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Fitzmaurice and Murray remind us that venous thromboembolism is not just a problem among surgical patients but an important cause of morbidity and mortality in medical patients too.1
We work in a hospital that implemented a thromboprophylaxis protocol for medical patients in 2004. In line with the recent recommendations of the UK government's Health Select Committee, the protocol states that every medical patient admitted to the hospital should have a risk assessment for venous thromboembolism and be prescribed thromboprophylaxis with low molecular weight heparin if indicated. When the protocol was introduced it was widely publicised within the hospital and made easily accessible to doctors in the patient's bedside file and on the hospital intranet.
In the year after the protocol had been introduced we audited all cases of hospital acquired venous thromboembolism, to assess concordance with the protocol. We found that only 18% of medical patients who had an indication for thromboprophylaxis according to the protocol were prescribed an appropriate dose of low molecular weight heparin. Furthermore, out of six patients who died due to pulmonary embolism, only two had received low molecular weight heparin, although it was indicated in all six.
Maybe a new approach to the problem is required. Electronic alerts to the need for thromboprophylaxis have been shown to be effective in increasing doctors' use of thromboprophylaxis and reducing rates of venous thromboembolism.2 This system, however, requires complete electronic records of patients' risk factors for venous thromboembolism. An alternative approach might be to mandate thromboembolism risk stratification and linked action as part of the standard admission procedure.
Competing interests: None declared.