Venous Thromboembolism Deep Vein Thrombosis Likely Based On Two Level Wells Score

Deep vein thrombosis likely
based on two-level Wells

score
A NICE pathway brings together all NICE guidance, quality
standards and materials to support implementation on a specific
topic area. The pathways are interactive and designed to be used
online. This pdf version gives you a single pathway diagram and
uses numbering to link the boxes in the diagram to the associated
recommendations.
To view the online version of this pathway visit:
http://pathways.nice.org.uk/pathways/venous-thromboembolism
Pathway last updated: 24 August 2012
Copyright NICE 2012. All rights reserved
NICEPathways
Pathways
Deep vein thrombosis likely based on two-level Wells score
Venous thromboembolism pathway

Copyright NICE 2012. Pathway last updated: 24 August 2012
NICE Pathways
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NICE Pathways
Two-level DVT Wells score1

Clinical feature
Points
Active cancer (treatment ongoing, within 6 months, or palliative)
Paralysis, paresis or recent plaster immobilisation of the lower extremities
Recently bedridden for 3 days or more, or major surgery within 12 weeks

requiring general or regional anaesthesia
Localised tenderness along the distribution of the deep venous system
Entire leg swollen
Calf swelling 3 cm larger than asymptomatic side
Pitting oedema confined to the symptomatic leg
Collateral superficial veins (non-varicose)
Previously documented DVT
An alternative diagnosis is at least as likely as DVT
Clinical probability simplified score
DVT likely

Points
2 points or
more
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DVT unlikely
NICE Pathways
1 point or
less
Adapted with permission from Wells PS et al. (2003) Evaluation of D-dimer in the diagnosis
of suspected deep-vein thrombosis.
Implementation tools
The following implementation tool is relevant to this part of the pathway.
Venous thromboembolic diseases: Two-level Wells score: templates for deep vein thrombosis
and pulmonary embolism
Is a proximal leg vein ultrasound scan available within 4 hours of

being requested?
No additional information
Proximal leg vein ultrasound scan
Was the proximal leg vein ultrasound scan positive?
D-dimer test
D-dimer is a product formed in the body when a blood clot (such as those found in DVT or PE)
is broken down. A laboratory or point-of-care test can be done to assess the concentration of Ddimer in a person's blood. The threshold for a positive result varies depending on the type of Ddimer test used and is determined locally. The result of the D-dimer test can be used as part of
probability assessment when DVT or PE is suspected.

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NICE Pathways
Was the D-dimer test positive?
Repeat the proximal leg vein ultrasound scan 68 days later
Was the repeat proximal leg vein ultrasound scan positive?
Diagnose DVT and treat
10 D-dimer test and interim 24-hour dose of parenteral anticoagulation

D-dimer test
D-dimer is a product formed in the body when a blood clot (such as those found in DVT or PE)
is broken down. A laboratory or point-of-care test can be done to assess the concentration of Ddimer in a person's blood. The threshold for a positive result varies depending on the type of Ddimer test used and is determined locally. The result of the D-dimer test can be used as part of
probability assessment when DVT or PE is suspected.
11 Proximal leg vein ultrasound scan within 24 hours of being requested

12 Was the proximal leg vein ultrasound scan positive?


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NICE Pathways
13 Was the D-dimer test positive?

14 Repeat the proximal leg vein ultrasound scan 68 days later

15 Was the repeat proximal leg vein ultrasound scan positive?

16 Diagnose DVT and treat

17 Diagnose DVT and treat

18 Treating venous thromboembolism

See Venous thromboembolism / Treating venous thromboembolism
19 Treating venous thromboembolism

See Venous thromboembolism / Treating venous thromboembolism
20 Advise the patient it is not likely they have DVT. Discuss with them the
signs and symptoms of DVT, and when and where to seek further
medical help. Take into consideration alternative diagnoses

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NICE Pathways
21 Advise the patient it is not likely they have DVT. Discuss with them the
signs and symptoms of DVT, and when and where to seek further
medical help. Take into consideration alternative diagnoses

