1.1 Hospital-acquired venous thromboembolism (VTE) covers all VTE that occurs in hospital and for 90 days after a hospital admission. The term encompasses both deep vein thrombosis (DVT) and pulmonary embolism (PE). Hospital-acquired VTE accounts for thousands of deaths annually in the NHS; fatal PE remains the most common cause of preventable in-hospital mortality.

1.2 VTE prophylaxis reduces the incidence of VTE. It includes mechanical methods (such as anti-embolism stockings (AES), foot impulse and intermittent pneumatic compression devices (IPC)) and pharmacological treatments (such as heparins and other anticoagulant drugs).

1.3 Reducing rates of hospital-acquired VTE has been a significant healthcare priority for the NHS in recent years. The national mortality rate from VTE is estimated to have fallen by 8–9% since the recommendations in national guidance titled “Venous thromboembolism: reducing the risk for patients in hospital” were introduced by NICE in 2010. This document was updated to NG89 in 2019 (NICE, 2019).

1.4 This guideline summarises the Trust’s approach to the risk assessment and prevention of VTE in patients aged ≥16 years. It aims to ensure that all patients admitted to the Trust are assessed for VTE risk and offered thromboprophylaxis where appropriate.

1.5 The guideline describes treatments and interventions that can be used to prevent VTE in medical and surgical patients. There is a separate guideline for pregnant women Thromboprophylaxis and the treatment of VTE in pregnancy and the puerperium.

1.6 The purpose of the guideline is to ensure that:

• All inpatients aged ≥16 years have an accurate VTE risk assessment using the Trust VTE risk assessment tool.

• Appropriate thromboprophylaxis for the prevention of VTE is offered to all patients according to their level of risk and individual clinical situation.

2.1 All patients aged ≥16 years admitted to the Trust must have an assessment performed and documented to identify the risk of VTE, and also the risk of bleeding. This should occur as soon as possible after the decision for admission with the expectation that, where indicated, the first dose of dalteparin would be administered within 14 hours of the decision to admit. The responsibility for this assessment +/- prescription lies with the admitting specialty, even if the patient remains in the emergency department at this time point. The risk assessment must be reviewed throughout the patient’s stay in hospital, particularly at the point of senior review and if their clinical situation changes. This includes our elective surgical patients who should have their VTE risk reassessed on the day of surgery, even though their VTE risk assessment may have been completed in pre-assessment clinic.

2.2 VTE risk should be assessed using the Trust risk assessment tool on EPIC (Appendix A). This tool guides clinicians on whether thromboprophylaxis is indicated for an individual and lists the potential contraindications to consider. This form must be completed for every patient, with the exception of those who fit the “cohort criteria” (Appendix B).

2.3 Overall responsibility for VTE risk assessment and any subsequent treatment belongs to the consultant/team looking after the patient at any given time. This responsibility will transfer along the patient pathway, from admitting team to ward team and potentially on to other ward teams during a patient’s inpatient stay. The VTE risk assessment can be completed by any appropriately trained health care professional, e.g., pre-operative assessment specialist nurse. However, the doctor prescribing the thromboprophylaxis must check the assessment prior to prescribing any treatment. The multi-disciplinary team should highlight any concerns regarding VTE prophylaxis to the patient’s medical team.

2.4 Overall responsibility for VTE risk assessment and any subsequent treatment belongs to the consultant/team looking after the patient at any given time. This responsibility will transfer along the patient pathway, from admitting team to ward team and potentially on to other ward teams during a patient’s inpatient stay. The VTE risk assessment can be completed by any appropriately trained health care professional, e.g., pre-operative assessment specialist nurse. However, the doctor prescribing the thromboprophylaxis must check the assessment prior to prescribing any treatment. The multi-disciplinary team should highlight any concerns regarding VTE prophylaxis to the patient’s medical team.

3.1 Encourage people to mobilise as soon as possible.

3.2 Ensure patients are adequately hydrated.

3.3 Advise patients to consider stopping oestrogen-containing oral contraceptives or hormone replacement therapy (HRT) at least 4 weeks before elective surgery.

3.3.1 If oestrogen-containing oral contraceptives are stopped, provide advice on alternative contraceptive methods.

3.3.2 If oestrogen-containing medications are not stopped before the day of surgery, consideration should be given to postponing the patient for at least 4 weeks or proceeding with increased VTE risk after disclosure to the patient and obtaining their informed consent.

