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Venous thromboembolism incidence in mental health services for older people: survey of in-patient units

  • Martin van Zyl (a1), Gillian Wieczorek (a2) and Joe Reilly (a3)
Abstract
Aims and method

To establish the incidence of venous thromboembolism (VTE) in mental health services for older people (MHSOP) in-patient units, and investigate current practice in terms of assessment of risk of VTE and treatment given. We conducted an incidence survey of VTE on in-patient units in MHSOP in a National Health Service trust, searching data of in-patients discharged over a 2-year period.

Results

Overall, 1495 individual patient records were searched. There were 17 confirmed VTEs, which is comparable with VTE incidence rates in general hospitals. There were no risk assessments done on admission and no thromboprophylaxis given. Use of compression stockings and mobilisation was limited.

Clinical implications

The study confirmed a significant VTE incidence and the need for increased awareness among MHSOP staff. This can be met by improved training of VTE awareness and management for clinical staff and the use of a VTE assessment tool on MHSOP in-patient units.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Martin van Zyl (martin.vanzyl@nhs.net)
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Declaration of interest

None.

Footnotes
References
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1 Office for National Statistics. Population Ageing in the United Kingdom, its Constituent Countries and the European Union. ONS, 2012.
2 Giuntini, C, Ricco, GD, Marini, C, Mellilo, E, Palla, A. Pulmonary embolism: epidemiology. Chest 1995; 107 (suppl 1): 3S9S.
3 Roopen, A (ed.). Venous Thromboembolism Prevention: A Patient Safety Priority. King's Thrombosis Centre, 2009.
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5 National Institute for Health and Clinical Excellence. Venous Thromboembolism: Reducing the Risk. Reducing the Risk of Venous Thromboembolism (Deep Vein Thrombosis and Pulmonary Embolism) in Patients Admitted to Hospital (Clinical Guideline CG92). NICE, 2010.
6 Stein, PD, Hull, RD, Kayali, F, Ghali, WA, Alshab, AK, Olson, RE. Venous thromboembolism according to age: the impact of an aging population. Arch Intern Med 2004; 164: 2260–5.
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BJPsych Bulletin
  • ISSN: 1758-3209
  • EISSN: 1758-3217
  • URL: /core/journals/bjpsych-bulletin
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Venous thromboembolism incidence in mental health services for older people: survey of in-patient units

  • Martin van Zyl (a1), Gillian Wieczorek (a2) and Joe Reilly (a3)
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eLetters

Venous thromboembolism risk assessment in Old Age Psychiatry

Abid H Choudry, CT3 Doctor
17 September 2013

As van Zyl et al have described, venous thromboembolism (VTE) risk assessment for patients admitted toold age psychiatric units has been a neglected area (1). NICE and theDepartment of Health guidelines (2,3) recommend that every patient admitted to hospital be assessed for VTE and managed appropriately. The failure to adequately screen and prevent VTE is believedto cause annually between 25 000 and 32 000 potentially avoidable deaths in the UK (4).

During my 6 month rotation in Old Age Psychiatry, we completed an audit looking into VTE risk assessment for elderly patients. The results were quite alarming with 13% of patients developing a deep vein thrombosis(DVT). Moreover, we looked at DVT risk factors retrospectively and this revealed a mean of 3.4 risk factors for patients admitted to our unit. Not one patient had been assessed for VTE or treated prophylactically on admission with pharmacological prophylaxis or graded compression stockings. Old age psychiatric units do not seem to have polices in place to recognise and manage patients accordingly, in contrast to general hospitals, where every patient undergoes a VTE assessment on admission andis commenced on appropriate prophylaxis immediately.

Unfortunately both the risks of thrombosis and of prophylaxis are increased in frail older people, and this means that careful risk assessment to weigh up the risks and benefits in each patient is essential. However, a more standardised national approach and greater awareness of the Department of Health risk assessment tool for VTE (3) may be needed.

References: 1. van Zyl M, Wieczorek G, and Reilly J.Venous thromboembolism incidence in mental health services for older people: survey of in-patient units. The Psychiatrist 2013; 37: 283-285.

2. Venous thromboembolism: reducing the risk of venous thromboembolismin patients admitted to hospital. National Clinical Guideline Centre, Jan 2010. http://guidance.nice.org.uk/CG92. 3. Department of Health. Venous thromboembolism Risk Assessment. March 2010. Gateway reference 10278. 4. Roopen A (ed.). Venous Thromboembolism Prevention: A Patient Safety Priority. King's Thrombosis Centre, 2009.

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Conflict of interest: None declared

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Venous thromboembolism prophylaxis- beware of potential risks

Rashmi K. Patel, MRC Clinical Research Training Fellow
17 September 2013

van Zyl, Wieczorek and Reilly's study (1) highlights the importance of increased awareness of venous thromboembolism (VTE) in mental health services for older people (MHSOP). However, it is also important to be aware of therisks of thromboprophylaxis within this setting. The authors claim that the incidence rates of VTE in MHSOP were comparable to those in general hospitals. However, it does not follow from this that the same approaches for VTE screening and thromboprophylaxis used in general hospitals shouldbe applied, particularly with respect to the risks of thrombocytopenia and bleeding from prophylactic low molecular weight heparin (2), which may be exacerbated in mental health inpatient settings where the average length of stay is likely to be longer than in an acute medical unit. In fact, recent meta-analyses have questioned whether such risks outweigh the potential benefits even withinthe general hospital setting (3). Further evidence should be sought before such VTE prevention strategies arewidely implemented in mental health care settings, lest they lead to patient harm.

References: 1. van Zyl M, Wieczorek G, and Reilly J. Venous thromboembolism incidence in mental health services for older people: survey of in-patient units.The Psychiatrist 2013; 37: 283-285

2. Wang TY, Honeycutt EF, Tapson VF, Moll S, Granger CB, Ohman EM (2012). Incidence of thrombocytopenia among patients receiving heparin venous thromboembolism prophylaxis. The American journal of medicine, 125 (12): 1214-21.

3. Lederle FA, Zylla D, Macdonald R, Wilt TJ (2011). Review Annals of Internal Medicine Venous Thromboembolism Prophylaxis in Hospitalized Medical Patients and Those With Stroke : A Background Review for an American College of Physicians Clinical Practice Guideline.



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Conflict of interest: None declared

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