Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Prophylaxis for Medical inpatients not entirely proven
- Domnick F D'Costa (21 May 2007)
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Effective Implementation of Thromboprophylaxis Strategies
- Christian Schwiebert, Barry Lambert, SpR Anaesthesia Imperial School, Queen Charlotte's Hospital, London SW3 6NP (21 May 2007)
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Implememting thromboprophylactic measures
- Hamed N Khan (22 May 2007)
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Improving use of thromboprophylaxis
- Lucy V Harding, Cuong Dang (specialist registrar in diabetes and endocrinology) and Robert Young (consultant physician and director of clinical effectiveness) (22 May 2007)
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Medical thromboprophylaxis- what a mess!
- Craig G Morris (23 May 2007)
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Holistic orthopods concern over prophylaxis guidelines
- Tim N Board, Martyn L Porter, Consultant Orthopaedic Surgeon (23 May 2007)
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Thromboprophylaxis for adults in hospital
- Gordon DO Lowe (25 May 2007)
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Modern Orthopaedic Surgery is not a "high risk" for thromboembolic disease.
- DAVID A MACDONALD, Chapel Allerton Hospital, Leeds. LS7 4SA (25 May 2007)
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Success of guideline depends on proper implementation
- Ruben Tauro, Samrat Bose, K. A. S. Mohamed Thahir, Krishna Prasad, Sujoy Ghosh (25 May 2007)
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Thromboprophylaxis in orthopaedic surgery, a question of balance.
- Roger M Atkins (25 May 2007)
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Moving thromboprophylaxis forward
- Eve M Knight (1 June 2007)
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Keep It Simple- Thromboprophylaxis of adults in hospital
- DR T K Madhuri, Simon Butler- Manuel, Anil Tailor (21 June 2007)
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Thromboprophylaxis prescribing still leaves a lot to be desired
- Craig Tinning, William JM Holmes (16 October 2007)
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Domnick F D'Costa, Consultant Physician, General Medicine & Care of the Elderly Royal Wolverhampton Hospitals ,WV10 0QP
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The authors have highlighted an important issue about thromboprophylaxis for adults in hospital (1), but failed to emphasise that the evidence is primarily for Surgical inpatients (2). They quote a 60-65% reduction of venous thromboembolism (VTE) - their first 2 references refer to surgical patients & the third to high risk medical patients aged over 60.I have 3 concerns. Firstly, a recent meta-analysis on anticoagulant prophylaxis to prevent symptomatic VTE in 19,958 hospitalised medical patients showed only modest benefit (3). The NNT's to prevent one PE was 345 (absolute risk reduction 0.29%) and to prevent a fatal PE was 400 (absolute reduction 0.25%). There was no significant differece in symptomatic DVT prevention and a nonsignificant increase in major bleeding(0.14%absolute increase).Thus, before rushing to use prophylactic anticoagulants in medical patients, clinicians should remember this and target only high risk medical patients ie-aged over 60 yrs, bed bound for 4 days, and have either heart failure, respiratory failure,inflammatory illness or cancer(as highlighted in their table)(1). Secondly, the authors report that VTE causes 25,000 potentially preventable deaths- it should be emphasised that these are merely estimates only and based on extrapolation from European data (4). Indeed, the authors of the DoH report indicate that the data on VTE in hospital patients are not sufficiently robust to enable secure conclusions to be drawn & the DoH is urged to initiate research to establish an accurate measure of death from VTE(4).Furthermore, the meta-analysis indicated that anticoagulant prophylaxis had no effect on all cause mortality (3). Finally, to date, there are no studies assessing the cost effectiveness of anticoagulant prophylaxis to prevent symptomatic VTE in hospitalised patients(3). The authors of the meta-analysis comment that because anticoagulant prophylaxis in medical inpatients has potential harm, increases health care costs & is associated with modest treatment benefit in terms of absolute risk reduction, its use should be selective & limited to higher risk medical patients. Perhaps, this is why NICE has produced a report only in Surgical patients. References 1 Fitzmaurice DA, Murray E. Thromboprophylaxis for adults in hospital BMJ 2007;334:1017-8. 2 NICE. Venous thromboembolism: reducing the risk of venous thromboembolism in patients undergoing surgery. April 2007. http://guidance.nice.org.uk/CG46. 3 Dentali F, Douketis JD, Gianni M, Lim M and Crowther MA. Meta-analysis: anticoagulant prophylaxis to prevent symptomatic venous thromboembolism in hospitalised medical patients. Ann Int Med 2007;146: 278-288. 4 House of Commons Health Committee. The prevention of venous thromboembolism in hospitalised patients. Second report of session 2004-5. London DoH, 2007. www.dh.gov.uk Competing interests: None declared |