4.1 An individual’s VTE risk assessment should be completed prior to prescribing prophylaxis. Any indicated pharmacological or mechanical prophylaxis should be prescribed and administered as soon as possible and within 14 hours of admission. If there is a reason to delay the start of the prophylaxis this should be clearly documented with a clear review date.

4.2 Dalteparin is the Frimley Health LMWH of choice for pharmacological prophylaxis. It is the recommended drug to be used for medical and surgical patients. The dalteparin dose is dependent on the patient’s weight and renal function.

4.3. The licensed standard dose of dalteparin for medical and surgical patients is 5000 units subcutaneously once daily – NB this varies according to weight and renal function.

We recommend the following dose adjustments according to weight and creatinine clearance (CrCl) (using Cockcroft-Gault; see online calculator) using actual body weight:

4.4 Routine doses of dalteparin should be administered at 18.00 (see also 4.8.1 below). Initial doses and first post operative doses may be prescribed at different (earlier) times and should be given as prescribed ie do not wait until 18.00. Monitoring of the anticoagulant effect of dalteparin with anti-Xa levels is not typically required, but should be considered in certain special circumstances such as extremes of weight and significant renal impairment in high-risk patients. This should be discussed with a haematologist if felt appropriate.

4.5 All patients who are to receive dalteparin should have a baseline platelet count checked. Routine monitoring for heparin induced thrombocytopenia (HIT) is not required for patients receiving dalteparin, except for in patients who have undergone cardiac surgery, who should have platelet counts performed every 2-4 days from day 4 to 14.

4.6 Pharmacological prophylaxis should not be prescribed for people who are fully anticoagulated, provided their anticoagulant therapy is continued. Consider VTE prophylaxis if anticoagulant therapy is interrupted, or the patient is not fully anticoagulated (e.g., INR<1.5 in patient on warfarin)

4.7 VTE prophylaxis should be offered to patients on antiplatelet agents whose risk of VTE outweighs their risk of bleeding.

4.8 Peri-operative dalteparin dosing (See also separate guideline on peri-operative anticoagulation: Management of anticoagulated patients undergoing elective surgery or invasive procedures)

4.8.1 The recommended standard peri-operative dosing of dalteparin is:

5000 units on the evening before surgery, followed by 5000 units every 24 hours. The timing of dalteparin post-operatively may be adjusted according to the surgeon’s discretion for individual cases. A split dosing regime may also be used, according to the surgeon’s preference: 2500 units 1-2 hours before surgery, then 2500 units 8-12 hours later, followed by a regular daily dose of 5000 units once daily. Surgical cases who return to the ward after 1800 should receive a dose of thromboprophylaxis 6-12 hours post op, whatever time this is unless the surgeon or anaesthetist has specifically prohibited this, e.g., due to concerns re bleeding or epidural management (see 4.9 below).

4.9 Alternatives to LMWH

4.9.1 Rivaroxaban is the preferred licensed option for VTE prophylaxis for elective total hip and knee replacements (see section 5.1). Dabigatran and apixaban are also licensed.

4.9.2 Fondaparinux is licensed for VTE prevention and can be used where there are contraindications to LMWH. The standard prophylactic dose is 2.5 mg subcutaneously once daily. Fondaparinux should be avoided if the CrCl is <20ml/min and should be dose- reduced to 1.5 mg subcutaneously once daily with CrCl 20-50 ml/min.

4.9.3 Be aware that heparins are of animal origin and this may be of concern to some people. Discuss the alternatives with people who have concerns about using animal products, after discussing their suitability, advantages and disadvantages with the individual. Fondaparinux is a synthetic alternative.

4.9.4 Intravenous unfractionated heparin infusions are rarely indicated for VTE prophylaxis and must be discussed with haematologist. They should generally only be used for this indication in specialist clinical areas, e.g., MADU/ITU.

4.10 Neuraxial anaesthesia

4.10.1 Dalteparin: Placement or removal of epidural catheters must be delayed for at least 12 hours after the last administration of prophylactic dalteparin. Dalteparin administration should be delayed for at least 4 hours after any lumbar puncture/spinal/epidural procedures.

