Regular Article
Venous thromboembolism prophylaxis in medical inpatients: a retrospective chart review

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Abstract

Background: Venous thromboembolic disease (VTE) is a major cause of morbidity and mortality in hospitalized patients. Most hospitalized patients with a fatal pulmonary embolism are medical patients who do not have a history of recent surgery [BMJ 302 (1991) 709; J. R. Soc. Med. 82 (1989) 198]. There is evidence suggesting that VTE prophylaxis is indicated in many high risk medical patients [Chest 119 (2001) 132S; NEJM 341 (1999) 793]. However, previous studies have shown that only about one third of high risk medical patients receive VTE prophylaxis [Ann. Intern. Med. 115 (1991) 591; Chest 106 (1994) 13; Chest 107 (1995) 296]. The objective of this study was to determine the frequency of use of VTE prophylaxis in medical inpatients at two teaching hospitals in Hamilton, Ontario. Methods: A retrospective chart review of consecutive patients admitted to medical wards at two acute care sites of McMaster University affiliated teaching hospitals between October 10, 2001 and December 11, 2001 was performed. For each patient, demographic data, risk factors for VTE, method of VTE prophylaxis and contraindications to VTE prophylaxis were recorded. Results: 756 patient charts were reviewed and 310 (41%) were excluded because the primary diagnosis required anticoagulation, the patients were being treated with anticoagulation (warfarin or heparin) before admission or the patient was admitted to the intensive care unit. Of the remaining 446 patients, 146 (33%) received some form of VTE prophylaxis. Of the patients receiving prophylaxis, 4% had early ambulation, 9% wore anti-embolic stockings (AES), 1% used intermittent pneumatic compression, 23% used unfractionated heparin and 3% used low molecular weight heparin. Two hundred five (46%) patients had one identifiable VTE risk factor and 63 (14%) had two or more risk factors. Patients with more VTE risk factors were more likely to receive prophylaxis. Interpretation: One third of medical inpatients at two teaching hospitals in Hamilton received some form of VTE prophylaxis.

Section snippets

Background

Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is a major cause of mortality and morbidity in hospitalized patients. In the absence of prophylaxis, the risk of venographic VTE in medical patients is, on average, 16%. This is comparable to the risk in moderate risk surgical patients [1]. Autopsy studies carried out in hospitalized patients have revealed that PE contributed to death in 15.6% of cases. Of the PE deaths, 18% occurred in surgical

Patients

The study population consisted of consecutive inpatients admitted to the medical wards of one of two McMaster University affiliated teaching hospitals (McMaster University Medical Centre (MUMC) and the Henderson Hospital) between October 10, 2001 and December 11, 2001. Each hospital has 50 inpatient medical beds, and most of the patients are admitted to the wards via the Emergency Department. MUMC has a clinical teaching unit (attending physicians and housestaff) whereas the Henderson does not.

Study design

Study population

For the period from October 10, 2001 to December 11, 2001, the charts of 756 patients were reviewed (299 from MUMC and 457 from Henderson Hospital). Three hundred ten (41%) patients were excluded (see Table 1). Thus, the study population consisted of 446 (59%) patients: 208 were from MUMC and 238 were from Henderson Hospital.

Demographic data

The mean average age of the included patients was 67 years (range 16–98 years). The mean average expected length of stay at MUMC was 4.5 days. Charts of patients admitted

Interpretation

Our study of admitted medical patients at two McMaster University affiliated teaching hospitals revealed that VTE prophylaxis is given to only about one third of patients. Even in subgroups of patients with two or more risk factors for VTE, prophylaxis was given in less than 50%. Consensus conferences universally recommend (Grade A evidence) the use of heparin for VTE prophylaxis in moderate to high risk medical patients. Each of the two McMaster University affiliated hospitals has a formal

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