1.1. Who is the focus?

1.2. Settings

1.3. Activities, services or aspects of care

1.4. Economic aspects

We will take economic aspects into account when making recommendations. We will develop an economic plan that states for each review question (or key area in the scope) whether economic considerations are relevant, and if so whether this is an area that should be prioritised for economic modelling and analysis. We will review the economic evidence and carry out economic analyses, using an NHS and personal social services (PSS) perspective, as appropriate.

1.5. Key issues and questions

While writing this scope we have identified the following key issues, and key questions related to them. The term ‘VTE’ in this section refers to both deep vein thrombosis (DVT) and pulmonary embolism (PE):

1. Risk assessment:

   1.1.

   What is the accuracy of individual risk assessment or prediction tools in predicting the likelihood of VTE in patients who are admitted to hospital?

   1.2.

   What is the accuracy of individual risk assessment or prediction tools in predicting the likelihood of VTE in patients who are having day procedures (including surgery and chemotherapy) at hospital?

   1.3.

   What is the accuracy of individual risk assessment or prediction tools in predicting the likelihood of VTE in pregnant women who are admitted to hospital or midwife units?

   1.4.

   What is the accuracy of individual risk assessment or prediction tools in predicting the likelihood of major bleeding or the risk of bleeding in patients who are admitted to hospital?

   1.5.

   What is the accuracy of individual risk assessment or prediction tools in predicting the likelihood of major bleeding or the risk of in patients who are having day procedures (including surgery and chemotherapy) at hospital?

   1.6.

   What is the accuracy of individual risk assessment or prediction tools in predicting the likelihood of major bleeding or the risk of bleeding in pregnant women who are admitted to hospital or midwife units?

   1.7.

   How clinically and cost effective are risk assessment or prediction tools at reducing the rates of VTE in patients who are admitted to hospital?

   1.8.

   How clinically and cost effective are risk assessment or prediction tools at reducing the rates of VTE in patients who are having day procedures (including surgery and chemotherapy) at hospital?

   1.9.

   How clinically and cost effective are risk assessment or prediction tools at reducing the rates of VTE in pregnant women who are admitted to hospital or midwife units?

   1.10.

   How effective is reassessment of patients who are admitted to or having day procedures at hospital?

   If appropriate evidence is not identified from the questions above (1.1 to 1.10) the following 2 questions may also be considered:

   1.11.

   What are the individual risk factors for VTE in patients who are admitted to hospital?

   1.12.

   What are the individual risk factors for VTE in patients who are having day procedures (including surgery and chemotherapy) at hospital?

   1.13.

   What are the individual risk factors for VTE in pregnant women who are admitted to hospital or midwife units?

2. Prophylaxis:
   Each of the following questions will investigate individual populations separately. Populations include:

   • people having the following types of surgery:

     –

     elective hip surgery

     –

     elective knee surgery

     –

     hip fracture

     –

     knee arthroscopy

     –

     other orthopaedic surgery

     –

     abdominal surgery (bariatric, liver, gastrointestinal, gynaecological, laparoscopic, thoracic and urological)

     –

     cranial surgery

     –

     spinal surgery

     –

     cardiac surgery

     –

     vascular surgery

     –

     dental/maxillofacial surgery

     –

     vaginal surgery

   • people discharged with lower-limb immobilisation (including boots, braces, Plaster of Paris [POP] and other devices]
   • people being treated for:

     –

     major trauma

     –

     spinal injury

     –

     stroke

     –

     acute coronary syndromes

     –

     cancer

   • people attending hospital as medical admissions
   • people with central venous catheters
   • people having palliative care
   • pregnant women and up to 6 weeks after giving birth
   • people with psychiatric disorders
   • people who are obese
   • people with kidney disease.
   Each of the questions will consider the following settings, if appropriate: people in hospital and those having day procedures (including surgery, chemotherapy)
   Each of the questions will include the following prophylaxis methods, if applicable:

   • mechanical prophylaxis, including:

     –

     anti-embolism stockings (above or below knee)

     –

     intermittent pneumatic compression devices (full leg or below knee)

     –

     foot impulse devices

     –

     electrical stimulation (including geko devices)

     –

     continuous passive motion

     –

     vena caval filters.

   • pharmacological prophylaxis, including:

     –

     apixaban

     –

     aspirin

     –

     dabigatran

     –

     fondaparinux

     –

     unfractionated heparin

     –

     low molecular weight heparin (LMWH)

     –

     rivaroxaban

     –

     vitamin k antagonists (for example warfarin).

