Prophylaxis for Venous Thromboembolism in General Medical Patients: DISCUSSION part 2

3 Oct
2010

The ACCP recommends that physicians be given hospital-specific data demonstrating the potential benefits of prophylactic strategies and that they be involved in educational programs, to motivate them to use such strategies. Despite the employment of these recommendations in educational interventions at the authors’ institution, rates of prophylaxis remained poor. Previous studies have found that didactic education, printed continuing education materials, conferences, and mailings are all weak tools for implementing change when used alone. To be successful, educational strategies must incorporate methods that continuously reinforce change, such as automated reminder systems (e.g., preprinted order sheets), academic detailing, and concurrent and retrospective feedback. Furthermore, multiple interventions are more effective than any single approach.

Several studies have highlighted underuse of VTE prophylaxis in medical patients and have indicated that only about one-third of eligible medical patients receive VTE prophylaxis upon admission to hospital (Table 5). The reasons for underuse may relate to uncertainty about optimal use of VTE prophylaxis in a clinical setting, including patient selection, optimal time to assess the need for VTE prophylaxis, appropriate type of VTE prophylaxis, and appropriate duration of therapy. However, because CHF and COPD have been identified as independent risk factors for VTE, there should be a greater appreciation of the need for prophylaxis in patients with these conditions. Only one other study has assessed a patient population similar to the one studied here; in that study, the rate of prophylaxis was also poor, but no educational intervention was undertaken. In another study that did involve an educational intervention, the rates improved significant­ly because orders for VTE prophylaxis were added to preprinted orders.
Viagra Super Active

Table 5. Other Clinical Trials Illustrating Underutilization of VTE Prophylaxis in Medical Patients







Patients Receiving VTE Prophylaxis







Study







Type of Study







Eligibility Criteria







ACCP-







ACCP-







Some Form of







Educational







Recommended







Recommended







Prophylaxis*







Intervention







Pharmacologic




Prophylaxis







Prophylaxis


Stark and



Chart review at
2


> 40
years of age,



LDUH
5000
units


6% (5/84)


31%
(26/84)


None


Kilzer13


US university


admitted for CHF


SC q8-12h


medical centers


(NYHA class III or IV),


OR


COPD, or respiratory


enoxaparin 40 mg


infection


SC once daily no


OR


dalteparin 2500 units


SC once daily


Stinnent et al.


Chart reviews


> 18
years of age;



LDUH
5000
units


Unknown


Before intervention:


Education and


before and after


admitted to


SC q8h


43%
(52/122)
of


development of a


intervention at a


cardiology,


OR


high-risk patientst


standard admission


US tertiary care


oncology, or


enoxaparin 40 mg


form that included


center


general medical


SC once daily


After intervention:


VTE risk



services for at least


71%
(70/99)
high-


stratification and


48 h


risk patientst


optimal VTE


prevention regimens


Rahim et al.


Chart review at


Inpatients admitted



LDUH
5000
units


Unknown


33% (146/446)


None


2
teaching hospitals


to medical wards


SC twice daily


overall


in Canada


OR


LMWH (drug and


43%
(27/63) of


dosage not specified)


patients with at


least 2 risk factors



VTE =
venous thromboembolism,
ACCP
=
American College of Chest
Physicians, CHF
=
congestive heart failure,



NYHA =
New York Heart Association,
COPD
=
chronic obstructive pulmonary
disease, LDUH
=
low-dose unfractionated heparin;



LMWH =
low-molecular-weight
heparin.


*Includes ambulation,
use of intermittent pneumatic compression devices, use of anti-embolic
stockings, and pharmacologic anticoagulation,


not necessarily
according to ACCP guidelines.



tDefined as
1 major
risk factor or
2
minor risk factors, according to a
risk stratification scheme used in the MEDENOX trial

The limitations of this study include the retrospective nature of the analysis, the limited sample size, and the short follow-up period. The methods used to determine the rates of VTE prophylaxis in the initial audit did not correspond to those used in the retrospective analysis; therefore, direct comparisons of these 2 data sets are not possible. In addition, this study included only medical patients with CHF or COPD and thus might not reflect VTE prophylaxis rates for all general medical patients at the authors’ institution.
canadian antibiotics

CONCLUSIONS

VTE prophylaxis was underused for medical patients with CHF or COPD exacerbation at the authors’ institution, and educational interventions alone were insufficient to ensure routine use of prophylaxis in clinical practice. After completion of this study, VTE prophylaxis was added to preprinted order sheets for patients admitted with CHF or COPD exacerbations, to ensure that these patients are considered for appropriate VTE prophylaxis.

top