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Before referring a patient to the GP Care DVT Pathway please familiarise yourself with the Exclusion Criteria to help reduce the number of inappropriate referrals made to the Community DVT Service.

Referral Guidelines

The Community DVT Service accepts referrals for patients registered with GPs in South Gloucestershire and Bristol North and ICE (inner city and east) and West localities with the primary aim of treating patients closer to home and reducing inappropriate attendance and admission to hospital.

Inclusion Criteria

Any patient, over 18, registered with a GP in South Gloucestershire, Bristol North, Inner City, East and West localities and temporary residents suitable for community treatment. Where the GP is uncertain about the suitability of any patient for the Community DVT pathway please seek guidance from a relevant secondary care consultant prior to referring patients to the Community DVT Service.

Patients with active cancer are not excluded from the pathway but GPs must use their clinical judgement regarding treatment options and the holistic needs of each individual patient.

The majority of pregnant and postpartum women will be suitable for the community DVT service but the on call Obstetric & Gynae Registrar should be contacted prior to referring pregnant women, see attached protocol for guidelines in pregnancy and the puerperium.

Exclusion Criteria

The following patients are excluded from this Service and should be referred to secondary care:

• Age less than 18 years

• Primary diagnosis of Pulmonary embolism

• Suspected upper limb DVT:

• Housebound patients with significant manual handling implications that cannot be managed within GP Surgeries e.g. no hoisting is available, must be able to transfer with the assistance of clinic staff

• Other disease process or acutely ill patient that requires admission to secondary care

• Weigh over 165kg

Phase 1: Patient visits their Registered GP/Out of Hours Provider

Where Patient presents with potential DVT (see separate guidance in pregnancy and puerperium):

• Registered GP/Out of Hours GP (“GP”) prepares Patient Record Card (electronic version available for auto completion of Patient details);

• GP performs Wells Score;

| | | |

|Wells Criteria: NICE cg144 | | |

|Present |Score | |

|Active cancer (treatment ongoing, within 6 months, or palliative) |+1 | |

|Paralysis, paresis or recent plaster immobilisation of the lower extremities |+1 | |

|Recently bedridden for three days or more or major surgery within 12 weeks requiring general or |+1 | |

|regional anaesthesia | | |

|Localised tenderness along the distribution of the deep venous system |+1 | |

|Entire leg swollen |+1 | |

|Calf swelling at least 3cm larger than asymptomatic side |+1 | |

|Pitting oedema confined to the symptomatic leg |+1 | |

|Collateral superficial veins (non-varicose) |+1 | |

|Previous documented DVT |+1 | |

|An alternative diagnosis is at least as likely as DVT |-2 | |

| | |

|Score = 2 or above DVT Likely – Refer for ultrasound | |

| | |

|Score = 1 or below DVT Unlikely – Perform D-dimer test | |

| | | |

• Where Wells Score is ≤1, GP performs D-dimer test using Near Patient Testing Kit;

• Select appropriate instruction dependent upon preferred D-Dimer Testing Kit used;

| |

|CLEARTEST D-dimer test: |

|Tear open foil pouch and place the test device on a clean and level surface. Note: |

|Best results will be obtained if the test is performed immediately after opening the foil pouch |

|Take finger prick blood sample: |

|Wash the patient’s hand with soap and warm water or clean with an alcohol swab. Allow to dry. |

|Massage the hand without touching the puncture site by rubbing down the hand towards the fingertip of the middle or ring finger. |

|Puncture the skin with a sterile lancet. Wipe away the first sign of blood. |

|Gently rub the hand from wrist to palm to finger to form a rounded drop of blood over the puncture site. |

|Note venous sample can be taken as alternative if necessary |

|Using the pipette supplied, hold the pipette horizontally and draw up sufficient blood for the test. |

|Allow 2 hanging drops of whole blood specimen (approximately 40 µL) to fall into the centre of the specimen well of the test device. |

|Immediately add 1 drop of buffer solution to the specimen well and start the timer. |

|Leave the test device lying horizontal and wait for the coloured line(s) to appear. Read results at 10 minutes (although positive results|

|can often be seen much earlier than this) |

|Do not interpret results after more than 15 minutes. |

| |

|CLEARVIEW D-dimer test: |

|Tear open foil pouch and place the test device on a flat horizontal surface. Note: |

|Once pouch is opened, commence use of the device within 10 minutes |

|Test and PC (Patient Control) zones are dyed yellow for manufacturing quality control purposes; the dye does not interfere with the test |

|results |

|Take finger prick blood sample: |

|Lance patient’s finger using sterile lancing device (min depth 1.8mm) |

|Using the capillary pipette provided collect finger prick blood sample (Do not use the venous pipettes.) |

|Hold a capillary pipette horizontally and touch the tip to the blood drop on the patient’s finger |

|Do not squeeze the bulb of the pipette during sampling or obstruct the vent; capillary action will automatically draw the blood into the |

|pipette |

|Allow the pipette to fill to the black line |

|Note venous sample can be taken as alternative if necessary |

|Immediately dispense all of the blood (35ul) from the capillary pipette into the round sample well of the test device |

|Hold the capillary pipette in a vertical position above the round sample well |

|Place a finger over the vent hole in the capillary pipette and dispense all of the blood into the well |

|Allow the blood sample to completely penetrate the sample pad before adding 2 drops of the buffer solution |

|Leave the test device lying horizontal and read the result at 10 minutes (although positive results can often be seen much earlier than |

|this) |

• If an ultrasound is not required, then GP completes sections 1a and 2 of the Patient Record Card and faxes to GP Care on 0303 334 0698 (unless part of the Bristol CCG LES pilot).

The Wells Score and D-dimer Test are designed as tools to aid clinical judgment. The full clinical picture must be reviewed when making a diagnostic decision taking into account the clinical signs and other relevant information such as the Wells pre-Test probability score or equivalent.

• If the Wells Score is 2 or more, or D-dimer is positive, then GP:

o Explains implications of DVT to Patient and that it is only a potential DVT at this stage;

o Books an Ultrasound Appointment by calling GP Care on 0333 332 2101 and informs the Patient of Ultrasound Appointment time and location;

o Completes the Patient Record Card, sections 1a,1b, 2, 3 and 4, immediately faxes to GP Care on 0303 334 0698 and gives original to Patient to take to the Ultrasound Appointment.

NB: If the Patient Appointment is after hours then the GP advises the patient that GP Care will telephone the patient as soon as possible on the next working day and ensures the telephone number that the patient will be contactable on is written on the Patient Record Card;

• Pre scan anti-coagulation

For waits of over 4 hours for a scan prescribe anti-coagulant, clexane or DOAC (direct oral coagulant also known as NOAC, new or novel anti-coagulant).

**LMWH is the preferred course of treatment pre scan for safe anticoagulation (as per NICE guidance).

Clexane dosage

o Calculate appropriate Clexane dosage (1.5mg per 1kg of body weight) and administer to Patient (see table one below) (for patients with creatinine clearance of ................
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