     2.1.

     What is the effectiveness of different pharmacological and mechanical prophylaxis strategies (alone or in combination)?

     2.2.

     What is the effectiveness of vena caval filters in people admitted to hospital who are at high risk of DVT or PE admitted to hospital?

     2.3.

     What is the most effective timing for starting prophylaxis with LMWH for people having surgery?

     2.4.

     What is the most effective prophylaxis duration (covering the time in hospital only or continuing after discharge)?

     2.5.

     What is the most effective prophylaxis strategy for inpatients in whom pharmacological prophylaxis is contraindicated?

     2.6.

     What is the most effective prophylaxis strategy for inpatients in whom mechanical prophylaxis is contraindicated?

     2.7.

     What is the most effective prophylaxis strategy for patients in whom both mechanical and pharmacological prophylaxis are contraindicated?

     2.8.

     What is the most effective VTE prophylaxis strategy for bridging patients who are already using anticoagulants agents for other reasons?

     2.9.

     What is the most effective VTE prophylaxis strategy in managing patients who are already using antiplatelets for cardiovascular disease?

     2.10.

     What is the most effective VTE prophylaxis strategy for pregnant women admitted to hospital or a midwifery-led unit during labour?

3. Information for patients, family members and carers:

   3.1.

   What specific information should be provided to people who need VTE prophylaxis?

   3.2.

   What information do patients, their family members and carers say they want about VTE prophylaxis?

1.6. Main outcomes

The main outcomes that will be considered when searching for and assessing the evidence are:

1. All-cause mortality
2. Pulmonary embolism
3. Fatal pulmonary embolism
4. Deep vein thrombosis (symptomatic or asymptomatic)
5. Major bleeding
6. Fatal bleeding
7. Heparin-induced thrombocytopenia
8. Post-thrombotic syndrome
9. Pulmonary hypertension
10. Quality of life (validated scores)
11. Hospital length of stay
12. Readmission
13. Neurological events (for example haemontiagic stroke)

2.1. NICE guidance

• Venous thromboembolism in adults admitted to hospital: reducing the risk (2010) NICE guideline CG92
• Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing (2012) NICE clinical guideline 144
• Caesarean section (2011) NICE clinical guideline 132
• Stroke: Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA) (2008) NICE clinical guideline 68.
• Apixaban tar the prevention of venous thromboembolism after total hip or knee replacement in adults (2012) NICE technology appraisal 245
• Dabigatran etexilate for the prevention of venous thromboembolism after hip or knee replacement surgery in adults (2008) NICE technology appraisal 157.
• Rivaroxaban for the prevention of venous thromboembolism after total hip or total knee replacement in adults (2009) NICE technology appraisal 170
• The geko device for reducing the risk of venous thromboembolism (2014) NICE medical technology guidance 19.

2.2. NICE quality standards

2.3. NICE Pathways

When this guideline is published it will update the existing NICE pathway on venous thromboembolism. NICE Pathways bring together all related NICE guidance and associated products on a topic in an interactive topic-based flow chart.

3.1. Key facts and figures

Hospital acquired venous thromboembolism, also known as hospital acquired thrombosis (HAT), covers all venous thromboembolism (VTE) that occurs in hospital and for 90 days after a hospital admission. Epidemiological studies have shown that HAT accounts for somewhere between 50–60% of all VTE seen. Hospital Episode Statistics showed that in 2013–14 there were 24,725 admissions for pulmonary embolism and 19,463 for DVT in England, resulting in 205,448 and 67,028 bed-days and 47,594 and 25,958 finished consultant episodes respectively. In 2013, in England and Wales there were 2,191 deaths recorded as due to pulmonary embolism (PE) and 2,816 due to deep vein thrombosis (DVT), but the actual number of people dying from these conditions is likely to be higher because of misdiagnosis and the failure to recognise VTE as the underlying cause. Thus hospital-acquired VTE accounts for thousands of deaths annually in the UK.

3.2. Current practice

In 2010, the CQUIN target introduced a payment linked to at least 90% of adults being risk assessed on admission to hospital. Figures reporting the uptake of some of the recommendations in CG92 are reported on NICE’s website. Recent evidence also estimates that the national mortality rate from VTE has fallen by 8–9% since the recommendations in CG92 were introduced.

In addition, since the publication of the last version of the guideline, CG92, two new interventions for preventing venous thromboembolism (VTE) have become available: apixaban and geko devices.

3.3. Policy, legislation, regulation and commissioning