Title : VTE Prophylaxis in Stroke
Abstract:
Background
Venous thromboembolism(VTE) prophylaxis is a recognised part of stroke management in European Stroke Organisation (ESO) guidelines, and a component in the NICE Stroke pathway. The practicalities of the prescribing and application of these modalities whether pharmacological or mechanical differs between organisations, and is dependent on the local stroke service.
Aim:
This work audited the practice of VTE prophylaxis in Stroke patients in a large UK tertiary centre and Stroke service provider against recommendations from NICE and ESO guidelines, to identify if the right VTE prophylaxis modalities were being prescribed and effectively given, and what barriers could exist to prevent these being effectively employed.
Methods:
Data was collected from 2 weeks of inpatient admissions to the local Stroke Unit. Clinical notes, online admission forms and drug records were reviewed to identify the VTE prophylaxis modality prescribed and given, taking into account stroke pathology and decisions on VTE prophylaxis with clinical information such as preexisting anticoagulation, whether a patient was thrombolysed, mobility and falls risk.The patient was also examined to see if mechanical prophylaxis such as intermittent pneumatic compression(IPC) devices were active on the patient. Data was collated, formatted and analysed with Microsoft Excel
Results:
Sample size of 51 patients. 50 patients had confirmed stroke on imaging 18% (9/51) hemorrhagic strokes, 78% (39/51) ischaemic strokes, 2% (1/51) mixed stroke, with the remaining one patient found to have an uncomplicated left intracranial aneurysm. 84% of patients (42/51) had appropriate VTE prophylaxis prescribed in the form of IPC devices or Low Molecular weight Heparin (LMWH) after clinical consideration, or had no VTE prophylaxis after an appropriate clinical assessment taking mobility and falls risk in account. Of the 8/51(16%) remaining patients, VTE prophylaxis deviated from guidelines, with Thrombo-Embolic Deterrent (TED) Stockings or inappropriate LMWH or a combination thereof or no VTE prophylaxis prescribed It was noted that a high number of patients who had VTE prophylaxis prescribed did not have them on or did not have them turned on - 26% (13/51) on admission, 14.3% (7/51) by 72 hours. here were however no associations with VTE incidences, bleeds or 30-day mortality within the limits of this audit.
Conclusions:
Following a local clinical governance meeting, it was found that most deviations from Stroke VTE prophylaxis guidelines happened due to patients moving from a medical admissions unit to the Stroke unit, where general medical junior doctors may not have been aware of stroke guidelines. With regards to IPC devices being prescribed but not being active on patients, it was highlighted that after physiotherapy or occupational therapy assessments, it was not clear who would be reattaching detached IPC devices after patients were returned to the bedside which was a potential source of deviation. The logistics of having IPC devices available in a general medical unit were also highlighted as Stroke unit beds may not always be available.
References
1. Dennis M, Caso V, Kappelle LJ, Pavlovic A, Sandercock P; European Stroke Organisation. European Stroke Organisation (ESO) guidelines for prophylaxis for venous thromboembolism in immobile patients with acute ischaemic stroke. Eur Stroke J. 2016 Mar;1(1):6-19. doi: 10.1177/2396987316628384. Epub 2016 Mar
2. Acute stroke: management in a specialist stroke unit, https://pathways.nice.org.uk/pathways/stroke Accessed 16 January 2022
What will audience learn from your presentation?
- It is important to identify if there are structures in place for ensuring patients with stroke have access to IPC devices should there be no Stroke Unit availability
- Physiotherapy and Occupational therapy sessions during which patients have IPC devices unattached and potentially left unattached can impact on the provision of VTE prophylaxis to stroke patients
- Local education for junior doctors outside of the Stroke unit on VTE prophylaxis in stroke versus the general inpatient population can be important for the overall provision of Stroke care.
