delivered by whom: electronic staff record (ESR) training.
• Where are the records of attendance held: electronic staff record (ESR) system.

5.2 Venous thromboembolism (VTE) prevention in secondary care

• Who by: all prescribers involved in assessment, informing and prescribing (this excludes medical colleagues), this is for inpatient areas only.
• How often should this be undertaken: annually.
• Length of training: 45 minutes.
• Delivery method: e-learning.
• Training delivered by whom: electronic staff record (ESR) training.
• Where are the records of attendance held: electronic staff record (ESR) system.

6 Monitoring arrangements

6.1 Completion of venous thromboembolism (VTE) risk assessment compliance

• How: report on re-portal.
• Who by: service manager.
• Reported to: quality meeting.
• Frequency: monthly.

7 Related documents and guidance

• Consent to care and treatment policy
• Infection prevention and control manual
• Mental Capacity Act (2005) policy
• Non-medical prescribing policy
• Healthcare record keeping policy
• British National Formulary 2022. British Pharmaceutical Society and British Medical Journal.
• Diagnosing Venous Thromboembolism in Primary, Secondary and Tertiary care National Institute for Health and Care pathway updated March (2018).
• Guideline for the Management of Venous Thromboembolism (Medicines Formulary) Doncaster and Bassetlaw NHS Foundation Trust (2022).
• Treating Venous Thromboembolism National Institute for Health and Care pathway updated March (2018).
• National Institute for Health and Care Excellence guideline 89 (NG89). Venous thromboembolism in over 16s reducing the risk of hospital acquired deep vein thrombosis or pulmonary embolism (2018).
• National Institute for Health and Care Excellence guideline 158 (NG158). Venous Thromboembolic diseases: diagnosis, management and thrombophilia testing (2020).
• National Institute for Health and Care Excellence quality standard 201 (QS201). Venous thromboembolism in adults.

8 Appendices

8.1 Appendix A risk assessment for venous thromboembolism

Refer to appendix A: risk assessment for venous thromboembolism (VTE) (staff access only).

8.2 Appendix B venous thromboembolism information leaflet

Refer to appendix B: venous thromboembolism (VTE) information leaflet (staff access only).

8.3 Appendix C quick guide

8.3.1 Assess

All inpatients over 16 years must undergo a mandatory risk assessment for the prevention of venous thromboembolism (VTE).

The venous thromboembolism risk assessment and clinical decision must be completed by a doctor or suitably trained qualified nurse in the patients records as soon as possible within 14 hours after admission.

8.3.2 Venous thromboembolism prophylaxis

Consider pharmacological venous thromboembolism prophylaxis with low molecular weight heparin (LMWH) for patients admitted to an inpatient service whose risk of venous thromboembolism outweighs their risk of bleeding.

Consider pharmacological venous thromboembolism prophylaxis with fondaparinux sodium if low molecular weight heparin is contraindicated for patients admitted to an inpatient service whose risk of venous thromboembolism outweigh their risk of bleeding.

8.3.3 Reduce risk

Continue pharmacological venous thromboembolism prophylaxis for people admitted to an inpatient service until the patient is no longer at risk of venous thromboembolism.

A risk management plan or care plan will be put into place giving clear guidance to clinical staff as to how the venous thromboembolism risk is to be managed.

8.3.4 Monitoring

Routine monitoring or dose adjustment of low molecular weight heparin prophylaxis is not required for once daily treatment regimen and not generally necessary for twice daily regimen treatment. If patient condition changes baseline investigations and venous thromboembolism risk reassessed.

8.3.5 Discharge

As part of the discharge plan, ensure that the venous thromboembolism information leaflet has been given to patients and, or carers.

Ensure that patient who are discharged with pharmacological and, or mechanical venous thromboembolism prophylaxis can use it correctly, or have arrangements made for someone to be available who will be to help them.

Notify the patient’s GP if the patient has been discharged with pharmacological and, or mechanical venous thromboembolism prophylaxis to be used at home.

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Page last reviewed: July 23, 2026
Next review due: July 23, 2027

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