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Christian Schwiebert, SpR Anaesthesia Imperial School Royal Brompton Hospital, London SW3 6NP, Barry Lambert, SpR Anaesthesia Imperial School, Queen Charlotte's Hospital, London SW3 6NP
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We welcome the new NICE guidelines to reduce the risk of venous thromboembolism in surgical patients. We agree with Prof Fitzmaurice, that the risks to patients of developing thromboembolism following surgery are well understood by clinicians. But the challenge of providing the recommended 100% compliance of prophylactic measures is substantial and can only be met by coordinated hospital wide strategies. We recently completed an audit of thromboprophylaxis for surgical patients at a major oncological centre. Despite a high awareness of the risks, over 50% of our patients were not receiving their risk appropriate low molecular weight heparin prescriptions. Correct use of mechanical prophylaxis was achieved in over 80% of patients. The practice of thromboprophylaxis varied substantially between different clinicians. Often there was no clear designated doctor, surgeon or anaesthetist who was responsible within the team for implementing prophylaxis. We strongly believe that patients should be classified into the risk categories suggested by NICE at the earliest opportunity, such as in pre-assessment clinics, with local hospital protocols suggesting the most suitable prophylactic strategy and who should implement it. This will give a greater number of patients the benefit of evidence based risk reduction. Competing interests: None declared |
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Hamed N Khan, FY1 surgery Homerton University Hospital, London, E9 6SR
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As a junior doctor working in surgery, I read this article with great interest. The decrease in incidences of thrombosis as a result of effective thromboprophylaxis is quite staggering, as demonstrated by the statistics quoted. Other colleagues who have written rapid responses have talked about audits they have done. I am also currently doing an audit on thromboprohylaxis on the surgical wards at my hospital. Previous audits on this topic have largely looked at whether the correct thromboprophylactic therapies are being prescribed by doctors. Although this is the key determinant in the effectiveness of thromboprophylaxis, one issue which seems to have not been explored quite as thoroughly is whether the thromboprophylactic measures doctors prescribe and recommend are actually implemented by nursing staff, and to some extent, patients themselves. From anecdotal accounts, I believe that this is certainly the case with stockings, such as TEDS. In my limited experience, I have often seen patients on wards without stockings, or wearing them in a way which renders them ineffective. Unlike heparin, stockings have no systemic side- effects and few contraindications. Hence they can be safely administered to most patients without much thought about possible adverse consequences. Patients often complain to me about the discomfort stockings cause, and this is something I empathise with. However if the risks of ineffective thromboprophylaxis are explained effectively, together with the additional risks of prolonged hospital admissions that may be a result of morbidity, I would imagine that most patients would happily bear the inconvenience. I also believe that this is something that we, as doctors, are not as proactive in educating our fellow health professionals, such as nursing staff. It is for this reason that I am investigating, as part of my audit, the number of patients who have stockings prescribed, but do not actually have them worn on their legs. I would suggest that colleagues elsewhere, who are also carying out audits on this issue, investigate this. The findings may be quite interesting. Competing interests: None declared |
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Lucy V Harding, F2 doctor in rheumatology Salford Royal NHS Foundation Trust, Hope Hospital, Salford, M6 8HD, Cuong Dang (specialist registrar in diabetes and endocrinology) and Robert Young (consultant physician and director of clinical effectiveness)
