Reminders: a simple measure to ensure the mandatory venous thromboembolism risk assessment of hospitalised patients

Abstract

To the Editor: The estimated number of potentially preventable deaths from venous thromboembolism (VTE) per year in the UK is in excess of 25,000 (1). It is known that pulmonary embolism is responsible for 10% of deaths in hospitalised patients in the Western world (2). In March 2007, the independent expert working group on the prevention of VTE in hospitalised patients came up with recommendations on behalf of the Department of Health (1). The group recommended that all medical patients should, as a part of a mandatory risk assessment, be considered for thromboprophylaxis measures (1). In particular, patients likely to be in hospital for longer than 4 days, with reduced mobility and with any of the following medical conditions: severe heart failure; respiratory failure (due either to exacerbation of chronic lung disease or pneumonia); acute infection; inflammatory illness and cancer, should be considered for prophylactic low-molecular-weight heparins (LMWH). Various studies have revealed that thromboprophylaxis in medical inpatients is still not adequate, with only 30–40% of suitable patients being prescribed appropriate thromboprophylaxis (3,4). Previous audits at the Ipswich Hospital NHS Trust have revealed variable thromboprophylaxis prescription rates, with a mean of 20% within the acute medical unit (AMU). Since then our hospital guidelines on VTE risk assessment and thromboprophylaxis prescription are displayed on the patient assessment areas. Enoxaparin is the LMWH available in our hospital. On the background of the above, we report the results of an interventional study carried out between September and November 2007, to improve VTE risk assessment and thromboprophylaxis prescription for all acute medical admissions. The enoxaparin prescription rates for medical inpatients before and after applying a reminder for VTE risk assessment on the AMU admission sheet were compared. Admission sheets for patients coming in over various days of the week were screened for adherence to the guidelines within 24 h of a consultant-led emergency post-take ward round. Ninety-five admission sheets were screened before applying reminder labels and then 95 each with a reminder at the beginning and at the end of the admission sheet respectively. The reminder label read: Think! Does your patient need thromboprophylaxis? Consider enoxaparin 40 mg unless contraindicated. Table 1 describes the diagnosis/organ system affection of the 285 patients. The thromboprophylaxis prescription pattern is shown below in Table 2. The improvement (from 42% to 77%) in enoxaparin prescription rates after applying reminder labels to the admission sheets was significant (p < 0.001). There was no difference whether the reminders were applied at the beginning or at the end of the admission sheet. We found one patient in the reminder group where enoxaparin was inappropriately prescribed. Adherence to audited clinical guidelines based on best clinical practice has a role to play in improving patient safety and care standards. It is also crucial when there is a quick turnover of junior medical staff as occurs in most hospital settings. This is especially true of thromboprophylaxis; given the documented consequences of omission potentially leading to avoidable deaths. Very few studies based on ‘adherence improving strategies’ or ‘reminders’ have been published in the past (5,6). This interventional study demonstrates an audited improvement in clinical practice. The use of a simple sticker improved VTE risk assessment significantly and enabled the hospital now to comply with the national guidelines. Following the success of this study, the hospital has redesigned the AMU admission sheet with a reminder for VTE risk assessment printed on the front page. The AMU will also focus more closely on VTE risk assessment at the junior doctors’ induction sessions. The effectiveness of this strategy will be re-audited in due course. Reminders on admission sheets can improve the rates of VTE risk assessment. This improvement will help to ensure compliance with national recommendations to improve VTE risk assessment of all hospitalised patients.