Pulmonary Embolism: training plan

Venous thromboembolic diseases:

the management of venous thromboembolic diseases and the role of thrombophilia testing
Published: June 2012
http://guidance.nice.org.uk/CG144

This training plan accompanies the clinical guideline: Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing (available at www.nice.org.u !guidance!"#$%%&. 'ssue date: (une )*$). +pdated ,ctober )*$- to include details of the .'"E /uality standard for management of venous thromboembolic diseases. The guideline has not changed

This is a support tool for implementation of the .'"E guidance. 't is not .'"E guidance. 'mplementation of the guidance is the responsibility of local commissioners and!or providers. "ommissioners and providers are reminded that it is their responsibility to implement this guidance0 in their local conte1t0 in light of their duties to avoid unlawful discrimination and to have regard to promoting e/uality of opportunity. .othing in the guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

What do you think? 2id this tool meet your re/uirements0 and did it help you put the .'"E guidance into practice3 4e value your opinion and are loo ing for ways to improve our tools. Please complete this short evaluation form. 'f you are e1periencing problems using this tool0 please email implementation5nice.org.u .

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; .ational 'nstitute for <ealth and "are E1cellence0 )*$-. 7ll rights reserved. This material may be freely reproduced for educational and not=for=profit purposes. .o reproduction by or for commercial organisations0 or for commercial purposes0 is allowed without the e1press written permission of .'"E.

Contents
"ontents ...............................................................................................................'ntroduction...........................................................................................................% 6earning ob>ectives...............................................................................................? @ey to terms .........................................................................................................? Pre=wor shop /ui8................................................................................................A Pre= wor shop /ui8 /uestions...........................................................................A Pre= wor shop /ui8 answers.............................................................................B .............................................................................................................................C .'"E Pulmonary embolism education and learning resources..........................$* Post=wor shop /ui8.............................................................................................$$ Post=wor shop /ui8 /uestions .......................................................................$$ Post= wor shop /ui8 answers.........................................................................$) Evaluation form...................................................................................................$% "ertificate of attendance.....................................................................................$D ,ther implementation tools.................................................................................)* 7c nowledgements.............................................................................................)*

Introduction
This training plan has been developed to provide the framewor for a wor shop designed to support education and learning about the diagnosis and management of pulmonary embolism (PE&. The plan consists of: 6earning ob>ectives @ey terms Pre=wor shop /ui8 to help assess current nowledge of venous thromboembolic diseases and outcomes. The /ui8 will help identify individual needs that can be aggregated for the group. This will ta e about ? minutes. 2etails of Eignposting to .'"E PE education and learning resources (including the details of how long each resource will ta e& Post=wor shop /ui8 to help people recognise what they have learnt from the wor shop and any outstanding needs. This will ta e about ? minutes. Evaluation form and certificate of attendance for use at group sessions. The evaluation form will ta e about ? minutes. Templates of the two=level 2VT and PE 4ells scores. These can be printed0 completed and added to patient records 2etails of further implementation tools accompanying the Venous thromboembolic diseases clinical guideline available from .'"E The duration of the wor shop can be tailored by ad>usting the number of cases considered and by underta ing some follow=up tas s by email. 'f all the components are used the wor shop will ta e about $ hour %* minutes.

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!earning ob"ectives
Participants will: become familiar with the diagnosis algorithm for PE understand the possible treatment options for PE and when these treatment options are recommended become familiar with the information patients re/uire understand when it is appropriate to initiate cancer screening and thrombophilia testing in patients with VTE.

#ey to terms
The following terms are used in this training plan and the clinical guideline. International normalised ratio $IN%& 7 standardised laboratory measure of blood coagulation used to monitor the ade/uacy of anticoagulation in patients who are having treatment with a vitamin @ antagonist. 'rovoked deep vein thrombosis $(V)& or pulmonary embolism $'E& 2VT or PE in a patient with an antecedent (within - months& and transient ma>or clinical ris factor for VTE F for e1ample surgery0 trauma0 significant immobility (bedbound0 unable to wal unaided or li ely to spend a substantial proportion of the day in bed or in a chair&0 pregnancy or puerperium F or in a patient who is having hormonal therapy (oral contraceptive or hormone replacement therapy&. 'ro imal (V) 2VT in the popliteal vein or above. Pro1imal 2VT is sometimes referred to as above= nee 2VT. %enal impairment Geduced renal function that may be acute or chronic. 7n estimated glomerular filtration rate of less than C* ml!minute!$.A- m) indicates a degree of renal impairment in chronic idney disease. (Hor .'"E guidance on the classification

