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Affix patient label here

Venous Thromboembolism Risk Factor Assessment & Guidelines

Date:_______________

Step 1: Risk Factors Associated with Clinical Setting

Choose no more than one of the below listed diseases or associated hospital service to determine the baseline risk factor score.
Score 1 factor
Score 2 factors
Score 3 factors
Score 5 factors

Major surgery with

Elective major lower extremity
Minor surgery
Major surgery (>45 mins.)
- Myocardial infarction or
arthroplasty
Patient confined to bed (>72 hrs)
Immobilising plaster cast

- Congestive heart failure or

- Severe sepsis/infection
Medical patient with

additional risk factors

Hip, pelvis, or leg fracture

Stroke

Multiple trauma
Acute spinal cord injury
(paralysis)

Step 2: Risk Factors Associated with Patient

Choose no more than one of the below listed diseases or associated hospital service to determine the baseline risk factor score.
Hypercoagulable States (Thrombophilia)
Clinical (1 factor unless otherwise noted)
Inherited
Acquired
(score 3 factors for each)
(score 3 factors for each)
Age 41 to 60 years
Factor V Leiden/Activated
Lupus anticoagulant
Age over 60 years (2 factors)
Antiphospholipic antibodies
protein C resistance
Previous DVT/PE (3 factors)
Antithrombin III deficiency
Myeloproliferative disorders
History of prior major surgery
Protein C or S deficiency
Disorders of plasminogen &
Pregnancy, or postpartum (<1 month)
Dysfibrinogenemia
plasmin activation
Prothrombin 20210A
Heparin-induced
Malignancy (2 factors)
Varicose veins
thrombocytopenia

Inflammatory bowel disease

Hyperviscosity syndrome

Obesity (>20% of ideal body weight)

Homocysteinemia

Oral contraceptives or
hormone replacement therapy

Baseline
Risk Factor
Score
(if score = 5
go to Step
4)

Total
Additional
Risk Factor
Score

Step 3: Total Risk Factor Score (Baseline + Additional)

Step 4: Recommended Prophylactic Management for Each Risk Category

Low Risk
(1 factor)

Early ambulation.
Consider Compression Stockings, or Low molecular
weight heparin if risks^

Moderate Risk
(2 factors)
Compression Stockings.
or
Intermittent Pneumatic Compression.
or
Low molecular weight heparin.

High Risk
(3 or more factors)
Compression stockings and
Low molecular weight heparin
or
Compression stockings and
Intermittent Pneumatic
Compression

List Risk

Step 5: Tick the corresponding Box if VTE prophylaxis is contraindicated:

Contraindications to Pharmcological Prophylaxis
Contraindications to Mechanical Prophylaxis
Active bleeding.
Severe peripheral vascular disease.
Adverse reaction to low molecular weight heparin or
Severe peripheral neuropathy.
unfractionated heparin.
High risk of bleeding e.g., untreated haemophilia,
Severe lower limb oedema, inflammation or dermatitis.
thrombocytopenia, active peptic ulcer.
Acute intracerebral haemorrhage.
Extreme leg deformity.
On current therapeutic anticoagulation.
Wounds, ulcers or skin graft on lower limb
History of Heparin Induced Thrombocytopaenia within Stroke (intermittent pneumatic compression may be used discuss with
100 days.
Specialist).
Morbid obesity where correct fitting of graduated compression stocking
Active gastrointestinal bleeding/ulceration.
cannot be achieved.
BIMC VTE Assessment & Guidelines May 2014 V 1.0

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Step 6. Document Interventions

Pharmacological Prophylaxis

YES

NO

Mechanical Prophylaxis
YES
NO
*Consider early mobilisation to reduce VTE risk

Name: .

Signature:.

Designation:

Guidelines:
All medical and surgical patients are to have a VTE Risk assessment completed within 24 hours of admission to hospital by a nurse or
doctor but exclude paediatric patients (check with admitting Specialist if required).
There should be evidence of a further risk assessment in those patients whose risk of VTE may have changed. For example, patients
undergoing surgical procedures.
Patients undergoing epidural/spinal anaesthesia should not have low molecular weight heparin (LMWH) prophylaxis administered 12
hours prior to procedure or for at least 4 hours following removal of the spinal catheter.
How to complete the Risk Assessment:
1. Tick the box associated with clinical setting in Step 1, add score in box.
2. Tick the box associated with patient risk factors in Step 2, add score in box.
3. Add Step 1 score and Step 2 score to determine risk category.
4. Read the recommended VTE management and check the patient has been ordered the appropriate management by the treating doctor
5. Review the patients history and ensure patient does not have any contraindications to pharmacological or mechanical prophylaxis.
6. Give the patient the "Reducing your risk of Blood Clots" brochure on admission.

References:
BIMC VTE Policy V 1.0 2014
NHMRC Clinical Practice Guideline for the Prevention of Venous Thromboembolism in Patients Admitted to Australian Hospitals, 2009.
Prevention of Venous Thromboembolism Asian Thromboembolism Guidelines 2012

BIMC VTE Assessment & Guidelines May 2014 V 1.0