1. Lewisham and Greenwich NHS
Trust
DVT Clinic follow up
Lewisham site specific
Stephen Harper
(AKA: ‘DVT Steve’)

2. Pathway
• At present there is no official pathway for G.P.s to refer directly to the DVT
Clinic
• Patients are seen in the Emergency Department with suspected DVT are
assessed, bloods taken for FBC, U&Es, LFTs, d dimer level, and clotting
• If suitable for outpatient management patients are given scan appointment
times with General Ultrasound with follow up in DVT Clinic and appropriate
anticoagulation commenced – either Rivaroxaban or Enoxaparin pending scan
• Scan times available are entered in a diary held in the Urgent Care Centre
Reception patient details entered by allocated time, patient notes and doppler
request are left with the diary
• Patient notes and doppler requests are picked up each morning by the DVT
Clinic Nurse
• After reviewing history, blood results and clarifying with A&E any queries
doppler requests are delivered to Ultrasound

3. Exclusion criterion for outpatient
DVT Clinic management
• Pregnancy or within six weeks of child birth – manages by
O&G
• Suspected bilateral DVT (patients with bilateral leg swelling
must be seen in A&E. Bilateral leg swelling in the absence of
heart failure ? Abdominal pathology. Bilateral DVT is rare
however constitutes a medical emergency if extension into
the inferior vena cava)
• Suspected upper limb thrombus – lower limb scans are
performed in general ultrasound with allocated scan times
daily. Upper limb scans are carried out in the Vascular
Laboratory – no allocated scan times

4. • Immobile patients requiring stretcher transport – there are
no facilities in the DVT Clinic for patients awaiting transport
home
• Haemo-dynamically unstable patients
• Known severe liver impairment
• Patients already on anticoagulation unless on Warfarin within
range 2-3 with suspected acute DVT as range can be
increased to 3-4. Patients who are bellow desired therapeutic
range should have dose increased with urgent
Anticoagulation Clinic follow up.

5. Negative scans
• Approximately 12% of patients referred have confirmed DVT
• Often there is no obvious alternative diagnosis and patients
are advised re analgesia and limb elevation for symptom
relief and to see G.P. if symptoms do not settle or worsen
• Alternative diagnosis made on scan treated as required
• If a patient has a negative proximal scan with strong clinical
suspicion of distal thrombus, i.e. loss of definition at the
ankle, a re scan is arranged with Vascular Lab and
anticoagulation continued pending scan if same day scan
unavailable

6. Positive DVT
• Patients found to have DVT are assessed in the DVT Clinic and
anticoagulation continued from A&E
• First line treatment for VTE at Lewisham is Rivaroxaban
• The LCCG have issued a six page Rivaroxaban initiation and
transfer of care document which includes a contraindication
checklist and dosing guidelines – 15mg B/D for 21 days after
which dose is reduced to either a once daily dose of 20mg or
15mg thereafter depending on renal function and clinical
risk assessment e.g. falls, bleeding risk
• Pages 1-4 are completed and one copy is sent to the hospital
pharmacy

7. Rivaroxaban
• Rivaroxaban is a ‘hospital only’ medication for up to three
months of treatment
• Pages 1-4 of 6 of the LCCG initiation document are faxed to
the patients’ G.P.s informing them that Rivaroxaban
treatment is being given
• Subsequent prescriptions and routine bloods are arranged in
the DVT Clinic
• G.P.s cannot take over prescribing of Rivaroxaban until
notified by Haematology who will advise re length of
treatment – pages 5-6 of 6 LCCG Rivaroxaban transfer of care
notification

8. Follow up
• Provoked DVTs and distal calf vein DVTs being treated with
Rivaroxaban are managed in the DVT Clinic with no formal
Haematology follow up
• Patients being managed solely in the DVT Clinic will have a re
scan to assess resolution prior to discontinuation of
treatment
• All inpatients with confirmed VTE on treatment with
Rivaroxaban are followed up in the DVT Clinic
• All patients with confirmed PE/unprovoked DVT are managed
in the DVT Clinic and Haematology referral made from there
• Rivaroxaban prescriptions and routine blood monitoring are
continued in the DVT Clinic until Haematology review

9. Graduated compression hosiery
Contraindications
• Non palpable pedal pulses
• Cellulitis or other skin conditions
• Peripheral neuropathy
• Person not able, or other unable to assist, to
don hosiery
• Known peripheral vascular disease
• Decompensated heart failure
• Sensitivity to hosiery fabric

10. Graduated compression hosiery
• Patients with confirmed DVT are assessed at one
week and grade 2 below knee gradated compression
hosiery issued, unless contraindicated, to be worn
during the day for a minimum of 2 years (NICE -
CG144 2012)
• The LCCG have agreed funding for one pair of hosiery
only to be issued from the DVT Clinic
• Replacement hosiery to be prescribed by G.P.

11. Graduated Compression Hosiery
• Any type of compression hosiery should be properly
measured and fitted professionally
• Leg measurements should be taken at levels as per
hosiery manufacturers measuring guide
• Persons should be instructed on how to don hosiery
• Some men find that hosiery slides down which is
usually due to leg hair in which case men should be
advised on hair removal

12. Graduated Compression Hosiery
Thigh or Below Knee length?
• Thigh length graduated compression hosiery is designed for patients who
are totally bed bound
• As soon as a person is able sit out of bed/mobilise graduated compression
hosiery should be changed to below knee
• Below knee hosiery should be worn at least 3cm below the knee crease
• Below knee hosiery should be worn during the day and removed at night
• Persons advised to cleanse and moisturise leg on removal
Prior to donning hosiery:
• Any moisturiser, unless produced by the hosiery manufacturer, should be
washed off as this may damage the hosiery fabric causing loss of
compression
• Skin should be examined for any breaks or signs of inflammation if
present person should be advised not to don hosiery

13. Length of treatment
recommended Venous Stasis
Consultant• Isolated distal calf thrombus – six weeks (subject to review)
• Proximal thrombus – three months (subject to review)
• Recurrent DVT/PE – Long term with annual review
• Pulmonary embolism – Haematology to determine
• Patients being followed up in DVT Clinic alone will have a re scan to assess
resolution of DVT prior to discontinuing treatment
• G.P. will be contacted if treatment to discontinue from DVT Clinic
• If residual acute thrombus at three months a referral will be made to
Haematology to determine length of treatment
• Prescriptions for Rivaroxaban will then continue to be given in the DVT
Clinic pending review

14. Management of complicated patients
on treatment with Rivaroxaban
As Rivaroxaban is a ‘hospital only’ medication for up to three
months some patients may have difficulty attending the hospital
for follow up and for prescriptions to be issued
•Patients who are housebound/Nursing Home Residents who
are unable to get to hospital – DVT Clinic arranges for
Rivaroxaban supply to be delivered to place of residence and
G.P.s are asked to monitor routine bloods pending Haematology
review if required
•Patients who have their medications in a dosette box provide
from community pharmacies – Community pharmacist is
contacted by DVT Clinic prescriptions are dispensed from the
hospital pharmacy and delivered from DVT Clinic to community
pharmacy

15. Useful contacts
For DVT Clinic enquiries
Stephen Harper – Senior Staff Nurse – DVT
Tel: 020 8333 3000 Ext: 8677 Mon – Fri 08:00 – 16:00
Mob: 07771780485 Mon – Fri 08:00 – 18:00 Sat – Sun 08:00 – 10:00
Email: stephenharper1@nhs.net
For Haematology enquiries
Haematology Registrar – via switchboard
Tel: 020 8333 3000 Bleep: 7014/7013