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Fitzmaurice and Murray remind us that venous thromboembolism is not just a problem amongst hospitalised surgical patients but a significant cause of morbidity and mortality in medical patients as well (1). We work in a hospital which implemented a thromboprophylaxis protocol for medical patients in 2004. In line with the recent recommendations of the UK government’s Health Select Committee, the protocol states that every medical patient admitted to the hospital should have a risk assessment for venous thromboembolism, and be prescribed thromboprophylaxis with low molecular weight heparin if indicated. When the protocol was introduced it was widely publicised within the hospital and made easily accessible to doctors in the bedside patient file, and on the hospital intranet. In the year following the introduction of the protocol we audited all cases of hospital-acquired venous thromboembolism to assess concordance with the protocol. We found that only 18% of medical patients who had an indication for thromboprophylaxis according to the protocol were prescribed an appropriate dose of low molecular weight heparin. Furthermore, out of 6 deaths due to pulmonary embolism, only 2 had received low molecular weight heparin, despite it being indicated in all 6 cases. The dissemination of information regarding thromboprophylaxis is important, but not the entire solution to ensuring 100% compliance with risk assessment for thromboprophylaxis. It may be that a new approach to the problem is required. Electronic alerts to the need for thromboprophylaxis have been shown to be effective in increasing doctors’ use of thromboprophylaxis and reducing rates of venous thromboembolism (2). This system, however, requires complete electronic records of patients’ risk factors for venous thromboembolism. An alternative approach might be to mandate thromboembolism risk stratification and linked action as part of the standard admission procedure. References 1) Fitzmaurice DA, Murray E. Thromboprophylaxis for adults in hospital. BMJ 2007;334:1017-1018 2) Kucher N, Koo S, Quiroz R, Cooper JM, Paterno MD, Soukonnikov B, Goldhaber SZ. Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med. 2005 Mar 10;352(10):969-77. Competing interests: None declared |
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Craig G Morris, Consultant Intensivist and Anaesthetist Derby Hospitals, DE12QY
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The editorial by Fitzmaurice is timely and welcome, but I share many of Dr D'Costa's concerns (Rapid Responses) about the ease with which we slide between the evidence (largely complete) for surgical and medical prophylaxis. I also reject the citing of an old post morten series that 10% of medical patients die from pulmonary embolus- this is controversial and does not translate to an argument for routine prophylaxis. After all, 2% of us have cerebral berry aneurysms at post mortem, and for that matter 100% have airway obstruction, that does not mean it killed you or that intervention will improve outcome. That said we are in a relatively strong position with evidence of efficacy to provide prophylaxis for high risk medical patients, and the "high risk" criteria mandated by Dr D'Costa appear almost identical to the list from NICE for at risk surgical patients. Surely we are at a point where this debate can move on and medical patients with easily identified risk factors receive prophylaxis of a comparable level to their surgical comparators (enoxoparin 40mg, fondaparinux or similar with pneumatic compression). If the medical community wish to target at risk medical patients, then why not use the NICE surgical criteria and cross out the word "SURGICAL". One final point which has troubled me since its publication was one of the key references in the Fitzmaurice editorial and carried by the BMJ, namely the fondaparinux study by the ARTEMIS investigators. This study confirming efficacy of fondaparinux in medical patients with risk factors was PLACEBO CONTROLLED. Surely this should have been run as a non-inferiority study against enoxoparin 40mg? The excess of deaths in the placebo group I find unacceptable and avoidable, and should put an end to our debating over whether at risk medical patients whould receive prophylaxis at all. References Fitzmaurice DA, Murray E. Thromboprophylaxis for adults in hospital. BMJ 2007;334:1017- 8 Samama MM, Cohen AT, Darmon JY et al for the Prophylaxis in Medical Patients with Enoxoparin Study Group. N Engl J Med 1999;341:793- 800 Cohen AT, Davidson BL, Gallus AS for the ARTEMIS Investigators. Efficacy and safety of fondaparinux for tyheprevention of venous thromboembolism in older medical patients: randomised placebo controlled trial. BMJ 2006;332:325- 9 Competing interests: None declared |
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Tim N Board, Lecturer in Orthopaedics The Hip Centre, Wrightington Hospital, Wigan, WN6 9EP, UK, Martyn L Porter, Consultant Orthopaedic Surgeon
