This guideline covers assessing and reducing the risk of venous thromboembolism (VTE or blood clots) and deep vein thrombosis (DVT) in people aged 16 and over in hospital. It aims to help healthcare professionals identify people most at risk and describes interventions that can be used to reduce the risk of VTE.

Contents

• Guideline committee members
• Obstetric subgroup members
• Orthopaedic subgroup members
• NGC technical team members
• Co-opted expert advisers
• Peer reviewers
• Acknowledgements
• Volume 1
  • 1. Guideline summary
    • 1.1. Full list of recommendations
    • 1.2. Key research recommendations
    • 1.3. How this guideline was updated
  • 2. Introduction
  • 3. Development of the guideline
    • 3.1. What is a NICE guideline?
    • 3.2. Remit
    • 3.3. Who developed this guideline?
  • 4. Methods
    • 4.1. Assumptions made in this guideline
    • 4.2. Developing the review questions and outcomes
    • 4.3. Searching for evidence
    • 4.4. Identifying and analysing evidence of effectiveness
    • 4.5. Identifying and analysing evidence of cost effectiveness
    • 4.6. Developing recommendations
  • 5. Risk assessment for medical, surgical and trauma patients
    • 5.1. Introduction
    • 5.2. Accuracy of risk assessment tools for VTE in hospital admissions
    • 5.3. Accuracy of risk assessment tools for bleeding in hospital admissions
    • 5.4. Effectiveness of risk assessment tools in hospital admissions
    • 5.5. Risk assessment for people having day procedures
    • 5.6. Accuracy of risk assessment tools for bleeding for day procedures
    • 5.7. Effectiveness of risk assessment tools for day procedures
    • 5.8. Recommendations and link to evidence
  • 6. Reassessment of VTE and bleeding risk
    • 6.1. Introduction
    • 6.2. Reassessment of risk for hospital admissions
    • 6.3. Reassessment of risk for day procedures
    • 6.4. Recommendations and link to evidence
  • 7. Risk assessment for pregnant women and women up to 6 weeks post-pregnancy
    • 7.1. Introduction
    • 7.2. Prognostic review question: What is the accuracy of individual risk assessment or predication tools in predicting the likelihood of VTE or major bleeding or the risk of bleeding in pregnant women who are admitted to hospital and midwife units including up to 6 weeks after giving birth?
    • 7.3. Intervention review question: What is the clinical and cost-effectiveness of risk assessment tools, when each tool is followed by the appropriate treatment, at reducing the rates of VTE and/or bleeding in pregnant women who are admitted to hospital or midwife units?
    • 7.4. Reassessment review question: How effective is reassessment of the risk of VTE and/or bleeding of pregnant women who are admitted to hospital or midwife units?
    • 7.5. Economic evidence
    • 7.6. Evidence statements
    • 7.7. Recommendations and link to evidence
  • 8. Giving information and planning for discharge
    • 8.1. Introduction
    • 8.2. Review question: What information about VTE and VTE prophylaxis should be given to people who are admitted to hospital, having day procedures or outpatients post-discharge, and their family or carers?
    • 8.3. Qualitative evidence
    • 8.4. Economic evidence
    • 8.5. Evidence statements
    • 8.6. Recommendations and link to evidence
  • 9. General VTE prevention for everyone in hospital
    • 9.1. Summary of the effectiveness of mechanical and pharmacological prophylaxis
    • All surgery
  • 10. Nursing care: Early mobilisation and hydration
    • 10.1. Early mobilisation and leg exercises
    • 10.2. Hydration
    • 10.3. Recommendations and link to evidence
  • 11. Obesity
    • 11.1. Introduction
    • 11.2. Review question: What is the effectiveness of weight based dose-adjustment strategies of LMWH compared to fixed dose strategies of LMWH for people who are obese?
    • 11.3. Clinical evidence
    • 11.4. Economic evidence
    • 11.5. Evidence statements
    • 11.6. Recommendations and link to evidence
  • 12. People using antiplatelet agents
    • 12.1. Introduction
    • 12.2. Review question: What is the effectiveness of different pharmacological and mechanical prophylaxis strategies (alone or in combination) for people using antiplatelet agents at time of presentation?