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of chronic idney disease see "hronic idney disease I.'"E clinical guideline A-J&. *nprovoked (V) or 'E 2VT or PE in a patient with: no antecedent ma>or clinical ris factor for VTE (see Provo ed deep vein thrombosis or pulmonary embolism above& who is not having hormonal therapy (oral contraceptive or hormone replacement therapy& or active cancer0 thrombophilia or a family history of VTE0 because these are underlying ris s that remain constant in the patient. Wells scores "linical prediction rules for estimating the probability of 2VT and PE. There are a number of versions of 4ells scores available. This guideline recommends the two=level 2VT 4ells score and the two=level PE 4ells score.

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're+,orkshop -ui.
Pre- workshop quiz questions
/0 What is: A: VTE? B: DVT? C: PE? 10 !ist four ma"or risk factors for V)E diseases

20 'E is a treatable condition3 but ,hat patient outcomes can severe cases lead to?

40 Which groups of patients presenting ,ith 'E are at highest risk of increased mortality?

50 6ortality is significantly higher ,ith 'E than ,ith (V): True ! Halse

70 If left untreated ,hat is the prognosis for 'E?

80 !ist four signs and symptoms of 'E

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Pre- workshop quiz answers

/0 What is: A: VTE? Venous thromboembolism (VTE& is a condition in which a blood clot (a thrombus& forms in a vein and then dislodges to travel in the blood (an embolus&. B: DVT? 7 venous thrombus most commonly occurs in the deep veins of the legs or pelvisK this is called a deep vein thrombosis (2VT&. :lood flow through the affected vein can be limited by the clot0 which normally causes swelling and pain in the leg but in some patients this may be asymptomatic. C: PE? 'f a thrombus dislodges and travels to the lungs0 to the pulmonary arteries0 it is called a pulmonary embolism (PE&0 which in some cases may be fatal. The term VTE includes both 2VT and PE. 10 !ist four ma"or risk factors for V)E diseases 7ny four of: prior history of 2VT0 age over D* years0 surgery0 obesity0 prolonged travel0 acute medical illness0 cancer0 immobility0 thrombophilia (an abnormal tendency for the blood to clot& and pregnancy. 20 'E is a treatable condition3 but ,hat patient outcomes can severe cases lead to? "ollapse and!or sudden death. Eome PEs are rapidly fatal0 and the ma>ority of fatal cases are not clinically diagnosed before death. 40 Which groups of patients presenting ,ith 'E are at highest risk of increased mortality? Those who are haemodynamically unstable and those who present in cardiorespiratory arrest. The outcome is dependent on the clot burden and the underlying cardiorespiratory function. 50 6ortality is significantly higher ,ith 'E than ,ith (V): )rue 9 :alse

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70 If left untreated ,hat is the prognosis for 'E? Poor = even when treated0 a small proportion of patients develop chronic thromboembolic pulmonary hypertension as a result of fibrotic0 occlusive organisation of thrombi or emboli and pulmonary vascular remodelling. 80 !ist four signs and symptoms of 'E 7ny four of the following: dyspnoea0 pleuritic chest pain (due to pleural irritation in pulmonary infarction&0 retrosternal chest pain (due to right ventricular ischaemia&0 cough and haemoptysis. 'n severe cases0 the right ventricle fails leading to di88iness and!or syncope. The signs include tachypnoea0 tachycardia0 hypo1ia0 pyre1ia0 elevated >ugular venous pressure0 a gallop rhythm0 a widely split second heart sound0 tricuspid regurgitant murmur0 pleural rub0 systemic hypotension and cardiogenic shoc .

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NICE 'ulmonary embolism education and learning resources

Educational slide set: The slide set focuses on the PE=related recommendations in Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing (.'"E clinical guideline $%%&. The slide set can be used as part of the wor shop proposed by this plan or as a stand=alone implementation tool. The full slide set will ta e about )? minutes. 2epending on the learning needs of your group0 you can delete unnecessary slides or add your own new ones. "linical case scenarios: There are five cases suitable for individual or group learning. "hose the cases to use based on the learning needs of your group. These clinical case scenarios are available in pdf format for individual learning and as PowerPoint slides.

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'ost+,orkshop -ui.
Post-workshop quiz questions
/0 In a patient in ,hom you suspect 'E ,ith a likely t,o+level 'E Wells score ,hat diagnostic investigations ,ould you offer?

