Background Recently published evidence1 highlighted high bleeding risks in palliative care (PC) cohorts. Evidence supporting venous thromboembolism prophylaxis (VTEP) generally comes from acute medicine or oncology.
Local trust guidelines mandated urgent VTEP assessment, recommending VTEP for most medical inpatients. No local guidance existed for PC. Anecdotally, practice within the attached specialist PC inpatient unit (IPU) varied.
Aims To audit VTEP assessment and administration against trust and NICE guidelines.
Methods Trust audit approval was obtained. Electronic and paper notes were examined for IPU stays between May-Aug 2017. Results were anonymised, using Excel for analysis.
Results Notes were available for 86/96 identified patient episodes. Thirteen patients receiving anticoagulation treatment were excluded, leaving n=73 episodes for analysis (including repeat stays). Most patients were elderly and had cancer. 86% of episodes had recorded VTEP initial assessments; 100% had VTEP prescribed (or a documented clinical reason), accordingly. Only 6/7 patients with potential VTEP complications had their VTEP re-assessed.
73% episodes included terminal care. Where death was unexpected (n=48), most patients stopped receiving VTEP either when dying was diagnosed (n=31) or at another time before death (n=8). This was not always a formal medical decision.
Actions Results were presented at the PC audit meeting. A departmental VTEP policy was drafted, which provided input to the trust thrombosis committee and future trust-wide policy. Holistic assessment of VTEP appropriateness and re-assessment at key clinical points were emphasised through teaching. IPU consultant ward-round stickers were created, encouraging formal re-assessment. Re-audit 2018 confirmed widespread improvement of targets.
Conclusions Variation in VTEP practice reflected lack of clarity about PC in the trust’s policy. Changes to departmental policy and engagement with trust policymakers helped effectively align practice with NICE guidance, prioritising patient-centric care, shared decision-making and minimising potentially harmful medications.
. Tardy B, et al. The RHESO study2017.
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