    • 12.3. Clinical evidence
    • 12.4. Economic evidence
    • 12.5. Evidence statements
    • 12.6. Recommendations and link to evidence
  • 13. People using anticoagulation therapy
    • 13.1. Introduction
    • 13.2. Review question: What is the effectiveness of different pharmacological and mechanical prophylaxis strategies (alone or in combination) when interrupting anticoagulant therapy?
    • 13.3. Clinical evidence
    • 13.4. Economic evidence
    • 13.5. Evidence statements
    • 13.6. Recommendations and link to evidence
  • 14. People with acute coronary syndromes
    • 14.1. Introduction
    • 14.2. Review question: What is the effectiveness of different pharmacological and mechanical prophylaxis strategies (alone or in combination) for people being treated for acute coronary syndromes (using anticoagulants and/or antiplatelet agents)?
    • 14.3. Clinical evidence
    • 14.4. Economic evidence
    • 14.5. Evidence statements
    • 14.6. Recommendations and link to evidence
  • 15. Acute stroke patients
    • 15.1. Introduction
    • 15.2. Review question: What is the effectiveness of different pharmacological and mechanical prophylaxis strategies (alone or in combination) for people who are admitted to hospital with a stroke or who have a stroke in hospital?
    • 15.3. Clinical evidence
    • 15.4. Economic evidence
    • 15.5. Evidence statements
    • 15.6. Recommendations and link to evidence
  • 16. Acutely ill medical patients admitted to hospital
    • 16.1. Introduction
    • 16.2. Review question: What is the effectiveness of different pharmacological and mechanical prophylaxis strategies (alone or in combination) for acutely ill medical patients admitted to hospital?
    • 16.3. Clinical evidence
    • 16.4. Economic evidence
    • 16.5. Evidence statements
    • 16.6. Recommendations and link to evidence
  • 17. People with cancer who are having day procedures
    • 17.1. Introduction
    • 17.2. Review question: What is the effectiveness of different pharmacological and mechanical prophylaxis strategies (alone or in combination) for people with cancer having day procedures?
    • 17.3. Clinical evidence
    • 17.4. Economic evidence
    • 17.5. Evidence statements
    • 17.6. Recommendations and link to evidence
  • 18. Central venous catheters
    • 18.1. Introduction
    • 18.2. Review question: What is the effectiveness of different pharmacological prophylaxis strategies (alone or in combination) for people with central venous catheters?
    • 18.3. Clinical evidence
    • 18.4. Economic evidence
    • 18.5. Evidence statements
    • 18.6. Recommendations and link to evidence
  • 19. People who are having palliative care
    • 19.1. Introduction
    • 19.2. Review question: What is the effectiveness of different pharmacological and mechanical prophylaxis strategies (alone or in combination) for people who are having palliative care?
    • 19.3. Clinical evidence
    • 19.4. Economic evidence
    • 19.5. Evidence statements
    • 19.6. Recommendations and link to evidence
  • 20. People admitted to critical care units
    • 20.1. Introduction
    • 20.2. Review question: What is the effectiveness of different pharmacological and mechanical prophylaxis strategies (alone or in combination) for people admitted to critical care units?
    • 20.3. Clinical evidence
    • 20.4. Economic evidence
    • 20.5. Evidence statements
    • 20.6. Recommendations and link to evidence
  • 21. Pregnant women and women up to 6 weeks post-pregnancy
    • 21.1. Introduction
    • 21.2. Review question: What is the effectiveness of different pharmacological and mechanical prophylaxis strategies (alone or in combination) for pregnant women admitted to hospital (including up to 6 weeks after giving birth)?
    • 21.3. Clinical evidence
    • 21.4. Economic evidence
    • 21.5. Evidence statements
    • 21.6. Recommendations and link to evidence.
  • 22. People with psychiatric disorders
    • 22.1. Introduction
    • 22.2. Review question: What is the effectiveness of different pharmacological and mechanical prophylaxis strategies (alone or in combination) for people with psychiatric disorders?
    • 22.3. Clinical evidence