10 In a patient in ,hom you suspect 'E ,ith an unlikely t,o+level 'E Wells score ,hat diagnostic investigations ,ould you offer?

20 When offering patients ,ith a diagnosis of 'E pharmacological treatment0 In ,hat clinical situations ,ould you not offer the recommended treatment of either !6WH or fondaparinu ?

40 When ,ould you offer patients ,ith 'E a Vitamin # ;ntagonist $such as ,arfarin& for more than 2 months?

5 a0 In ,hich people ,ith a diagnosis of 'E ,ould you consider investigations for cancer?

5 b0 If these are negative3 for ,hich patients ,ould you then consider further investigations3 and ,hich further investigations ,ould you offer?

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Post- workshop quiz answers

/0 In a patient in ,hom you suspect 'E ,ith a likely t,o+level 'E Wells score ,hat diagnostic investigations ,ould you offer? 'mmediate "PT7 or immediate interim parenteral anticoagulant therapy followed by a "TP7 if "PT7 cannot be carried out immediately. 'n those who have renal impairment0 a contrast allergy or in whom radiation should be ept to a minimum0 V!L EPE"T or planar V!L may be considered. Eee recommendations $.$.C and $.$.$$ in the .'"E clinical guideline. 10 In a patient in ,hom you suspect 'E ,ith an unlikely t,o+level 'E Wells score ,hat diagnostic investigations ,ould you offer? 2=dimer. 'f the result is positive offer either immediate "TP7 or immediate interim parenteral anticoagulant therapy followed by a "TP7 if "PT7 cannot be carried out immediately. 'n those who have renal impairment0 a contrast allergy or in whom radiation should be ept to a minimum0 V!L EPE"T or planar V!L may be considered. Eee recommendations $.$.$* and $.$.$$ in the .'"E clinical guideline. 20 When offering patients ,ith a diagnosis of 'E pharmacological treatment0 In ,hat clinical situations ,ould you not offer the recommended treatment of either !6WH or fondaparinu ? Patients with severe renal impairment0 patients at increased ris of bleeding and patients who are haemodynamically unstable. Eee recommendation $.).$. 't is also important to note that people with cancer should be offered 694< (not fondaparinu1&. Eee recommendation $.).) in the .'"E clinical guideline. 40 When ,ould you offer patients ,ith 'E a Vitamin # ;ntagonist $such as ,arfarin& for more than 2 months? Hor patients with an unprovo ed PE0 ta ing into account their ris of VTE recurrence and whether they are at increased ris of bleeding. 2iscuss with the patient the benefits and ris s of e1tending their V@7 treatment. Eee recommendation $.).% in the .'"E clinical guideline.

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5 a0 In ,hich people ,ith a diagnosis of 'E ,ould you consider investigations for cancer? 'n people with a diagnosis of unprovo ed 2VT or PE offer physical e1amination0 chest M=ray0 bloods tests and urinalysis. Eee recommendation $.?.$ in the .'"E clinical guideline. 5 b0 If these are negative3 for ,hich patients ,ould you then consider further investigations3 and ,hich further investigations ,ould you offer? "onsider further investigations in patients older than %* with a first unprovo ed 2VT or PE who do not have signs or symptoms of cancer based on initial investigations. These further investigations should be: an abdomino=pelvic "T scan for all0 and also a mammogram for women. Eee recommendation $.?.) in the .'"E clinical guideline.

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Evaluation form
'nsert date and time of wor shop: ;dministration The information you received before the wor shop was: Too much (ust right .ot enough 2ont now

The time allowed to complete the pre=wor shop tas s was: Too much Workshop <as the session improved your nowledge of the guidance3 Nes Partly .o 2ont now (ust right .ot enough 2ont now

'f not0 what were the reasons3 ............................................................................................................... ................ ............................................................................................................................... 2id the session e1plain how the guidance should be used3 Nes0 completely Partly .o 2ont now

'f not0 what were the reasons3 ............................................................................................................... ................ ............................................................................................................................... 4ere the case studies helpful3 Nes Partly .o 2ont now

4ill areas of your practice change as a result of this session3 'f so0 how and if not0 what are the reasons3 OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO........ ............................................................................................................................... ............................................................................................................................... 2o you have any other comments or suggestions for improvement3 OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO........ ...............................................................................................................................

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............................................................................................................................... ................................................................ Than you for your feedbac .

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This is a TE9P67TE F please add your own organisation details

'nsert your organisations logo here

Certificate of attendance
.................................................... completed a

Pulmonary embolism workshop

(based on NICE clinical guideline CG144

on ................................... at ...................................
!igned............................................... "esignation..........................................

