Risk Factors in Venous Thromboembolism Risk Assessment

Introduction

Venous thromboembolism, commonly known as VTE is a condition in which a blood clot develops mostly in deep veins of the leg, groin or arm and travels in the circulation and lodging in the lungs, called pulmonary embolism (PE). VTE generally occurs after major general surgery and if not taken care of on time, it might become life threatening (Laryea and Champagne, 2013). Therefore, proper risk assessment is essential.

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Waterlow score, also known as Waterlow scale, provides an estimated risk for the development of a pressure sore in a patient. This tool was developed in 1985 by Judy Waterlow, a clinical nurse teacher (Thorn et al., 2013). Waterlow score is often used for risk assessment in surgical patients. Therefore, it is of great use for risk assessment for VTE since surgical patients are more vulnerable to develop it, as stated before. This too, is helpful for the patients to evaluate the risks and benefits of the surgery as a part of the informed consent. It is also used for identifying elective and emergency patients who would benefit the most from the management in ICU setting. The purpose of the risk assessment is to identify the extent to which the surgical patients are at a risk of developing VTE so that measures can be taken in advance to this is a preventable health issue (Henke and Pannucci, 2010). The Waterlow tool uses seven items for assessing the risk of developing a pressure ulcer. Those scoring 10-14 are at risk, those scoring 15-19 are at high risk and patients are at very high risk if they score 20 and above (Healthcare-Improvement-Scotland, 2009). In case the risk assessment is not undertaken, the patients would develop VTE that might be difficult to be treated. This, in turn, would cost huge to NHS as treating patients suffering from advanced stage of VTE involves a lot of expenditure. At the same time, this would have a severe physical and psychological impact on the patients. This is because the treatment is not only long terms, but such patients might be discriminated although VTE is a non-communicable disease.

Discussion

The different risk factors included in the risk assessment and explain their relevance

As already stated above, the Venous Thromboembolism is about clotting of blood in the deep veins of leg, groin or arm (Thachil and Bagot, 2018). The very definition of the issue highlights the involved risks that patients suffering from it tend to face. As a result, a timely and careful risk assessment risk assessment process is something that is required to be undertaken in order to manage its progress further. However, as with any other risk assessment process, it is always essential to identify the risks involved in the circumstance, which in this case is Venous Thromboembolism or VTE. In a study conducted Henke and Pannucci (2015), the risk factors involved in VTE depend on multiple factors of which inherited risk factors including the deficiencies of natural anticoagulant proteins (e.g. Antithrombin), genetic abnormalities such as factor V Leiden or prothrombin 20210A, and/or the other miscellaneous hypercoagulable states such as anti-phospholipid syndrome could be involved. Patients exposed to these inherited risk factors might have no actual way of avoiding this issue. Besides, with these inherited risk factors they tend to become more vulnerable to contract VTE if they undergo surgery, infection, trauma, etc. In other words, their chances of acquiring VTE increase to a great extent than those with no inherited risk factors.

Other than genetic and hereditary factors, VTE also involves external risks factors, which are also known as the acquired ones, including history of VTE, age, obesity, presence of malignancy, etc (Henke and Pannucci, 2015). In a study conducted by Johnson and Kumar (2015), it has been stated that in Europe, VTE is considered to be the third most common cause of vascular death after myocardial infarction and stroke and mostly people contract it during and after hospitalisation for surgery and acute medical illness. The period of healing process in the post-surgical scenario is pivotal, as it is during this time that patients’ immune system tend to work at a slow speed, which increases their chances of being attracted by infections. The contraction of VTE therefore, can give rise to other co-morbidities like malignancy, as the issue is closely related with deep venous thrombosis (DVT) and pulmonary embolism (PE) (Smith et al., 2014). Seen from another perspective, the existence of risk factors (the co- morbidities) like tumour-induced hypercoagulability, vascular injury from surgical treatment, chemotherapy, radiation, and venous stasis, etc can help the health care professionals to give attention on the patients’ vulnerability to contract VTE, which in turn can lead to early intervention process to prevent it or address it. Another risk factor, which although remained understudied, is increasingly being associated with the deaths associated with VTE, is renal cell carcinoma (RCC). In the study of Smith et al. (2014), the association between RCC and VTE has been shed light upon, as the authors argued that “among newly diagnosed patients with RCC who had localized disease, occurrence of VTE has been linked to increased risk of death within 1 year of cancer diagnosis”. A deep study about the association between RCC and VTE can be relevant for the patients as they can be prescribed with thromboprophylaxis to prevent the clots for forming in the veins.

