Objectives & Background Patients with acute lower limb injuries and temporary immobilisation are at risk of subsequent venous thromboembolic disease (VTE). Recent National Institute of Health and Care Excellence has recommended formal risk assessment in the emergency department and consideration of prophylaxis for those considered high risk. Subsequent RCEM guidance has been produced to support decision making in the form of the GEMNet guidelines. Despite these documents, practice remains inconsistent and patients continue to have adverse outcomes.
We sought to evaluate local practice and implement change to improve standardisation.
Methods A prospective audit cycle over 2 discrete monthly episodes in 2015. Patient episodes coded as lower limb fractures were retrospectively assessed over a 4 week period to collect data on use of the local orthopaedic pathway and national GEMNet pathway. Adherence to local policy was assessed. Following the initial period of assessment, a series of interventions were agreed with local stakeholders in an attempt to standardise care and improve patient experience. The interventions included redesign of the pathway to adhere to GEMNet guidance, local education and launch, electronic patient record discharge prompt/block and orthopaedic engagement. After delivery of the interventions, patient episodes were re-evaluated to ascertain improvement in delivery of care and staff opinion.
Results During the initial month of evaluation, only 32% (20/62) of applicable patients evaluated had a documented VTE risk assessment. Of these patients, none received thromboprophylaxis as per the local policy. A substantial proportion of these patients (40%) would have been considered eligible under GEMNet guidance. Following launch of the new pathway and delivery of the interventions, 93.1% (54/58) of applicable patients over the month had a documented risk assessment recorded in the medical notes. Of this cohort, 43% (25/58) were considered high risk by GEMNet guidelines and accordingly prescribed thromboprophylaxis. No clinical short term complications were encountered on chart review.
Conclusion A series of interventions including simplification of risk assessment, stakeholder agreement, local education and electronic prompt led to a clear improvement in documented VTE risk assessment for ambulatory patients with temporary immobilisation secondary to lower limb injury.
- emergency departments
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