4.10.2 Rivaroxaban: If an epidural is used, the catheter must not be removed earlier than 18 hours after the last administration of rivaroxaban. The next rivaroxaban dose is to be administered no earlier than 6 hours after the removal of the catheter. If traumatic puncture occurs, the administration of rivaroxaban is to be delayed for 24 hours. Rivaroxaban must not be administered whilst the catheter is in situ; LMWH should be used instead. If in doubt, please discuss with an anaesthetist.

5.1 Options for mechanical thromboprophylaxis include anti-embolism stockings (AES), intermittent pneumatic compression (IPC) and foot impulse devices. They should be prescribed on the drug chart by a doctor, or by a nurse as a non-medical prescriber.

5.2 In medical patients with an indication for VTE prophylaxis, but a contraindication to pharmacological prophylaxis, mechanical thromboprophylaxis should be considered, ideally with IPC and otherwise with AES.

5.3 Mechanical thromboprophylaxis should be routinely offered to surgical patients with a contraindication to pharmacological prophylaxis. Mechanical thromboprophylaxis should also be offered in addition to pharmacological prophylaxis in high-risk patients, e.g., those undergoing abdomino-pelvic surgery.

5.4 Mechanical thromboprophylaxis should not be routinely offered to patients with low thrombotic risk (i.e., those scoring 0 on the VTE risk assessment tool) undergoing low risk surgical procedures (see Appendix C).

5.5 Registered nursing staff responsible for fitting AES or IPC must be appropriately trained. They should ensure that the devices are appropriately fitted to help prevent VTE. Nursing care plans, specific to mechanical thromboprophylaxis, must be updated on a daily basis.

5.6 People who need AES should have their legs measured to ensure they are provided with the correct size of stocking. People who develop oedema or post-operative swelling should have their legs re-measured and AES refitted. AES should produce a calf pressure of 14-15mmHg.

5.7 AES should be removed daily for hygiene purposes and to inspect skin condition. In people with a significant reduction in mobility, poor skin integrity or sensory loss, inspect the skin 2 or 3 times a day, particularly over the heels and bony prominences. If suitable, offer IPC as an alternative.

5.8 Do not offer AES to people who have:

• Suspected or proven arterial disease

• Peripheral arterial bypass grafting

• Peripheral neuropathy or other causes of sensory impairment

• Any local conditions in which AES may cause damage, e.g., fragile skin, dermatitis or recent skin graft

• Known allergy to material of manufacture

• Severe leg oedema

• Major limb deformity or unusual leg size preventing correct fit.

Use caution and clinical judgement when applying AES over venous ulcers or wounds. IPC should not be used in people with a known allergy to the material of the manufacture.

5.9 Advise the person to wear their AES/IPC for as much time as possible, until they no longer have significantly reduced mobility.

6.1 Orthopaedic surgery

6.1.1 All patients undergoing major orthopaedic surgery of the pelvis or lower limb should receive calf or foot pumps.

6.1.2 Elective hip replacement surgery

Offer VTE prophylaxis to people undergoing elective hip replacement surgery whose risk of VTE outweighs their risk of bleeding. Choose from the following options:

• Rivaroxaban 10mg OD for 35 days

• Prophylactic dalteparin for 28 days

Start DOAC or LMWH at 6-12 hours post-surgery (see 4.8.1).

6.1.3 Elective knee replacement surgery

Offer VTE prophylaxis to people undergoing elective knee replacement surgery whose risk of VTE outweighs their risk of bleeding. Choose from the following 3 options:

• Rivaroxaban 10mg OD for 14 days

• Prophylactic dalteparin for 14 days

Start DOAC or LMWH at 6-12 hours post-surgery (see 4.8.1).

6.1.4 Other lower limb surgery

Consider LMWH for 14 days (starting 6-12 hours after surgery) if: total anaesthesia time is more than 90 minutes or the person’s risk of VTE outweighs their risk of bleeding. Rivaroxaban 10mg OD can be used as an alternative. We would recommend pharmacological prophylaxis in any individuals with a personal history of VTE. Aspirin may be considered for VTE prophylaxis in individuals who are considered low risk and have no previous VTE history who are undergoing low-risk foot and ankle procedures.

