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LETTERS: Domnick F D'Costa Prophylaxis for medical inpatients is not entirely proven BMJ 2007; 334: 1127 [Full text]

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Thromboprophylaxis needs to start in the emergency department

Rhian S Farquharson, P. Adrian Evans, Reader in emergency medicine, School of Medicine, Swansea University   (6 July 2007)

Thromboprophylaxis needs to start in the emergency department 6 July 2007
Rhian S Farquharson, SpR in emergency medicine Morriston Hospital, Swansea SA6 6NL, P. Adrian Evans, Reader in emergency medicine, School of Medicine, Swansea University Send response to journal: Re: Thromboprophylaxis needs to start in the emergency department	As doctors working in emergency medicine, we have concerns regarding the lack of thromboprophylaxis administered to our patients. It is with interest we read the letter from Dr D’Costa1 and agree that high risk medical patients need to be targeted. Such patients have already been highlighted in the CMO’s working party recommendation2 – “patients likely to be in hospital for more than 4 days and with reduced mobility, with either severe heart failure, respiratory failure, acute infection, inflammatory illness or cancer.” We feel however that it is as these patients enter the hospital doors that risk stratification needs to be occurring early in the emergency department and prophylaxis commenced in line with clear guidelines. It is in an emergency department that medical patients are often at their most thrombogenic, due to marked physiological impairment associated with other factors including inflammation, hypoxia and dehydration, as evidenced by altered biochemical markers. Often they have been progressively deteriorating at home in bed for days and this coupled with ongoing immobility must put them at a increased risk. We conducted a national survey of all 14 major accident and emergency departments in Wales. This involved units that look after a total of approximately 877,000 patients annually and despite this obvious risk only one department had a policy whereby thromboprophylaxis in high risk patients was commenced in the emergency department. If this situation is mirrored throughout emergency departments within the UK then this would represent an unacceptable delay to treatment. We feel that policies need to be targeted and implemented to provide thromboprophylaxis to high risk medical in- patients earlier, with the inception of an integrated care pathway in the emergency department, where these patients are potentially at highest risk of thrombogenesis and venous thromboembolism. References 1. D’Costa DF. Prophylaxis for medical inpatients is not entirely proven. BMJ 2007;334:1127 (2 June) 2. Department of Health. Recommendations of the expert working group on the prevention of thromboebolism (VTE) in hospitalised patients. London: DoH 2007 Competing interests: None declared