Dr Frances Akor and Professor Terry McCormack discuss the updated NICE guideline on VTE, focusing on recommendations that are relevant to primary care
Read the related Guidelines summary
- The incidence of VTE is likely to rise during the COVID-19 pandemic because of increased sedentary lifestyle, particularly of the vulnerable patients such as those with active cancer. The prolonged bed rest of people with symptoms at home will also put those people at greater risk of developing VTE
- Severely ill COVID-19 patients in intensive care have revealed evidence of increased thrombotic coagulopathy (elevated D-dimers and fibrinogen) and an incidence of VTE ranging from 25% to 31%25,26
- When carrying out a remote review, remember to use the Wells DVT and PE scores and consider using PERC also. Most of the items on the lists are part of the history, and heart rate can be measured by the patient or their carer
- If a face-to-face examination is required you should pre-plan the examination and the history should be established remotely; again consider the Wells score
- A D-dimer should only be carried out if the Wells DVT Score is 1 or 0, or the Wells PE Score is 4 or less. D-dimer is not necessary if the PERC is zero, but that does require access for oximetry to be performed
- If a D-dimer is carried out, consider using an age-adjusted score to reduce the need for further imaging investigations
- Using DOACs removes the need for INR testing and therefore reduces the need for face-to-face contact
- Outpatient treatment for low-risk PE is likely to be introduced in all areas at this time
- Patients discharged from hospital with high risk of VTE are likely to be on extended prophylaxis involving DOACs or LMWH and primary care may be asked to continue supplies27
- The 3-monthly review can be carried out via a remote visit. Consider sending the patient information via digital links. Thrombosis UK and Anticoagulation UK are sources of information about VTE.
These are the views of the authors and not the NICE VTE Guideline Committee.
VTE=venous thromboembolism; DVT=deep vein thrombosis; PERC=pulmonary embolism rule-out criteria; DOACs=direct-acting oral anticoagulants; INR=international normalised ratio; PE=pulmonary embolism; LMWHs=low molecular weight heparins
Implementation actions for STPs and ICSs
written by Dr David Jenner, GP, Cullompton, Devon
The following implementation actions are designed to support STPs and ICSs with the challenges involved with implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources.
- Review local care pathways for the management of VTE in light of the significant changes in this updated NICE guidance
- Consider the acquisition of point-of-care D-Dimer testing machines for GP practices and/or PCNs to facilitate rapid diagnosis
- Investigate CCG/ICS funding for these machines as the consequent savings will be made to CCG drug and referral budgets and reduce pressure on specialist services
- Update local hospital and GP formularies to reflect the new guidance on prescribing DOACs in cancer patients
- Offer education on the new guidance and on the use of the PERC tool to GP practices/PCNs and first contact services.
STP=sustainability and transformation partnership; ICS=integrated care system; VTE=venous thromboembolism; PCNs=primary care networks; CCG=clinical commissioning group; DOACs=direct-acting oral anticoagulants; PERC=pulmonary embolism rule-out criteria
The guideline referred to in this article was produced by Guideline Updates Team for the National Institute for Health and Care Excellence (NICE). The views expressed in this article are those of the authors and not necessarily those of NICE.
National Institute for Health and Care Excellence (2020) Venous thromboembolic diseases: diagnosis, management and thrombophilia testing. Available from www.nice.org.uk/guidance/ng158
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