6.1.5 Lower limb immobilisation: Consider pharmacological prophylaxis with LMWH or Rivaroxaban 10mg OD (unlicensed indication) for people with lower limb immobilisation whose risk of VTE outweighs their risk of bleeding. We would recommend its use in any individuals with a personal history of VTE. Consider stopping prophylaxis if lower limb immobilisation continues beyond 42 days.

6.1.6 Fragility fractures of the pelvis, hip or proximal femur. Offer LMWH prophylaxis for 35 days. Start LMWH at 6-12 hours post-surgery. Consider pre-operative VTE prophylaxis if surgery is delayed beyond the day after admission, stopping 12 hours before surgery. Consider IPC for people at the time of admission, particularly if pharmacological prophylaxis is contraindicated. Continue until the person no longer has significantly reduced mobility relative to their normal or anticipated mobility.

6.1.7 Upper limb surgery: VTE prophylaxis is generally not needed if giving local or regional anaesthetic for upper limb surgery. Consider LMWH prophylaxis for people undergoing upper limb surgery if the person’s total time under general anaesthetic is over 90 minutes or where their operation is likely to make it difficult for them to mobilise.

6.1.8 Spinal surgery. Offer mechanical VTE prophylaxis with anti-embolism stockings (AES) or intermittent pneumatic compression (IPC) to people undergoing elective spinal surgery. Continue until the person no longer has significantly reduced mobility relative to their normal or anticipated mobility. Consider adding LMWH prophylaxis for people undergoing elective spinal surgery whose risk of VTE outweighs their risk of bleeding, taking into account individual patient and surgical factors and according to clinical judgement. If using LMWH for people undergoing elective spinal surgery, start giving it 24-48 hours postoperatively according to clinical judgement. Continue until the person no longer has significantly reduced mobility.

6.2 Major trauma patients

6.2.1 Offer mechanical VTE prophylaxis with IPC on admission to people with serious or major trauma. Continue until the person no longer has significantly reduced mobility relative to their normal or anticipated mobility.

6.2.2 Reassess risk of VTE and bleeding at least daily.

6.2.3 Consider pharmacological VTE prophylaxis as soon as possible when the risk of VTE outweighs the risk of bleeding.

6.3 Abdominal surgery (GI, gynaecological, urological)

6.3.1 Start mechanical VTE prophylaxis on admission for people undergoing abdominal (GI, gynaecological, urological) surgery who are at increased risk of VTE using AES or IPC. Continue until the person no longer has reduced mobility relative to their normal or anticipated mobility.

6.3.2 Add LMWH prophylaxis for a minimum of 7 days for people undergoing abdominal surgery whose risk of VTE outweighs their risk of bleeding. Consider extending pharmacological prophylaxis to 28 days postoperatively for people who have had major cancer surgery in the abdomen.

6.3.3 Offer VTE prophylaxis to people undergoing bariatric surgery.

6.3.4 The urology department have produced specific guidelines on their preferred choice of VTE prophylaxis, according to procedure (see Appendix D).

6.4 Vascular surgery

6.4.1. Consider LMWH for a minimum of 7 days for people undergoing the following procedures, if risk of VTE outweighs risk of bleeding:

• Open vascular surgery or major endovascular procedures

• Lower limb amputation

6.4.2 Where pharmacological prophylaxis is contraindicated, consider mechanical VTE prophylaxis with AES or IPC until the person no longer has significantly reduced mobility relative to their normal or anticipated mobility.

6.4.3 Consider LMWH for 7 days for patients undergoing varicose vein surgery if the total anaesthesia time is more than 90 minutes or the person’s risk of VTE outweighs their risk of bleeding.

6.5 Oral or maxillofacial (OMF) surgery and ear/nose/throat (ENT) surgery

6.5.1 Consider LMWH prophylaxis for a minimum of 7 days for people undergoing OMF or ENT surgery whose risk of VTE outweighs their risk of bleeding.

6.5.2 Consider mechanical VTE prophylaxis with AES or IPC where pharmacological prophylaxis is contraindicated, continued until the person no longer has significantly reduced mobility relative to their normal or anticipated mobility.

6.5.3 Individuals undergoing certain minor ENT procedures under local anaesthetic are included in Appendix B as a cohort group that do not require individualised VTE assessment.