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Fitzmaurice and Murray1 make a compelling case for implementing the NICE guidelines on thromboprophylaxis. Indeed it concludes by stating, “Meanwhile more than 25,000 people may have died needlessly each year because of the failure to implement simple thromboprophylaxis in UK hospitals”. They also feel that thromboprophylaxis is poorly implemented “as a result of poor education….” and that “health professionals lack awareness of this condition”. However, many Orthopaedic surgeons would profess to a different point of view. Firstly, there is, as yet, no evidence from published studies that thromboprophylaxis significantly reduces the mortality rate in patients undergoing elective hip or knee replacements. Secondly, there is much concern regarding the attempted prevention of what the authors themselves dub a “silent” disease. Whilst orthopaedic surgeons have not traditionally been seen as the pioneers of holistic medicine, we are reticent to expose our patients to increased risks from treatment for a condition only identified by a radiological test. Indeed the NICE guidelines own statistics emphasise this point by documenting the incidence of VTE(radiologically diagnosed DVT and PE) following hip replacement without prophylaxis as 44% and the symptomatic VTE incidence in the same group as only 0.51%2. Thirdly, we are disappointed by the lack of appropriate secondary outcome measures in the NICE analysis. There is no mention of wound haematoma, wound discharge or joint infection. If these are not thought to be important issues then the millions of pounds spent every year attempting to prevent infection in hip replacement are clearly ill spent. Whilst the intentions of NICE are to be applauded it is not entirely clear whether the recommendations (specifically in relation to elective hip and knee replacements) are based on rigorous analysis of entirely appropriate data. Many orthopaedic surgeons in the UK are less confident that benefit will be delivered to patients. 1. Fitzmaurice DA, Murray E. Thomboprophylaxis for adults in hospital BMJ 2007;334:1017-8. 2. National Institute for Health and Clinical Excellence. Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients undergoing surgery. April 2007. http//guidance.nice.org.uk/CG46. Competing interests: None declared |
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Gordon DO Lowe, Professor of Vascular Medicine University of Glasgow, Royal Infirmary, Glasgow G31 2ER
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David Fitzmaurice and Ellen Murray note there is compelling evidence that thromboprophylaxis reduces the risk of venous thromboembolism in hospital patients (medical and surgical); however thromboembolic mortality remains high in the UK.1 In 1992, the British Medical Journal published an 8-page, centre-spread, illustrated review of this evidence, by the Thromboembolic Risk Factors (THRIFT) Consensus Group2. They recommended that all medical and surgical patients admitted to hospital in the UK should be assessed for risk of thromboembolism; and should receive thromboembolic prophylaxis according to their degree of risk. The choice between antithrombotic drugs and mechanical methods would depend on the balance of risks of thromboembolism and bleeding.2 In NHS Scotland, this consensus review2 was superseded in 1995 by the first national, evidence-based guideline from the Scottish Intercollegiate Guidelines Network (SIGN)3 which was updated in 2002.4 One measure of the impact of this guideline has been a significant reduction between 1994 and 2002 in the number of patients dying of venous thromboembolism who did not receive antithrombotic prophylaxis despite high risk, in the Scottish Audit of Surgical Mortality (SASM).5 As reviewed by Fitzmaurice and Murray,1 the recent publication of similar guidance for other countries in the UK by the National Institute for Health and Clinical Excellence (NICE) for surgical patients, and by the Westminster Government Health Select Committee expert working group for medical and surgical patients, is welcome; and will hopefully reduce this preventable cause of death in hospital patients throughout the UK. However, it is sobering to recall that the BMJ published evidence based UK recommendations for routine risk assessment and thromboembolic prophylaxis fifteen years ago.1 Gordon Lowe
1. Fitzmaurice DA, Murray E. Thromboprophylaxis for adults in hospital. BMJ 2007;334:1017-8. 2. Lowe GDO, Greer IA, Cooke TG, et al. (THRIFT Consensus Group). Risk of and prophylaxis for venous thromboembolism in hospital patients. BMJ 1992;305:567-74. 3. Scottish Intercollegiate Guidelines Network (SIGN). Prophylaxis of venous thromboembolism. A national clinical guideline. Edinburgh: SIGN;1995. 4. Scottish Intercollegiate Guidelines Network (SIGN). Prophylaxis of venous thromboembolism. A national clinical guideline. Edinburgh: SIGN;2002. 5. Thompson AM, Ashraf Z, Burton H, Stonebridge PA. Mapping changes in surgical mortality over 9 years by peer review audit. Br J Surg 2005;92:1449-52. Competing interests: I chaired the THRIFT Consensus Group review2 and the guideline development groups for the two SIGN guidelines.3,4 I am currently Chair of SIGN. |
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DAVID A MACDONALD, Consultant Orthopaedic Surgeon Leeds Teaching Hospitals NHS Trust, Chapel Allerton Hospital, Leeds. LS7 4SA
