This audit forms part of a wider project looking at the effective identification and management of risk of thromboembolism on our psychiatric wards. This project and its accompanying audits were agreed at the Medicines Safety Management Committee meeting in August 2011.
The risk of thromboembolism for psychiatric patients has been recognised long ago, (Durrazzo 2010, Maly 2008) and more specifically in association with use of antipsychotics (Thomassen 2000,) and physical restraint (Dickson 2009).
Aims and objectives
Our objectives were:
1). To identify all the inpatients that have been prescribed PVP as opposed to treatment of VTE in our Trust in the last 2 years.
2). Subsequently, to examine how often the decision to prescribe PVP was properly documented and how much consideration has been given to the presence of reduced mobility and of thrombotic and hemorrhagic risk factors.
3) Also, to examine the similarities and differences in the decision making process in those cases where any type of heparin had already been initiated by another medical team prior to psychiatric admission.
Reasons for implementing your project
The case for medical inpatients and more specifically, in non-surgical patients, after it is ascertained that a) they have had, or are expected to have reduced mobility for more than 3 days as inpatients b) they present with a number of thrombotic risk factors from a list provided c) their thrombotic risk is not outweighed by the presence of one or more hemorrhagic risk factors and d) they do not have any contra-indications for PVP, then Fondaparinux, LMWH or Unfractionated heparin (UFH) are recommended for prophylaxis. The risks are then reviewed in 24 hours and a similar decision making process is followed. Administration of PVP is to continue until risks are no longer present.
How did you implement the project
Audit Form: The form was developed by one of the audit leads (TB) and it incorporates the stages of decision making process and the risk factors that need consideration at each stage as outlined in the NICE CG92 and the accompanying audit support document. (Please see appendix I) Outcome measures: Primary outcome measure: The rate of the presence of a documented decision to initiate PVP, on the basis of a balanced risk assessment of VTE/Hemorrhagic risk factors in the selected patients. Secondary outcome measures:
a) The rate of use of any type of heparin for prophylaxis as opposed to treatment b) the rate of use of any type of heparin that had been initiated or suggested by another medical team c) The quality of documentation of decision making i.e. whether a separate consideration of thrombotic and hemorrhagic factors is present and a clear description of the rationale for it. d) the frequency of different risk factors present in patients prescribed PVP.
Forty inpatients (n=40) were identified as having been prescribed Dalteparin or Fragmin or other LMWH at least once between August 2009 and August 2011. For 38 of them (95%) electronic records were found, and these served as the sample for which all the audit conclusions applied (N=38). All prescriptions were for dalteparin.
- The rate of use of any type of heparin for prophylaxis (PVP) as opposed to treatment:
Out of 38 patients (N=38), fifteen were prescribed for prophylaxis (PVP) (n=15, 39% of total) and seventeen had it for treatment (n=17, 45% of total) For the remaining patients (n=6, 16% of total) no information could be found at any place in their electronic notes on why there were on LMWH.
- Who prescribed it: the rate of use of LMWH that was initiated or suggested by psychiatric team as opposed to another medical team:
In only six inpatients (6 out of 38, 16% of total) decision was made by the psychiatry doctors on the psychiatric ward. In sixteen inpatients (16 out of 38, 42% of total) the decision was made by a doctor from another team (GP, Medical team, DVT clinic etc) whose recommendation was subsequently followed. In the remaining 16 patients (42%) no mention in the notes could be identified as to whose decision it had been to start the LMWH, despite meticulous searching of electronic records. If narrowed down to PVP patients only, in 2 out of 3 cases (67%) the decision was made by the psychiatry doctor on the ward and in one it was a doctor from another team.
- Subgroup receiving Prophylaxis (PVP): The rate of the presence of a documented decision making
Focusing on the subgroup of prophylaxis, only for three out of a total of fifteen (3/15, 20%) the decision to initiate PVP was documented properly, by explaining the reasons for this decision and a plan to be followed afterwards.
Expected Standard: 100%
Actual Performance: 20%
- The quality of documentation of decision making i.e. number and nature of risk factors taken into account.
In these three cases where a decision making to start PVP had been documented properly, reduced mobility and two to four additional thromboembolic risk factors had been taken into account. However, in none of them was there any mention of the absence of hemorrhagic risk factors, which would ensure that these had been considered as well.
Key learning points
- To repeat this audit six to nine months after the introduction of the CP22 policy that included robust assessment and management of Thromboembolic risk as part of the initial assessment of inpatients. This will help identify differences in the rates of identification of patients at risk.
- Re-auditing will also look at any changes in the documentation of decision making, since the VTE risk assessment pro-forma makes this much more straightforward.
- Specific mention of the VTE risk policy could become part of standard trainee induction pack.
- The issue of proper documentation of decisions made by other teams could be addressed in the same way as the medicines reconciliation process. This would require ward doctors to acknowledge on each admission:
1) all the medication patients already receive prior to admission
2) that they are mindful of the reasons why patients are on them, and
3) whether any of these require ongoing review during admission