6.6 Palliative care patients

6.6.1 Consider pharmacological VTE prophylaxis with LMWH for people who are having palliative care. Take into account temporary increases in thrombotic risk factors, risk of bleeding, likely life expectancy and views of the person, their family members, carers, and the MDT.

6.6.2 Do not routinely offer VTE prophylaxis to people in the last days of life. Review VTE prophylaxis daily for these patients.

6.7 Critical care

6.7.1 Provide LMWH to people admitted to the critical care unit if pharmacological VTE prophylaxis is not contraindicated.

6.7.2 Consider mechanical VTE prophylaxis, particularly if pharmacological prophylaxis is contraindicated. Continue until the person no longer has reduced mobility relative to their normal or anticipated mobility.

6.7.3 Reassess VTE and bleeding risk daily for people in the critical care unit, or more frequently if the person’s condition is changing rapidly.

6.8 Acute stroke patients

6.8.1 Clinical assessment of VTE risk should be made in all acute stroke patients on admission. Stroke patients are deemed to be at risk of VTE if:

• Patient is unable to independently mobilise to the bathroom

• Patient has a leg weakness of at least 2 on the National Institute for Stroke Scale

6.8.2 IPC should be prescribed in all at-risk stroke patients within 24 hours of admission.

6.8.3 IPC should be provided for 30 days, or until the person is mobile or discharged, whichever is sooner.

6.8.4 LMWH should not be used within the first 14 days of an index stroke event unless decided upon by a consultant stroke physician or consultant neurologist.

6.9 Covid-19 positive patients

6.9.1 Covid-19 infection is associated with increased risk of thrombosis, though rates of VTE are now lower than those we saw with the early waves of Covid infection when patients were unvaccinated. Patients should be risk assessed as usual and given standard doses of pharmacological thromboprophylaxis where indicated. PE should be considered in the differential in patients with unexplained desaturations. Selected patients with Covid-19 infection who are not on ITU can be considered for a treatment dose of LMWH if felt to be at particularly high thrombotic risk with low bleeding risk.

7.1. All patients (and/or carers) should be offered verbal and written information on VTE prevention as part of the admission process. A patient information leaflet (Appendix E) should be offered, and the risk assessment form (Appendix A) marked accordingly to confirm this has been done. All patients should have the opportunity to ask questions on VTE assessment and prophylaxis.

7.2 As part of the discharge plan, offer patients and/or their families or carers verbal and written information on VTE, including the signs and symptoms to watch for. If discharged with prophylaxis, the patient should be provided with verbal and written instructions by the discharging nurse on the indication for prophylaxis, administration of prophylaxis. A self- administration form should be completed and filed in the patient’s medical notes. Patients should be made aware of the indication for prophylaxis and how/when to seek help if needed. If a patient is discharged on pharmacological thromboprophylaxis then additional instructions should be provided as part of the discharge letter. When a patient is discharged the mandatory VTE field on the discharge summary must be completed.

7.3 Ensure that people who are discharged with AES understand the benefits of wearing them, the importance of wearing them correctly, and the need to remove them daily for hygiene purposes. They should be able to remove and replace them themselves or have someone available to do this for them. They should know what to look for and who to contact if there is a problem (e.g., skin marking or blistering).

8.1 Data are collected to quantify the number of adult hospital admissions being risk assessed for VTE in order to allow appropriate prophylaxis based on national guidance from NICE. Relevant data will be collected via coding and uploaded to UNIFY2 system monthly. This data collection serves as the mechanism to enable the Trust to demonstrate an ongoing commitment to Patient Safety and benchmark achievements nationally. Also, as part of the Quality Schedule, the Trust is contractually required to collect these data to demonstrate compliance in completion of a VTE Risk assessment for all adults admitted to hospital.

9.1 An information analyst from coding generates a monthly report that is sent to the Head of Patient Safety, monitoring compliance with VTE risk assessment on admission. This compliance is monitored as part of the Patient Safety Dashboard and Performance Report presented to the Hospital Executive Board and Board of Directors.

9.2 The Patient Safety Team produces a quarterly audit report that includes the results of the audit (20 sets of notes per month) monitoring compliance with VTE risk assessment on admission and appropriate prophylaxis, as well as the number of hospital-acquired VTE events that occur in all sites.

