Best practice guidelines for Australia and New Zealand on the prevention of venous thromboembolism: Issues and implications for nurses

We have been invited to comment on the recently released best practice guidelines for Australia and New Zealand on the prevention of venous thromboembolism (Australia & New Zealand Working Party on the Prevention of Venous Thromboembolism - ANZWPPVT 2007). In this editorial we first provide a short overview of venous thromboembolism (VTE) and then we discuss issues surrounding implementation of these guidelines, focusing on current work in Queensland.We conclude by suggesting that, in addition to educating individual clinicians on the guidelines, a human factors engineering approach can be useful in change behaviours, such clinicians' practices surrounding VTE prophylaxis.VTE is comprised of deep vein thrombosis (DVT) and pulmonary embolism (PE). VTE occurs in nearly 30,000 Australians annually and has been identified as a priority area for improving patient safety (National Institute of Clinical Studies 2003). It is now a significant problem for both medical and surgical patients and can lead to serious illness, poor quality of life and even death.VTE events not only extend hospital length of stay but also increase hospital costs associated with anticoagulant therapy.There are a number of risk factors associated with VTE, including: ischaemic stroke; active cancer; decompensated heart failure; acute on chronic lung disease; acute on chronic inflammatory disease; hip/knee arthroplasty; major trauma; and hip fracture surgery or any major surgery (greater than 45 minutes duration) conducted on a patient over the age of 40 years.Most hospitalised patients have one or more risk factors for VTE. Importantly, these factors are generally considered cumulative (ANZWPPVT 2007). Additional risk factors include immobility, use of oestrogen preparations, pregnancy or puerperium, a strong family history of VTE and obesity.Current studies indicate that DVT occurs in over 50% of some categories of hospitalised patients if prophylaxis is not used.This has been found to occur in several categories including stroke (56%), elective hip replacement (51%) and multiple trauma (50%). However, due to the silent nature of DVT, many of these events are asymptomatic. The long-term sequelae of DVT are often chronic venous insufficiency (CVI), which leads to post-thrombotic syndrome (PTS) in up to 60% of patients who develop a DVT. PTS is often characterised by chronic pain, oedema, cellulitis and venous ulceration. Approximately 25% of all venous ulcers can be attributed to DVT and may cost the Australian Health Care system over $200 million annually (ANZWPPVT 2007).PE, the second VTE condition, is one of the single most preventable causes of hospital deaths, and accounts for approximately 10% of all deaths in hospital (ANZWPPVT, 2007). Non-fatal PE occurs in approximately 20 per 100 000 people per year in comparison to 50 per 100 000 people per year for fatal PE. Interestingly, up to 75% of fatal PE that occur in hospital are in medical patients.As the fourth edition of the VTE prophylaxis guidelines outline, VTE prophylaxis should be considered for every hospitalised patient. Currently recommended prophylactic methods are cost effective in patients at moderate and high risk of VTE due to the high cost of diagnosis and treatment of VTE in these patients. Effective VTE prophylaxis and treatment should also reduce the costs of managing the post-thrombotic syndrome and its consequences, especially chronic venous leg ulcers associated with PTS.It is well recognised that there are also risks associated with anticoagulant medication use. In Queensland, the Health Quality and Complaints Commission (HQCC) developed a set of seven surgical standards that focus on what health service users should receive with respect to the quality of health care (HQCC 2007). One of these standards requires all surgical patients to be reviewed and have a documented risk assessment for VTE and any patients with a moderate to high risk of VTE should receive an appropriate prophylactic intervention if not contraindicated. …