Do protocols improve VTE prophylaxis in practice?

Andrew McNally, William Marlow, Stephen Lipscombe

Background: VTE prophylaxis practice varies between/within hospitals. There is poor consistency particularly in treating NWB patients immobilised in casts. This inconsistency was previously demonstrated in an initial audit. The solution had been to implement a protocol based on national guidelines.

Methods: A retrospective analysis of 40 patients was conducted to ascertain the impact of the changes. Data was collected from notes and pharmacy records. Data from the initial cycle was extracted to identify patients matching the inclusion criteria for the protocol for comparison with the second cycle.

Results: This cycle demonstrated a fall in documentation of risk factors from 42% to 27%. Documentation of bleeding risk was seen in only 3%. Despite this, there were only 4 cases where no prophylaxis was prescribed and there was no documentation. Retrospective analysis of these cases could identify no risk factors which would have mandated prophylaxis. The proportion of cases not prescribed prophylaxis fell from 35% to 10% - whether this change was appropriate is not known due to the high rate of poor documentation.

Discussion: Following the implementation of protocols, the proformas were rarely used and documentation of risk factors in dictated letters fell significantly. Although the rate of prescription increased significantly, it is not clear whether this was appropriate – the documentation was insufficient where it was prescribed. 90% prescription may reflect an overly aggressive reactive response to the previous audit presentation. The audit process may have highlighted the issue and proformas, however knowledge of these proformas was virtually non-existent among doctors on rotation.

Conclusion: Without first improving documentation we cannot assess the impact of our changes. The changes implemented initially were lost when that cohort of doctors rotated. Failure to integrate the changes into the existing culture of the permanent MDT staff are likely to have contributed to this transiency.