9.3 The Patient Safety Team performs root-cause analysis of all hospital-acquired VTE episodes, and all potentially preventable events are reported on RL System, attributable to the consultant in charge during any major omissions of VTE prophylaxis.

National Institute for Health and Care Excellence. Venous thromboembolism in over 16s: Reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism.

2019. Available from: https://www.nice.org.uk/guidance/ng89

Catterick D, Hunt BJ. Impact of the national venous thromboembolism risk assessment tool in secondary care in England: retrospective population-based database study. Blood Coagul Fibrinolysis 2014; 25: 571–576. Full-text available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4162339/

The following groups of patients have been identified within Frimley Health following consultation with lead clinicians as those considered at low thrombotic risk:

• Breast Surgery Service

All day case patients where discharged home same day (not requiring overnight stay) UNLESS having a procedure with a Regional, Spinal or General Anaesthetic.

• Chemotherapy Day Unit Patients

These patients are all ambulant and are classified as low risk. They do not require VTE prophylaxis. This is documented in the admission documentation. Thromboprophylaxis may be given with specific drugs, e.g., IMIDs.

• Clinical Haematology

All day case patients where discharged home same day (not requiring overnight stay) – e.g., top up infusions, dressing changes to wound, bloods.

• Dental Medicine

All day cases, including those where tooth extraction required general anaesthetic if discharged home same day (not requiring overnight stay).

• Dermatology Day Case Patients

Dermatology day case patients undergoing minor procedures under local anaesthetic remain ambulant and are therefore low risk of VTE and do not require prophylaxis.

• Endocrinology

All day case patients where discharged home same day (not requiring overnight stay).

• Endoscopy Outpatients

Patients attending as an outpatient for an Endoscopy procedure have been identified as low risk for VTE as they are ambulant within 2-4 hours and therefore require no VTE prophylaxis. This will be recorded on the admission documentation. This decision is supported by the Clinical Director for Surgery.

• Elective patients for Coronary Angiography, angioplasty and pacing procedures

These patients are all at low risk of VTE as they are ambulant within 4 hours of procedure, discharged within 24 hours and therefore do not require any prophylaxis treatment.

• Elective patients for Vascular Angiography, Vascular angioplasty, Radiofrequency Ablation of Varicose Vein of Leg, and Avulsion of Varicose Vein of Leg

These patients are at low risk of VTE as they are ambulant and discharged same day

• Gastroenterology Service

Those patients where discharged home same day, UNLESS requiring regional, spinal or general anaesthetic

• General Internal Medicine

All elective day case admission if discharged home same day (not requiring overnight stay), and all emergency admissions (e.g., ED (Emergency Department) LODGED, A&E) if discharged home same day (not requiring overnight stay).

• General Surgery

All day case patients if discharged home same day (not requiring overnight stay, UNLESS:

• requiring a procedure with a Regional, Spinal or General Anaesthetic, or

• admitted under another listed speciality

• Gynaecology

Those patients where discharged home same day, UNLESS requiring regional, spinal or general anaesthetic.

• IVAS/MIDU patients

Individuals attending for outpatient infusional therapies as day cases remain ambulant and are considered at low risk of VTE and do not require prophylaxis treatment. This includes all patients (regardless of speciality) who attend IVAS/MIDU and are discharged home same day (not requiring overnight stay), where no general anaesthetic was used.

• Interventional Radiology day cases

All interventional radiology procedures where no anaesthetic (null), and those requiring only topical, local anaesthetic or sedation.

• Minor operations

Those patients discharged home same day and where only local, sedation or topical anaesthetic required.

• Neurology Patients

Patients being treated as a day case by the neurologist remain ambulant and considered at low risk of VTE and do not require prophylaxis treatment.

• Ophthalmology

Elective patients admitted for eye procedures under local anaesthetic are at low risk of VTE. They therefore do not require prophylaxis against VTE.

• Oral and Maxillofacial

All day cases where discharged home same day (not requiring overnight stay) UNLESS requiring regional, spinal or general anaesthetic.

• Paediatric (16+) -

Those admitted to PAU and CACOU if discharged home same day (not requiring overnight stay). Admissions to PAU and CACOU are generally for assessment and decision making rather than for procedures.

