Thromboprophylaxis for adults in hospital
BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39210.496505.BE (Published 17 May 2007) Cite this as: BMJ 2007;334:1017
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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
Competing interests: No competing interests
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
Director and Co-founder AntiCoagulation Europe
Competing interests:
None declared
Competing interests: No competing interests
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 naïve 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
Competing interests: No competing interests
SUCCESS OF GUIDELINE DEPENDS ON PROPER IMPLEMENTATION:
Ruben Ajay Tauro, Samrat Bose, K. A. S. Mohamed Thahir, Krishna
Prasad, Sujoy Ghosh
Department of General Medicine, The Ayr Hospital, Ayr, Ayshire, Scotland,
U.K.
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Professor of Vascular Medicine, University of Glasgow,
Royal Infirmary, Glasgow G31 2ER.
g.d.lowe@clinmed.gla.ac.uk
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.
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
Thromboprophylaxis prescribing still leaves a lot to be desired
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
Competing interests: No competing interests