Actions that could be implemented to reduce these risk factors, including any multi‐agency involvement

After identifying the risks associated with VTE, the next step is to assessing and managing those. As already stated, VTE is a preventable disease; therefore the practitioners need to choose their actions judiciously. A common action that is often undertaken by the professionals is prophylaxis, which acts to reduce the clotting of blood in the veins, thereby helping the patients to get rid from swelling or inflammation. In the study conducted by Nwulu et al. (2014), patients with the risk of contracting deep venous thrombosis (DVT), undergoing colorectal procedures, are often prescribed the use of preoperative prophylaxis, as it reduces the chances of DVT. Therefore, it can be stated that the professionals, after consulting with the patients, their family members and the other team members can decide whether to prescribe the patient with preoperative or post-operative prophylaxis. The same study have also stated that a combination of intermittent pneumatic compression (IPC) devices with pharmacological methods tend to give better results in managing the issue of VTE than either method alone. Therefore, actions can be taken to include IPC along with pharmacological interventions to relief the patients from swelling and deep venous blood clots by squeezing their legs and increase blood flow through the veins (Laryea and Champagne, 2013). This action can be adopted in the case of DVT of leg or thighs. However, this action can lead to certain side effects, which can be relevant for the patients’ level of discomfort, as they may involve skin breakdown, injury due to pressure, damaging the nerves, discomfort, etc. Hence, it is essential for the care professionals to involve only specialists to handle the cases of VTE and take consent from the patient and/ or the family members before its application. In this regard, it can also be stated that patients with DVT and the history of colorectal surgery, can specifically be provided with thromboprophylaxis along with low-dose heparin (Laryea and Champagne, 2013).  As far as sole pharmacological interventions are concerned, the professionals can consider prescribing low-dose unfractionated heparin (LDUH) and low-molecular-weight heparins (LMWHs). Another action that can be undertaken by the professionals to diagnose the level of risks patients are involved in is the usage of risk assessment tools like “Roger Score” “Water Low Score “and “Caprini Score”, among others to be specific, the usage of the Water Low Score before operating a patient can help the professionals to diagnose the risks, if involved, in developing of the pressure sore after the surgery (Laryea and Champagne, 2013). If the Roger Score is >10 and Caprini Score = 3-4, then decisions can be taken in behalf of prescribing pharmacologic or mechanical prophylaxis with IPC.

In the health and social care sector, multi-agency working plays an important role. This is because people suffering health issues often require various types of services. The need for multidisciplinary team working is growing rapidly. This is because of growing co-morbidities and growing complexities of care. Time has gone when GPs and nurses would solely delivery the needed care service. In today’s health care context, it has become essential to ensure professionals belonging to various health care occupations work together to deliver optimum quality and wide variety of care services under one roof. This is even more important for certain health issues and diseases and Venous thromboembolism is one such disease. Treating Venous thromboembolism requires skilled nurses. This is because they are responsible for injecting drugs such as heparin or low molecular weight heparin, or tablets such as apixaban, dabigatran, rivaroxaban, edoxaban and warfarin.  These medications are prescribed for quite a few numbers of months. In case VTE occurs after a provoking factor like pregnancy, surgery, trauma and/or hormone therapy etc. such medications are given for relatively longer time period. Therefore, engaging a GP for such a long time is not feasible. The role of nurses would be important in prophylaxis since it involves treating the patients orally to help them in getting rid of inflammation and swelling.

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Surgical procedures are often adopted for treating VTE. This might involve placing a filter in the largest vein of the body, i.e. inferior vena cava in order to prevent blood clots from travelling to the lungs of the patients. It might also involve removing a large amount of blood clot from the vein or injecting clot-busting medicines in the vein or lung artery (Heart.org, 2019). This requires the involvement of the nurses as well as GPs. This is because surgical procedures require expert knowledge and skills, considering the risk factors involved in case of incorrect procedure performed. At the same time, the nurses are also required for carrying out certain basic activities like injecting medicines, supplying the tools and equipments to the GPs etc. Unless the GPs and nurses work together it would not be possible to undertake a surgical procedure for treating VTE effectively.   

