Medical Inspection – Health Blog

INTRODUCTION

Venous thromboembolism, a medical condition that y encompasses pulmonary embolism and deep vein thrombosis, is a major cause of morbidity, mortality, and resource expenditure. Solid principles and scientif­ic evidence support the use of prophylactic regimens to prevent this condition. First, because most hospital patients have at least one risk factor for venous throm- boembolism (Table 1), the prevalence of this condition is high. In the absence of thromboprophylaxis after surgery, the risk of pulmonary embolism ranges from 0.1% to 10% and that of deep vein thrombosis ranges from 2% to 80%. Second, venous thromboembolism is associated with serious sequelae. For example, pul­monary embolism accounts for 10% of in-hospital deaths, whereas deep vein thrombosis may be associat­ed with long-term morbidity such as post-thrombotic syndrome. Finally, pooled analysis has demonstrated that thromboprophylaxis with heparin or low- molecular-weight heparin (LMWH) reduces the risk of deep vein thrombosis by up to 76%. Although there is a risk of bleeding with any anticoagulant therapy, a previous meta-analysis showed little or no increase in the risk of a clinically significant bleeding episode with prophylactic doses.

Despite strong evidence supporting thrombopro- phylaxis and the existence of clinical guidelines to direct the practitioner, studies evaluating the adequacy of and adherence to guidelines for prophylaxis of venous thromboembolism after surgery have shown suboptimal utilization of anticoagulation. For surgical patients, adherence to recommended guidelines varies widely (from 13.3% to 94%). The most common reasons for poor adherence were lack of knowledge needed to appropriately stratify the patient’s risk or lack of prescription of a thromboprophylactic regimen.
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Table 1. Risk Factors for Venous Thromboembolism

Surgery
Trauma (major or lower extremity) Immobility, paresis Malignancy Cancer therapy
Previous venous thromboembolism Age > 40 years
Pregnancy or postpartum period Estrogen-containing oral contraception Hormone replacement therapy Selective estrogen receptor modulators Myocardial infarction Heart or respiratory failure Inflammatory bowel disease Nephrotic syndrome Myeloproliferative disorders Paroxysmal nocturnal hemoglobinuria Obesity Smoking Varicose veins
Central venous catheterization
Inherited or acquired thrombophilia
Antiphospholipid antibody syndrome

In 2000, a patient died because of postoperative pulmonary embolism at the authors’ institution, the Vancouver Island Health Authority—South Island (VIHA-SI), located in Victoria, British Columbia. The death was thought to have occurred secondary to a lack of thromboprophylaxis. This event prompted develop­ment of a preprinted prophylactic protocol for venous thromboembolism, which was included on surgical order forms. The protocol was based on the thrombo- prophylaxis guidelines of the American College of Chest Physicians (ACCP). Deviations from the ACCP guidelines were based on practicality and availability of thromboprophylactic agents at the VIHA-SI and included use of sequential compression devices instead of graduated compression stockings or intermittent pneumatic compression devices. Before implementa­tion, the protocol was reviewed by a member of the ACCP expert panel for thromboprophylaxis. The VIHA-SI’s recommended thromboprophylactic regimen for each risk level is given in Table 2.
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Table 2. Classification of Risk* and Recommended Thromboprophylactic Regimens at the Vancouver Island Health Authority—South Island

After development of the thromboprophylactic protocol, a quality assurance audit was conducted. The objective of this clinical audit was to determine the rate of adherence to the prophylactic protocol for surgical patients. suhagra

Related Posts:

• Retrospective Clinical Audit of Adherence to a Protocol: DISCUSSION part 2
• Retrospective Clinical Audit of Adherence to a Protocol: DISCUSSION
• Retrospective Clinical Audit of Adherence to a Protocol: RESULTS
• Retrospective Clinical Audit of Adherence to a Protocol: METHODS