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I was concerned enough to write to you in 2001(1) following an editorial from a retired haematologist suggesting that all hip and knee replacement patients should be given drugs to increase the risk of bleeding because of a supposed high risk of thromboembolic disease. I am concerned to now read an editorial from a department of primary care who are sponsored by an interested party (Leo Laboratories) Both NICE and Fitzmaurice and Murray have fallen into the previous pitfall of using historical references to assess this high risk. Modern surgical, anaesthetic and rehabilitation techniques have now made hip and knee replacement procedures "low risk". In my last 2729 consecutive hip and knee replacements, I have had 3 fatal pulmonary emboli (0.11%), 24 non fatal symptomatic pulmonary emboli (0.88%) and 34 symptomatic deep venous thromboses (1.24%). All patients had mechanical calf pumps, no stockings and no low molecular weight heparin (unless having had previous thromboembolic event). These incidences are similar to all recent large cohort studies. With this incidence NICE would consider such procedures "low risk" and hence only require mechanical prophylaxis and early mobilisation. I am afraid the British Medical Journal is again "scare mongering" without justification. An editorial from the British Orthopaedic Association would be more appropriate than an article from Primary care. 1. Macdonald DA. Many surgeons prefer not to prescribe chemoprophylaxis after arthoplasty. BMJ 2001;322:1546 Competing interests: None declared |
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Ruben Tauro, Senior House Officer The Ayr Hospital, KA6 6DX, Samrat Bose, K. A. S. Mohamed Thahir, Krishna Prasad, Sujoy Ghosh
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SUCCESS OF GUIDELINE DEPENDS ON PROPER IMPLEMENTATION: Ruben Ajay Tauro, Samrat Bose, K. A. S. Mohamed Thahir, Krishna
Prasad, Sujoy Ghosh
We have read with interest the write up on the summary of the NICE guidance and the accompanying editorial. Prevention and management of deep vein thrombosis and pulmonary embolism is an oft neglected area. [1, 2] We did an audit in our hospital (a district general hospital) in which we looked at how well we were implementing the British Thoracic Society (BTS) guidelines on the management of suspected pulmonary thromboembolism. [3] The results of the audit were significant. We found that even though documentation of history and clinical findings were satisfactory, the response to such findings and subsequent risk assessment was often inappropriate. A significant proportion of patients with low probability and intermediate probability of pulmonary embolism (PE) often did not have a d-dimer test done. On the other hand some patients with high probability of PE often had a d-dimer test done inappropriately. VQ scans were often done inappropriately in low & intermediate probability of PE without undergoing a d-dimer test. CTPA on the other hand was an underutilized tool for the diagnosis of PE in high risk cases. In only about 20% patients with suspected PE were we following the BTS guidelines properly. The findings of the audit highlight a major problem area. Guidelines are formulated to help healthcare workers to manage patients safely and utilize resources judiciously. We fear that the guidance issued by NICE (Reducing the risk of venous thromboembolism in inpatients having surgery) would also face similar problems when it comes to implementation of the same. [1] Hill J, Treasure T. Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients having surgery: summary of NICE guidance. BMJ. 2007 May 19;334(7602):1053-4. [2] Fitzmaurice DA, Murray E. Thromboprophylaxis for adults in hospital. BMJ. 2007 May 19;334(7602):1017-8. [3] British Thoracic Society guidelines for the management of suspected acute pulmonary embolism. British Thoracic Society Standards of Care Committee Pulmonary Embolism Guideline Development Group. Thorax 2003; 58: 470-484. Competing interests: None declared |
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Roger M Atkins, British Orthopaedic Association Lead Councillor for NICE Department of Orthopaedic Surgrey, Bristol Royal Infirmary, Bristol, BS2 8HW, England