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NICE Pathways
Glossary
DVT
Deep vein thrombosis
PE
Pulmonary embolism
Source guidance
Venous thromboembolic diseases: the management of venous thromboembolic diseases and
the role of thrombophilia testing. NICE clinical guideline 144 (2012)
Patient-centred care
Patients and healthcare professionals have rights and responsibilities as set out in the NHS
Constitution all NICE guidance is written to reflect these. Treatment and care should take into
account individual needs and preferences. People should have the opportunity to make
informed decisions about their care and treatment, in partnership with their healthcare
professionals. If someone does not have the capacity to make decisions, healthcare
professionals should follow the Department of Health's advice on consent and the code of
practice that accompanies the Mental Capacity Act. In Wales, healthcare professionals should
follow advice on consent from the Welsh Government. If the person is under 16, healthcare
professionals should follow the guidelines in Seeking consent: working with children.
Your responsibility
The guidance in this pathway represents the view of NICE, which was arrived at after careful
consideration of the evidence available. Those working in the NHS, local authorities, the wider
public, voluntary and community sectors and the private sector should take it into account when
carrying out their professional, managerial or voluntary duties. Implementation of this guidance
is the responsibility of local commissioners and/or providers. Commissioners and providers are
reminded that it is their responsibility to implement the guidance, in their local context, in light of
their duties to avoid unlawful discrimination and to have regard to promoting equality of
opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent
with compliance with those duties.
Page 8 of 9
NICE Pathways
Copyright
Copyright National Institute for Health and Clinical Excellence 2012. All rights reserved. NICE
copyright material can be downloaded for private research and study, and may be reproduced
for educational and not-for-profit purposes. No reproduction by or for commercial organisations,
or for commercial purposes, is allowed without the written permission of NICE.
Contact NICE
National Institute for Health and Clinical Excellence
Level 1A, City Tower
Piccadilly Plaza
Manchester
M1 4BT
www.nice.org.uk
nice@nice.org.uk
0845 003 7781

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Venous Thromboembolism Deep Vein Thrombosis Likely Based On Two Level Wells Score

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Deep vein thrombosis likely

based on two-level Wells

Deep vein thrombosis likely based on two-level Wells score

Venous thromboembolism pathway

Deep vein thrombosis likely based on two-level Wells score

Two-level DVT Wells score1

Active cancer (treatment ongoing, within 6 months, or palliative)

Paralysis, paresis or recent plaster immobilisation of the lower extremities

Recently bedridden for 3 days or more, or major surgery within 12 weeks

Localised tenderness along the distribution of the deep venous system

Entire leg swollen

Calf swelling 3 cm larger than asymptomatic side

Pitting oedema confined to the symptomatic leg

Collateral superficial veins (non-varicose)

Previously documented DVT

An alternative diagnosis is at least as likely as DVT

Clinical probability simplified score

Venous thromboembolism pathway

Deep vein thrombosis likely based on two-level Wells score

Is a proximal leg vein ultrasound scan available within 4 hours of

Proximal leg vein ultrasound scan

Was the proximal leg vein ultrasound scan positive?

Venous thromboembolism pathway

Deep vein thrombosis likely based on two-level Wells score

Was the D-dimer test positive?

Repeat the proximal leg vein ultrasound scan 68 days later

Was the repeat proximal leg vein ultrasound scan positive?

Diagnose DVT and treat

10 D-dimer test and interim 24-hour dose of parenteral anticoagulation

11 Proximal leg vein ultrasound scan within 24 hours of being requested

12 Was the proximal leg vein ultrasound scan positive?

Venous thromboembolism pathway

Deep vein thrombosis likely based on two-level Wells score

13 Was the D-dimer test positive?

14 Repeat the proximal leg vein ultrasound scan 68 days later

15 Was the repeat proximal leg vein ultrasound scan positive?

16 Diagnose DVT and treat

17 Diagnose DVT and treat

18 Treating venous thromboembolism

19 Treating venous thromboembolism

Venous thromboembolism pathway

Deep vein thrombosis likely based on two-level Wells score

Venous thromboembolism pathway

Deep vein thrombosis likely based on two-level Wells score

Deep vein thrombosis likely based on two-level Wells score

Venous thromboembolism pathway

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