Retrospective Clinical Audit of Adherence to a Protocol: DISCUSSION
This clinical audit provided insight into prophylaxis for venous thromboembolism after elective surgery at VIHA-SI. Most of the surgical patients included in the audit had received thromboprophylaxis. However, comparison of each patient’s thromboprophylactic regimen with the regimen recommended for the assessed level of risk revealed that a large proportion of the patients (71%) were receiving suboptimal therapy. In fiscal year 2005/2006, the VIHA-SI had a total of 30 181 surgical cases (both emergent and elective). As such, more than 20 000 patients may have received suboptimal thromboprophylaxis, which might have led to cases of preventable venous thromboembolism. The low rate of adherence is consistent with the results of other studies that have examined compliance with thromboprophylaxis guidelines. For example, Yu and others reported compliance rates for hospitals throughout the United States. They found that for 123 304 medical and surgical patients, adherence to the ACCP guidelines was low (13.3%). More specifically, only 12.7% of patients who underwent general surgery and 9.9% of those who underwent urologic surgery received adequate therapy in terms of the ACCP guidelines.
Reasons for inadequacy of thromboprophylaxis identified in the current audit are consistent with those reported in other studies. The major reason for inadequacy of therapy was inappropriate risk stratification. Any patient whose risk of venous thromboembolism was assessed in the “highest risk” category should have received a thromboprophylactic regimen appropriate to that category, such as LMWH. However, many such patients received a “moderate risk” thromboprophylactic regimen instead, such as heparin 5000 units every 12 h. This situation represents under- stratification of risk. Practitioners might have understrat- ified patients’ risk secondary to appropriate concerns about potentially excessive bleeding with utilization of thromboprophylaxis after a surgical procedure, a belief that the risk of venous thromboembolism was low, or a lack of awareness of the recommended guidelines. Unfortunately, current risk assessment tools do not take into account the patient’s risk of hemorrhage. If the patient’s history as recorded in the chart was missing risk factor data, the patient’s risk might have been understratified according to the thromboprophylaxis protocol, which might further reduce the adequacy rate found in this audit.
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Failure to start thromboprophylaxis within 24 h after surgery accounted for 14% (10/71) of cases of inadequate therapy. One weakness of the current thromboprophylaxis protocol is the absence of a recommended time of initiation of anticoagulation therapy. The recommended duration of therapy is also absent from the protocol, although no cases of inappropriate duration of thromboprophylaxis were revealed by this audit. The issues of time of initiation and duration of thromboprophylaxis will be addressed in a future revision of the protocol.
The major risk associated with thromboprophylaxis is hemorrhage. In this audit, several minor hemorrhages were documented. However, the causality of hemorrhage was difficult to assess, as this complication may be associated with thromboprophylaxis or with the surgical procedure. Because anticoagulation was continued in every such case, the hemorrhages were considered to be routine following the surgical procedure and not related to the thromboprophylaxis. cialis soft tabs online
The results of this audit will help in revising the thromboprophylaxis protocol on surgical order forms in the VIHA-SI. McEleny and others conducted an audit and feedback study assessing the proportion of at-risk patients who received thromboprophylaxis and its adequacy in relation to the recommendations of the 1995 Scottish Intercollegiate Guidelines Network (SIGN). They determined that 73% of patients had received thrombo- prophylaxis, but the adequacy rate was only 55%. After an iterative process, whereby initial audit results were presented to clinical specialists and local guidelines consistent with the SIGN guidelines were implemented, another audit showed improvement in both outcomes, with 97% of at-risk patients receiving thromboprophylaxis and an adequacy rate of 96% (p < 0.001).