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Fitzmaurice and Murray plead for greater use of low molecular weight heparins (LMWH) particularly in orthopaedic patients. They suggest that orthopaedic surgeons do not prescribe LMWH either because of ignorance or lack of funding. They are well wide of the mark. Orthopaedic surgeons are very aware of the risks of venous thromboembolic disease (vte) and have striven over the last five decades to reduce avoidable death and morbidity. Having introduced the revolutionary, life enhancing interventions of total joint replacement, the orthopaedic community sought to prevent associated vte’s with unfractionated heparin or warfarin. These interventions either did not work or caused unacceptable haemorrhage. When first introduced, we embraced LMWH as the solution to these problems. However, our experience has been that LMWH do not universally prevent lethal vte’s and their use is in fact accompanied by bleeding complications (1), contrary to the original literature. It is of course inherently naďve to suggest that a general technique such as LMWH will avoid thrombus in damaged veins centimetres away from major surgical wounds, while allowing optimal wound healing. Our efforts to avoid bleeding in patients on LMWH involved slower operations and delayed mobilisation, which themselves predispose to vte. In consequence, when intermittent compression devices, which definitely do not carry a risk of bleeding were introduced, we made these the mainstay of our vte prophylaxis. Thus we would strongly support NICE’s emphasis on mechanical methods of prophylaxis. The evidence is that in orthopaedic surgery, mechanical methods are as efficacious as LMWH and produce less soft tissue side effects (2), so the question is what if any chemical prophylaxis is it necessary or safe to add? NICE was not able to identify direct evidence of significant additionality in orthopaedic patients. Recent presentations to EFORT (Florence 2007) suggest that no such additionality exists. The argument which Fitzmaurice and Murray advance for the prevalence of vte is fatally flawed in that it is based on historic controls from an era when total hip replacement was undertaken more slowly than today and patients were bed bound for a considerable time. Current orthopaedic techniques include rapid surgery and early mobilisation which will lower the native rate of vte and this should be taken into account when determining prophylaxis (3). Unpublished data from UK orthopaedic units suggests that without the routine use of LMWH, the rate of fatal vte’s following joint replacement is extremely low but that patients may die of other causes (3). It is intriguing to note that the National Joint Registry records a death rate in patients not given thromboprophylaxis of 0.33% and 0.23% for total hip and knee replacement respectively. These rose to 0.65% and 0.50% when thromboprophylaxis was employed (4). So perhaps thromboprophylaxis increases deaths from other causes. It is a tragedy that are so few good, independently funded studies. In other words, this is a highly complex area. It is a pity that orthopaedic surgeons were not more fully involved at an earlier time and clearly a robust debate must follow in the interests of our patients. In the meantime we would welcome an apology from Fitzmaurice and Murray for their suggestion that orthopaedic surgeons are ignorant of the issues. The boot is perhaps on the other foot. 1. Burnett RS, Clohisy JC, Wright RW, McDonald DJ, Shively RA, Givens SA, Barrack RL. Failure of the American College of Chest Physicians-1A protocol for lovenox in clinical outcomes for thromboembolic prophylaxis. J Arthroplasty. 2007 Apr;22(3):317-24. 2. Warwick D, Harrison J, Glew D, Mitchelmore A, Peters TJ, Donovan J. Comparison of the use of a foot pump with the use of low-molecular-weight heparin for the prevention of deep-vein thrombosis after total hip replacement. A prospective, randomized trial. J Bone Joint Surg Am. 1998 Aug;80(8):1158-66. 3. Murray DW, Britton AR, Bulstrode CJ. Thromboprophylaxis and death after total hip replacement. J Bone Joint Surg Br. 1996 Nov;78(6):863-70. 4. National Joint Registry for England and Wales. 2nd Annual Report, September 2005. Tables 66 and 67 Pp 100-102. Competing interests: None declared |
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Eve M Knight, Executive Director AntiCoagulation Europe BR2 9WP
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Dear Sir AntiCoagulation Europe welcomes both the NICE guidance and the recent guidance issued by the Chief Medical Officer concerning Venous Thromboembolism (VTE). It has taken a long time to get to this point, UK recommendations were published in the British medical Journal (BMJ) nearly fifteen years ago and yet people have continued to die needlessly while others have suffered chronic and disabling ill health as a result of VTE. In particular we welcome the recommendation that all patients should be risk assessed before surgical procedures, and would hope that guidance for medical patients will be produced soon. However we are concerned that NICE chose to recommend that the age for risk assessment should be over 60. This is out of line with other International guidance which recommends 40 years, and puts a significant portion of the population at unnecessary risk. Also the NICE guidance, in some instances, went against the Chief Medical Officers guidance In order for lives to be saved the guidance will need to be rigorously implemented and a national risk assessment tool produced as soon as possible. Even then it remains to be seen whether individual hospitals will find the necessary resources to put the guidance into practice effectively and quickly. A further concern is that from the published responses to Prof Fitzmaurice’s article it is clear that it will take more than NICE guidance to change the mind set of some clinicians. AntiCoagulation feels that ways will need to be found of ensuring that there is 100% take up of the guidance. One of the ways of ensuring this would be through the healthcare Commission. However, at present it is unclear if the Healthcare Commission will include VTE in their Annual Hospital Health Check audits. Yours sincerely Eve Knight