    • 22.4. Economic evidence
    • 22.5. Evidence statements
    • 22.6. Recommendations and link to evidence
  • Reference list
• Volume 2
  • 23. Anaesthesia
    • 23.1. Introduction
    • 23.2. Clinical evidence on anaesthesia
    • 23.3. Cost-effectiveness evidence
    • 23.4. Recommendations and link to evidence
  • 24. Lower limb immobilisation
    • 24.1. Introduction
    • 24.2. Review question: What is the effectiveness of different pharmacological and mechanical prophylaxis strategies (alone or in combination) in people with lower limb immobilisation?
    • 24.3. Clinical evidence
    • 24.4. Economic evidence
    • 24.5. Evidence statements
    • 24.6. Recommendations and link to evidence
  • 25. Fragility fractures of the pelvis, hip and proximal femur
    • 25.1. Introduction
    • 25.2. Review question: What is the effectiveness of different pharmacological and mechanical prophylaxis strategies (alone or in combination) for people with fragility fractures of the pelvis, hip or proximal femur?
    • 25.3. Clinical evidence
    • 25.4. Economic evidence
    • 25.5. Evidence statements
    • 25.6. Recommendations and link to evidence
  • 26. Elective hip replacement surgery
    • 26.1. Introduction
    • 26.2. Review question: What is the effectiveness of different pharmacological and mechanical prophylaxis strategies (alone or in combination) for people undergoing elective hip replacement?
    • 26.3. Clinical evidence
    • 26.4. Economic evidence
    • 26.5. Evidence statements
    • 26.6. Recommendations and link to evidence
  • 27. Elective knee replacement surgery
    • 27.1. Introduction
    • 27.2. Review question: What is the effectiveness of different pharmacological and mechanical prophylaxis strategies (alone or in combination) for people undergoing elective knee replacement surgery?
    • 27.3. Clinical evidence
    • 27.4. Economic evidence
    • 27.5. Evidence statements
    • 27.6. Recommendations and link to evidence
  • 28. Non-arthroplasty orthopaedic knee surgery
    • 28.1. Introduction
    • 28.2. Review question: What is the effectiveness of different pharmacological and mechanical prophylaxis strategies (alone or in combination) in people having non-arthroplasty knee surgery?
    • 28.3. Clinical evidence
    • 28.4. Economic evidence
    • 28.5. Evidence statements
    • 28.6. Recommendations and link to evidence
  • 29. Foot and ankle orthopaedic surgery
    • 29.1. Introduction
    • 29.2. Review question: What is the effectiveness of different pharmacological and mechanical prophylaxis strategies (alone or in combination) in people having foot and ankle surgery?
    • 29.3. Clinical evidence
    • 29.4. Economic evidence
    • 29.5. Evidence statements
    • 29.6. Recommendations and link to evidence
  • 30. Upper limb orthopaedic surgery
    • 30.1. Introduction
    • 30.2. Review question: What is the effectiveness of different pharmacological and mechanical prophylaxis strategies (alone or in combination) in people having upper limb surgery?
    • 30.3. Clinical evidence
    • 30.4. Economic evidence
    • 30.5. Evidence statements
    • 30.6. Recommendations and link to evidence
  • 31. Elective spinal surgery
    • 31.1. Introduction
    • 31.2. Review question: What is the effectiveness of different pharmacological and mechanical prophylaxis strategies (alone or in combination) for people undergoing spinal surgery?
    • 31.3. Clinical evidence
    • 31.4. Economic evidence
    • 31.5. Evidence statements
    • 31.6. Recommendations and link to evidence
  • 32. Cranial surgery
    • 32.1. Introduction
    • 32.2. Review question: What is the effectiveness of different pharmacological and mechanical prophylaxis strategies (alone or in combination) for people undergoing intracranial surgery?
    • 32.3. Clinical evidence
    • 32.4. Economic evidence
    • 32.5. Evidence statements
    • 32.6. Recommendations and link to evidence
  • 33. Spinal injury
    • 33.1. Introduction
    • 33.2. Review question: What is the effectiveness of different pharmacological and mechanical prophylaxis strategies (alone or in combination) for people with spinal injury?
    • 33.3. Clinical evidence
    • 33.4. Economic evidence
    • 33.5. Evidence statements
