1. Dr.H.Chandrashekar, Dr.A.Chaudhuri, Dr. A. Douglas, Dr. D. Lowdon
Initiation of Prophylaxis for Venous Thromboembolism in an Acute Medicine Unit: A Prospective Study in a University Hospital of Scotland
Dr.H.Chandrashekar, Dr.A.Chaudhuri, Dr. A. Douglas, Dr. D. Lowdon
Department of Acute Medicine - Ninewells Hospital and Medical School, Dundee, UK
Introduction:
Prophylaxis Prescribed By 17 19 10 20 30 40 50 60 70 80 90
100
Junior
Doctors
Specialist
Registrars
Consultants
Venous thromboembolism is a common but preventable serious complication in hospitalised patients. About 25% of all the cases of venous thromboembolism are associated with hospitalisation 1,2, and 50 to 75% of these cases occur in hospitalised medical patients 3,4. Initiation of thromboprophylaxis in acute medicine unit is key to preventing death from thromboembolic diseases in the medical wards. According to the guidelines provided by the Scottish Intercollegiate Guidelines Network (SIGN) any patient admitted with an acute medical illness likely to involve > 3 days bed rest should receive Venous Thromboembolism (VTE) prophylaxis. This apart all immobilized patients and those with heart failure, respiratory failure, infections, diabetic coma; inflammatory bowel disease, malignancy, nephrotic syndrome, hemiparesis and paraparesis should receive prophylaxis routinely. Subcutaneous low dose Unfractionated Heparin (UFH) or Low Molecular Weight Heparin (LMWH) is the prophylaxis of choice. When these agents are contraindicated they should be substituted with Graduated Elastic Compression Stockings (GECS) as in the patients with acute stroke.
Type of Prophylaxis 47 6 10 20 30 40 50 60 70 80 90
100
LMWH
GECS
Methods & Aim
This Study was done in the Acute Medicine Unit (AMU) of Ninewells Hospital and Medical School. Here patients are usually seen first by junior doctors, then reviewed by the Specialist Registrars and finally by the Consultants. Both Acute Physicians (dedicated to the acute medicine unit) and Consultants from other specialties are involved in post-take ward round for the final decision making process. The aim of this study was to see whether the SIGN guidelines for VTE prophylaxis were strictly followed in the unit and to examine the differences in prescribing VTE prophylaxis between the acute physicians and the other specialists. In this study the patients admitted to the AMU in December 2007 were randomly selected and prospectively reviewed to look into the number of patients eligible for VTE prophylaxis according to the SIGN guidelines and the percentage of eligible patients receiving prophylaxis.
Pattern of VTE Prophylaxis
64% 9%
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10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
Acute Physicians
Other Specialists %
Results:
A total of 100 patients were eligible for VTE prophylaxis. Average age of the patients was 72 years. Out of the 100 eligible patients 53 patients received prophylaxis and 43 did not. 4 patients were on warfarin and hence they were not considered for any prophylaxis. Of the 53 patients who received prophylaxis, 47 got subcutaneous LMWH and other 6 patients received GECS.
Of the 53 patients who received VTE prophylaxis 17 patients (31%) received prophylaxis after being seen by junior doctors, another 17(31%) patients were prescribed prophylaxis after Specialist Registrar review and 19(38%) patients received prophylaxis after the consultant ward round. 16/25(64%) patients seen by the Acute Physicians received VTE prophylaxis whereas only3/37(9%) patients seen by the other specialists received prophylaxis. There were 9 patients with acute stroke in the study population out of which only 4 patients received prophylaxis with GECS.
Our study shows that around 40% of patients did not receive VTE prophylaxis in the AMU However it clearly demonstrates that acute physicians, dedicated to the acute medicine unit are much more pro-active in prescribing VTE prophylaxis than other consultant physicians (P<0.0001). We recommend that Initiation of VTE prophylaxis in the AMU should be actively encouraged.
Conclusions:
1. Antiplatelet Trialists' Collaboration. Collaborative overview of randomised trials of antiplatelet therapy. III. Reduction in venous thrombosis and pulmonary embolism by antiplatelet prophylaxis among surgical and medical patients. BMJ 1994;308:  
References: 53 43 4 10 20 30 40 50 60 70 80 90
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Yes No
On warfarin
Initiation of VTE Prophylaxis
2. Heit JA, Silverstein MD, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ III. Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study. Arch Intern Med 2000;160:  
3. Anderson FA Jr, Wheeler HB, Goldberg RJ, et al. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism: the Worcester DVT Study. Arch Intern Med 1991;151:  
4. Goldhaber SZ, Dunn K, MacDougall RC. New onset of venous thromboembolism among hospitalized patients at Brigham and Women's Hospital is caused more often by prophylaxis failure than by withholding treatment. Chest 2000;118:
5. Prophylaxis for Venous Thromboembolism: SIGN Publication No 62