Accuracy of venous thromboembolism assessment and compliance to prophylaxis in a tertiary care center.

BACKGROUND: Proper assessment of venous thromboembolism (VTE) risk level in hospitalized patients is vital to providing adequate prophylaxis. Clinical decision support (CDS) tools with electronic medical record (EMR) have been used by institutions to improve assessment and prophylaxis. As such, this study was conducted after implementing such a system to compare admitting service (AS) assessment of VTE risk level to the VTE consult service (CS) assessment. In addition, compliance of ordered prophylaxis based on AS assessment was evaluated. METHODS: At a tertiary care center, we performed a review of randomly selected patients assessed within 18 h of admission for VTE risk over a five-month period. A total of 104 patients were evaluated, four of which were excluded because of VTE presence on admission. Patients were assessed for VTE risk independently, first by the AS, followed by the VTE CS. Prophylaxis orders were then reviewed based on AS assessment compliance to CDS recommendations for prophylaxis based on ACCP guidelines. RESULTS: All 100 patients underwent VTE risk assessment within 18 h from admission. The mean age was 63 years. Comparing AS to CS assessment, 13 patients had incorrect assessments (p < .001). Of these, six patients were under-assessed (p = .029), and seven patients were over-assessed (p = .014). Based on AS assessment there were eight patients who had incorrect prophylaxis ordered. Unnecessary exposure to complications due to inappropriate prophylaxis occurred in five patients. CONCLUSION: Despite the use of EMR CDS tools, there continues to be a significant number of patients that are being under-assessed and under-prophylaxed for VTE resulting in exposing patients to potential harm. Quality programs need to be instituted to further improve VTE assessment and prophylaxis.

Clinical thromboembolic detterrent stockings application: are thromboembolic detterrent stockings in practice matching manufacturers application guidelines.

BACKGROUND: Thromboembolic detterrent (TED) stockings have been shown to be effective in the reduction of thromboembolic events in post operative patients. These manufactured stockings create graduated compression from ankle to calf. AIM: To assess whether the manufacturers' recommendations for application were being met in a District general hospital setting and whether this achieved the desired gradient of compression. METHODS: We carried out pressure measurements on 100 legs in post-operative patients and recorded reasons for poorly fitting stockings. Pressure measurements were taken at standard positions around calf and ankle using a pre-calibrated subbandage pressure measuring device. RESULTS: About 20% of stockings were worn incorrectly by patients. Median pressure applied at the ankle was 13 mmHg (range, 6.5-18.5) compared to the manufacturers' intended compression of 18 mmHg. Only 14% of the stockings showed an acceptable gradation of reduced pressure between ankle and calf. About 23% of the stockings exerted a positive pressure at calf level compared to the ankle. CONCLUSION: Most TED stockings do not produce a standardised Siegel profile pressure gradient decrease from ankle to calf. This may be due in part to fluid changes after surgery in combination with the large variation in size of lower limbs. Our District general hospital utilises three of the six sizes of TED stocking, and remeasurement was not taking place every 24 h as per guidance. This as the result show not only negates the benefit of TED stockings but may also exert harm in terms of venous thromboembolism risk. This finding adds further weight to the argument of whether TED stockings may not be having the desired prophylactic effect and may even be resulting in harm in select cases.

Litigation claims relating to venous thromboembolism in the NHS.

AIM: Litigation costs for clinical negligence in the management of venous thromboembolism have escalated in the last five years. The National Health Service Litigation Authority estimates these claims have cost in excess of £112 million. Our aim is to identify the areas of practice where these claims are most likely to arise to help improve patient outcome. METHODS: The National Health Service Litigation Authority provided de-identified data on individual medical negligence claims against the NHS since 2007. We subcategorised the data into (a) the nature of the venous thromboembolism event, (b) the area of specialist practice and (c) the damages incurred. Inter-group differences were evaluated using ANOVA, Kruskal-Wallis test and Mann-Whitney U Test. RESULTS: Failure to prevent and to diagnose pulmonary emboli and deep vein thrombosis occurs across the spectrum of clinical specialties. In the study period 189 claims were made. The majority of claims were in surgical specialties and the financial burden was significantly greater than in the medical specialities (£3,257,394 vs. £1,532,996). The amounts paid out by specialty was not significantly different but had significant variance (p < 0.0001). CONCLUSIONS: The National Institute of Clinical Excellence provides comprehensive guidelines on venous thromboembolism risk assessment. Poor compliance has contributed to morbidity and mortality while the cost has continued to escalate. A multimodal approach to education is needed to improve patient outcome. Improved venous thromboembolism prevalence data are also needed.