    • 33.6. Recommendations and link to evidence
  • 34. Major trauma
    • 34.1. Introduction
    • 34.2. Review question: What is the effectiveness of different pharmacological and mechanical prophylaxis strategies (alone or in combination) for people with major trauma?
    • 34.3. Clinical evidence
    • 34.4. Economic evidence
    • 34.5. Evidence statements
    • 34.6. Recommendations and link to evidence
  • 35. Abdominal surgery (excluding bariatric surgery)
    • 35.1. Introduction
    • 35.2. Review question: What is the effectiveness of different pharmacological and mechanical prophylaxis strategies (alone or in combination) for people undergoing abdominal surgery (gastrointestinal, gynaecological, urological)?
    • 35.3. Clinical evidence
    • 35.4. Economic evidence
    • 35.5. Evidence statements
    • 35.6. Recommendations and link to evidence
  • 36. Bariatric surgery
    • 36.1. Introduction
    • 36.2. Review question: What is the effectiveness of different pharmacological and mechanical prophylaxis strategies (alone or in combination) for people undergoing bariatric surgery?
    • 36.3. Clinical evidence
    • 36.4. Economic evidence
    • 36.5. Evidence statements
    • 36.6. Recommendations and link to evidence
  • 37. Cardiac surgery
    • 37.1. Introduction
    • 37.2. Review question: What is the effectiveness of different pharmacological and mechanical prophylaxis strategies (alone or in combination) for people undergoing cardiac surgery?
    • 37.3. Clinical evidence
    • 37.4. Economic evidence
    • 37.5. Evidence statements
    • 37.6. Recommendations and link to evidence
  • 38. Thoracic surgery
    • 38.1. Introduction
    • 38.2. Review question: What is the effectiveness of different pharmacological and mechanical prophylaxis strategies (alone or in combination) for people undergoing thoracic surgery?
    • 38.3. Clinical evidence
    • 38.4. Economic evidence
    • 38.5. Evidence statements
    • 38.6. Recommendations and link to evidence
  • 39. Vascular surgery
    • 39.1. Introduction
    • 39.2. Review question: What is the effectiveness of different pharmacological and mechanical prophylaxis strategies (alone or in combination) for people undergoing vascular surgery?
    • 39.3. Clinical evidence
    • 39.4. Economic evidence
    • 39.5. Evidence statements
    • 39.6. Recommendations and link to evidence
  • 40. Head and neck surgery
    • 40.1. Oral and maxillofacial surgery
    • 40.2. ENT surgery
  • 41. Acronyms and abbreviations
  • 42. Glossary
    • 42.1. Guideline-specific terms
    • 42.2. General terms
  • Reference list
• Appendices
  • Appendix A. Scope
  • Appendix B. Declarations of interest
  • Appendix C. Clinical review protocols
  • Appendix D. Health economic review protocol
  • Appendix E. Clinical study selection
  • Appendix F. Health economic study selection
  • Appendix G. Literature search strategies
  • Appendix H. Clinical evidence tables
  • Appendix I. References
  • Appendix J. Health economic evidence tables
  • Appendix K. GRADE tables
  • Appendix L. Forest plots
  • Appendix M. Network meta-analyses (NMAs)
  • Appendix N. Excluded clinical studies
  • Appendix O. Excluded health economic studies
  • Appendix P. Cost-effectiveness analysis: Prophylaxis strategies for people undergoing elective total hip and elective total knee replacement surgeries
  • Appendix Q. Unit costs
  • Appendix R. Research recommendations
  • Appendix S. How this guideline was updated
  • Appendix T. Department of Health’s National VTE Risk Assessment Tool
  • Appendix U. Royal College of Obstetricians and Gynaecologists’ VTE risk assessment tool
  • Appendix V. NICE technical team
  • Appendix W. References

Final

Developed by the National Guideline Centre, hosted by the Royal College of Physicians

Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and, where appropriate, their carer or guardian.

Local commissioners and providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.

Update information August 2019: Recommendation 1.12.11 (1.5.30 in this document) was amended to clarify when anti-embolism stockings can be used for VTE prophylaxis for people with spinal injury.

See www.nice.org.uk/guidance/ng89 for more information