• Pain Procedures

Patients being admitted to the day unit remain ambulant and therefore low risk of VTE and do not require VTE prophylaxis, UNLESS required regional, spinal or general anaesthetic.

• Renal

All day case patients, including renal dialysis, if discharged home same day (not requiring overnight stay).

• Respiratory Day Unit Patients

These patients undergoing minor procedures remain ambulant and therefore low risk of VTE and do not require prophylaxis treatment.

• Selected ENT Patients

ENT patients undergoing minor procedures under local anaesthetic including skin lesions, lymph node biopsies, Grommets, TNO, LAUP and electrocautery remain ambulant and are therefore low risk of VTE and do not require prophylaxis treatment.

• Selected Plastic Surgery patients

Patients undergoing minor plastic surgery procedures under local anaesthetic including image-guided steroid injection, Dupuytren’s surgery, trigger finger release, carpal/cubital tunnel decompressions, excision of skin lesions/ganglions/mucous cysts, nail bed repair/release remain ambulant and are at low risk of VTE and do not require prophylaxis treatment. These patients are all ambulant and have a length of stay less than 24 hours and are considered low risk, UNLESS required regional, spinal or general anaesthetic

• Spinal Surgery Service

All day cases where discharged home same day (not requiring overnight stay), and if requiring only local anaesthetic, topical or sedation for chronic pain management.

• Urodynamics

Patients admitted as a day case for Urodynamics remain ambulant and therefore low risk of VTE and do not require prophylaxis treatment.

• Urology

All day cases where discharged home same day (not requiring overnight stay), UNLESS having a procedure requiring regional, spinal or general anaesthetic.

Patients who are at low thrombotic risk (defined as those with no thrombotic risk factors on the VTE risk assessment tool in Appendix A) who are undergoing the following low-risk surgical procedures should not be routinely offered anti-embolism stockings:

Ear, nose and throat surgery

• Septoplasty

• Stapediectomy

• Tonsillectomy

• Mastoidectomy or tympanoplasty with anticipated anaesthetic time <90 minutes

General surgery

• Excision of sebaceous cyst

• Incision and drainage of abscess

• Excision of lipoma

Breast surgery

• Excision biopsy of duct

• Excision biopsy of breast tissue

• Excision of the subareolar ducts to prevent nipple discharge

Colorectal surgery

• Banding of haemorrhoids under general anaesthesia

• Examination under general anaesthesia

• Excision and/or biopsy of perianal lesions

• Excision of haemorrhoids

• Haemorrhoid “HALO” procedures

• Injection of botox or lateral anal sphincterotomy for anal fissure

• Laying open of fistulae

• Pilonidal sinus surgery

Gynaecology

• Diagnostic hysteroscopy

• Endometrial ablation

• Laparoscopic sterilisation

• Laparoscopic cystectomy (benign ovarian)

• Laparoscopic oophorectomy

• Laparoscopic ovarian drilling

• Laparoscopic salpingectomy for hydrosalpinx

• Removal of polyps from the cervix uterus

• Hysteroscopic procedures

Orthopaedics

• Arthroscopy of elbow

• Arthroscopy of wrist

• Carpal or cubital tunnel decompression

• Excision (or replacement) of radial head

• Excision of Dupuytren's contracture

• Excision of ganglia around the wrist

• Excision of skin lesion +/- local flap or graft

• Excision of mucous cyst

• Finger surgery

• Image-guided steroid injection

• Knee arthroscopy

• Nail bed repair/revision

• Open shoulder surgery

• Release of extensor origin from lateral (or flexor origin from medial) epicondyle of elbow

• Release of thumb tendons (De Quervain's tenovaginitis)

• Release of trigger finger or thumb

• Scar revision

• Shoulder arthroscopic surgery

• Trapeziectomy

• Ulnar nerve decompression

• Nerve and fracture repairs of the hands

Urology

• Adult circumcision

• Cystoscopy

• Endoscopic insertion of prosthesis into ureter

• Excision of epididymal cyst

• Excision of urethral warts

• Hydrocelectomy

• Orchidopexy

• Ureteroscopy

• Urethral surgery

• Varicocelectomy

• Vasectomy

Available at

Preventing hospital-associated blood clots

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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