As stated earlier, VTE has high chances of leaving a strong physical and psychological impact on the patients. Thus, there is a need for counsellor also apart from GPs and nurses. The counsellor would be responsible for making the patients understand that they are not suffering from any communicable disease that would isolate them from the rest of the society. At the same time, effective counselling would enable them to reduce their physical pain out of VTE and its treatment. Apart from this, there is a need for physiotherapy and psychologist. The physiotherapist would be responsible for the physical movements of the VTE patients after their surgery and the psychologist would be responsible for developing an understanding of the patients’ current state of mind since its has a direct impact on their physical health and well-being.

Conclusion

The above discussion, therefore has been successful in bringing out few facts clearly, like VTE, although a major issues tend to occur in patients undergoing surgery, is a preventable condition, if the practitioners use both mechanical as well as pharmacological interventions judiciously. However, while undertaking any action to prevent the condition or manage it , it is mandatory to make a wise usage of various assessment tools like Waterlow Score, Roger Score, etc, in order to diagnose the involves risk factors and the patients likelihood to develop the issue. Multi-disciplinary team plays a vital role in treating VTE. This is because th patients of VTE require various types of services. Treating VTE is not an easy task. It requires trained nurses who have proper knowledge of medication as they would be responsible for injecting medicines to the patients’ body while supplying essential medical equipments and tools to the GPs during surgery. One the other hand, GPs play the most important role as they are the ones who actually perform a surgery and prescribe medications for VTE. There is a need for psychologist, physiotherapist and counsellor also. This is because after the surgery the VTE patients often feel restricted physical movements and, on the other hand, they are at a risk of developing psychological issues due to feeling inferior than others in the society.

References

• Healthcare-Improvement-Scotland (2009) Adapted Waterlow Pressure Area Risk Assessment Chart, [Online], Available: Adapted Waterlow Pressure Area Risk Assessment Chart [20 May 2019].
• Heart.org (2019) Prevention and Treatment of Venous Thromboembolism (VTE), [Online], Available: https://www.heart.org/en/health-topics/venous-thromboembolism/prevention-and-treatment-of-venous-thromboembolism-vte [20 May 2019].
• Henke, P. and Pannucci, C. (2010) 'VTE Risk Factor Assessment and Prophylaxis', Phlebology, pp. 219-223.
• Henke, P. and Pannucci, C. (2015) 'VTE Risk Factor Assessment and Prophylaxis', Phlebology, vol. 25, no. 05, Jun, pp. 219-223.
• Johnson, O. and Kumar, S. (2015) 'Risk assessment and prophylaxis of venous thromboembolism in surgical inpatients: improving adherence to national guidelines', BMJ, vol. 04, no. 01.
• Laryea, J. and Champagne, B. (2013) 'Venous Thromboembolism Prophylaxis', Clin Colon Rectal Surg., vol. 26, no. 03, Sep, pp. 153-159.
• Laryea, J. and Champagne, B. (2013) 'Venous Thromboembolism Prophylaxis', Clin Colon Rectal Surg., pp. 153-159.
• Nwulu, U., Brooks, H., Richardson, S., McFarland, L. and Coleman, J.J. (2014) 'Electronic risk assessment for venous thromboembolism: investigating physicians’ rationale for bypassing clinical decision support recommendations', BMJ Open, vol. 04, no. 09, Sep.
• Smith, A.B., Horvath-Puhó, E., Nielsen, M.E., Lash, T.L., Baron, J.A. and Sørensen, H.T. (2014) 'Effect of comorbidity on risk of venous thromboembolism in patients with renal cell carcinoma', Urol Oncol., vol. 32, no. 04, May, pp. 466-472.
• Thachil, J. and Bagot, C. (2018) Handbook of Venous Thromboembolism, John Wiley & Sons.
• Thorn, C.C., Smith, M., Aziz, O. and Holme, T.C. (2013) 'The Waterlow score for risk assessment in surgical patients', Ann R Coll Surg Engl., pp. 52–56.