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)emplate t,o+level Wells scores

These can be printed0 completed and added to patient records These templates can also be accessed in a separate document in order to facilitate printing.

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'nsert your organisations logo

Euspected deep vein thrombosis

Patient name......................................................................................................... Patient hospital number......................................................................................... 2ate of assessment............................................................................................... 7ssessors name (print&..............................................Eigned................................

),o+level (V) Wells score

Clinical feature 7ctive cancer (treatment ongoing0 within D months0 or palliative& Paralysis0 paresis or recent plaster immobilisation of the lower e1tremities Gecently bedridden for - days or more or ma>or surgery within $) wee s re/uiring general or regional anaesthesia 6ocalised tenderness along the distribution of the deep venous system Entire leg swollen "alf swelling at least - cm larger than asymptomatic side Pitting oedema confined to the symptomatic leg "ollateral superficial veins (non=varicose& Previously documented 2VT 7n alternative diagnosis is at least as li ely as 2VT Clinical probability simplified score 2VT likely 2VT unlikely

'oints $ $ $ $ $ $ $ $ $ P)

'atient score

) points or more $ point or less

7dapted with permission from: = 4ells PE et al. ()**-& Evaluation of 2=dimer in the diagnosis of suspected deep=vein thrombosis. .ew England (ournal of 9edicine -%C: $))AF-? = The .ational "linical #uideline "entre

Template Two=level 2VT 4ells score Hrom .'"E clinical guideline $%% VTE diseases ((une )*$)&

'nsert your organisations logo

Euspected pulmonary embolism

Patient name......................................................................................................... Patient hospital number........................................................................................ 2ate of assessment.............................................................................................. 7ssessors name (print&.............................................. Eigned..............................

),o+level 'E Wells score

Clinical feature "linical signs and symptoms of 2VT (minimum of leg swelling and pain with palpation of the deep veins& 7n alternative diagnosis is less li ely than PE <eart rate Q $** beats per minute 'mmobilisation for more than - days or surgery in the previous % wee s Previous 2VT!PE <aemoptysis 9alignancy (on treatment0 treated in the last D months0 or palliative& Clinical probability simplified scores PE likely PE unlikely

'oints $.? $.? $.? $ $

'atient score

9ore than % points % points or less

7dapted with permission from = 4ells PE et al. ()***& 2erivation of a simple clinical model to categori8e patients probability of pulmonary embolism: increasing the models utility with the EimpliGE2 2= dimer. Thrombosis and <aemostasis B-: %$DF)* = The .ational "linical #uideline "entre

Template two=level PE 4ells score. Hrom .'"E clinical guideline $%% VTE diseases ((une )*$)&

<ther implementation tools

.'"E has developed tools to help organisations implement the clinical guideline on Venous thromboembolic diseases. These are available on the .'"E website (www.nice.org.u !guidance!"#$%%&. 2VT training plan0 clinical case scenarios and slide set. "osting statement F details of the li ely costs and savings when the cost impact of the guideline is not considered to be significant. 7udit support including electronic data tools F for monitoring local practice.

NICE -uality standard for diagnosis and management of venous thromboembolic diseases
Published in 9arch )*$-. This /uality standard defines clinical best practice within this topic area. 't provides specific0 concise /uality statements0 measures and audience descriptors to provide the public0 health and social care professionals0 commissioners and service providers with definitions of high= /uality care. This /uality standard covers the diagnosis and treatment of venous thromboembolic diseases in adults0 e1cluding pregnant women.

;ckno,ledgements
.'"E would li e to than the .ational "linical #uideline "entre and the #uideline 2evelopment #roup0 especially #erard Etansby0 Professor of Vascular Eurgery0 Hreeman <ospital and .ewcastle +niversity Eusan :allard 2avid :erridge0 "onsultant Vascular Eurgeon0 6eeds #eneral 'nfirmary Gichard 2ay0 "onsultant Physician (#eriatrics&0 Poole <ospital .<E Houndation Trust :everley <unt0 Professor of Thrombosis and <aemostasis0 @ings "ollege0 6ondon and 9edical 2irector of 6ifeblood

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2avid @eeling0 "onsultant <aematologist0 ,1ford +niversity <ospitals .<E Trust Eteven 9oser0 "onsultant Gadiologist0 'mperial "ollege <ealthcare .<E Trust0 6ondon @aren Eheares0 Gespiratory "onsultant with an interest in pulmonary vascular diseases0 Papworth <ospital .<E Houndation Trust

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