Competing interests: None declared |
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DR T K Madhuri, Clinical Fellow GynaeOncology Royal Surrey County Hospital, Guildford GU2 7XX, Simon Butler- Manuel, Anil Tailor
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2005 UK government’s Health Select Committee reported that VTE (venous thromboembolism) caused more than 25,000 deaths a year most of which are preventable. We work in a tertiary GynaeOncology Unit. We operate on patients with suspected and confirmed gynaecological malignancies and often other risk factors for VTE. We have achieved a very high success rate with no hospital admissions for VTE for 6 months post surgery in our patients following a recently concluded study where we looked at patient compliance with extended thromboprophylaxis following admission for surgery. Staff in the pre-assessment clinic including the Doctor is educated about the importance of thromboprophylaxis and prevention of VTE. The patient is explained in depth about thromboprophylaxis, risks and how it can be prevented. Patients are sent home with a kit which includes a DVD, printed information on thromboprophylaxis and self administration following discharge. The patient is then taught the same on the ward on Day 3 post op. In cases where the patients were not keen to self administer, families/ District Nurses were involved. The thromboprophylaxis was carried on for up to 21 days post surgery in malignancies and major laparotomies and limited to duration of hospital stay in laparoscopic procedures. We followed up our patients with questionnaires, consent for which was sought at the pre-assessment clinic. If VTE can be so easily prevented, why do we still have such high mortality figures? Are we lacking in motivation? Competing interests: None declared |
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Craig Tinning, FY2 Hairmyres Hospital, East Kilbride G758RG, William JM Holmes
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The Chief Medical Advisor’s independent expert group, the Scottish Intercollegiate Guidelines Network (SIGN) and the National Institute for Health and Clinical Excellence (NICE) have recommended strategies for VTE prevention in surgical patients. Key components of these strategies are mandatory risk factor assessment, the use of graduated compression stockings for all inpatients unless contra-indicated and the addition of low molecular weight heparin as guided by risk factor profile. As a group, junior doctors undertake the majority of initial VTE risk assessment and prescription of prophylaxis. The current SIGN guidelines have abolished the risk stratification system in favour of advocated that all patients should have mechanical thromboprophylaxis prescribed unless contraindicated, and LMWH if one or more risk factor . We audited a busy tertiary surgical centre and found that whilst the prescribing of LMWH was high (84%) only 41% of patients were using mechanical prophylaxis. The percentage of patients with one or more risk factor, on mechanical prophylaxis and LMWH was only 33%. A questionnaire completed by all juniors responsible for thromboprophylaxis prescribing showed good knowledge of the guidelines (58%), but this knowledge did not translate into better prescribing in keeping with SIGN recommendations. Mortality from thromboembolism accounts for around 25,000 deaths a year . The production of guidelines and working group recommendations are beneficial, but irrelevant if not implemented at patient level. They must address issues such as how to promote these guidelines into current practice, designating who should be responsible and methods to guarantee adherence. Strategies for improving thromboprophylaxis prescribing have been largely unsuccessful. We are in agreement with a previous letter that mandatory thromboembolism risk stratification should be documented for all admission clerk-ins . Additionally, it must be the responsibility of the doctor to prescribe TED stockings and ensure their compliance. This role could be easier fulfilled by the junior. 1. Prophylaxis of venous thromboembolism. SIGN 62. October 2002. 2. Fitzmaurice DA, Murray E. Thromboprophylaxis for adults in hospital. BMJ2007;334:1017-8 (19 May) 3. Harding LV, Dang C, Young R. Improving use. BMJ 2007;334:1128 Competing interests: None declared |
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