Important Update to the County Durham and Darlington DVT Pathway

We have become aware that some practices were either not using the County Durham and Darlington DVT Pathway, or were using an incorrect version and this had led to a serious untoward incident. As a result we have taken the opportunity to review the Pathway and to re-launch it so everyone is now using the correct version. Most of the changes are subtle, but there are a few important points we want to emphasise:

• Please ensure that you only use the most up to date version of the County Durham and Darlington DVT Pathway and that you delete any previous versions.

• The current DVT Pathway can now be found on GPTeamNet, or on the NECS Medicines Optimisation website:
  • DVT pathway information
  • Investigation proforma: rivaroxaban
  • Investigation proforma: enoxaparin

• It’s really important to familiarise yourself with the changes to the Pathway, as this incorporates lessons learned from a serious untoward incident.

Summary of Key Changes

1. Greater emphasis has been placed on the following:

That patients with a negative initial ultrasound scan, but a positive d-dimer will have their treatment stopped until the results of the second scan, 6-8 days later, are known.

This is because the patient will have one of the three scenarios below:

1. Not have a DVT at all
2. Have an isolated calf vein DVT that would not have extended, or
3. Have an isolated calf vein DVT that would have extendedNot

Giving anticoagulation for the week is unnecessary for 1 and 2. In 3, continuing treatment would very likely stop extension for the week it is given (making the second scan pointless as it will be negative). When anticoagulation is then stopped the clot may then extend proximally and remain untreated – one week of anticoagulation being insufficient.

A repeat scan should be booked via 111 for 6 – 8 days after the initial scan and this should be recorded on the second page of the patient held record.

2. Guidance to seek secondary care advice strengthened

Unless you are happy this is a provoked distal DVT we strongly recommend you seek advice on duration of treatment and further investigations either by referring to haematology or communicating with your local haematologist.

3. For patients receiving rivaroxaban, there is now a NOAC patient alert card and this has been added to the guidance:

In addition to the DVT patient held record, the patient will also carry a NOAC patient alert card which should be given to the patient with the starter packs, or will be supplied by the pharmacy if a prescription is given. In addition patients should also be counselled to let other health care professionals, such as dentists, involved in their care, know that they are taking rivaroxaban.

Click here for further information on the NOAC alert card from the Northern England Strategic Clinical Networks.

GP practices and community pharmacies can request a supply of the NOAC alert cards by emailing england.nescn@nhs.net.